Mobilization of Stem and Progenitor Cells in Septic Shock Patients.

Septic shock is associated with multiple injuries to organs and tissues. These events may induce the regenerative response of adult stem cells. However, little is known about how endogenous stem cells are modulated by sepsis. This study analyzed the circulation of hematopoietic stem cells (HSCs), endothelial progenitor cells (EPCs) and very small embryonic-like stem cells (VSELs) in the peripheral blood of patients with septic shock. Thirty-three patients with septic shock and twenty-two healthy control subjects were enrolled in this prospective observational study. Blood samples were collected on the first, third and seventh days of septic shock. Populations of stem cells were analyzed by flow cytometry. Chemotactic mediators were analyzed by HPLC and ELISA. Populations of early HSCs (Lin-CD133+CD45+ and CD34+CD38-) were mobilized to the peripheral blood after an initial decrease. Mobilized HSCs showed significantly increased expression of Ki-67, a marker of cell proliferation. Circulating EPCs and VSELs were mobilized to the blood circulation upon the first day of sepsis. Patients with a greater number of Lin-CD133+CD45+ HSCs and Lin-CD34+CD45- VSELs had a significantly lower probability of 60-day survival. The concentration of CXCL12 was elevated in the blood of septic patients, while the concentration of sphingosine-1-phosphate was significantly decreased. As an emergency early response to sepsis, VSELs and EPCs were mobilized to the peripheral blood, while the HSCs showed delayed mobilization. Differential mobilization of stem cell subsets reflected changes in the concentration of chemoattractants in the blood. The relationship between the probability of death and a large number of HSCs and VSELs in septic shock patients can be used as a novel prognostic marker and may provide new therapeutic approaches.

Monitoring of procalcitonin but not interleukin-6 is useful for the early prediction of anastomotic leakage after colorectal surgery.

BACKGROUND: Early recognition of patients who have developed anastomotic leakage (AL) after colorectal surgery is crucial for the successful treatment of this complication. The aim of this study was to assess the usefulness of the assessment of procalcitonin (PCT) and interleukin-6 (IL-6) levels in the prognosis of AL. METHODS: This observational study included 157 patients who underwent major elective colorectal surgery. The most common indications for surgery were cancer and inflammatory bowel diseases. Serum samples were obtained directly before surgery (D0) and 1 day (D1) after surgery, and the relationships between the serum concentrations of PCT and IL-6 and development of AL were assessed. RESULTS: In total, 10.2% of patients developed post-surgical infections due to AL. PCT levels on D1 were significantly higher in patients who developed AL [2.73 (1.40-4.62)] than in those who recovered without complications [0.2 (0.09-0.44)]. The area under the ROC curve for PCT on D1 was 0.94, 95% CI (0.89-0.98). The sensitivity and specificity of the prediction of an infection were 87% and 87%, respectively, for PCT on D1, which was higher than 1.09 ng/mL. The increase in PCT concentration between D0 and D1 was significantly higher in patients with AL (p<0.001). Patients who developed AL had higher concentrations of IL-6 on D1, but the difference was not significant (p=0.28). CONCLUSIONS: This study confirms that surgical trauma increases serum PCT concentrations and that the concentration of PCT on D1 can predict AL after colorectal surgery. However, IL-6 is not a good early marker for developing AL.

The Early Expression of HLA-DR and CD64 Myeloid Markers Is Specifically Compartmentalized in the Blood and Lungs of Patients with Septic Shock.

Identification of reliable biomarkers is key to guide targeted therapies in septic patients. Expression monitoring of monocyte HLA-DR and neutrophil CD64 could fulfill the above need. However, it is unknown whether their expression on circulating cells reflects the status of tissue resident cells. We compared expressions of HLA-DR and CD64 markers in the circulation and airways of septic shock patients and evaluated their outcome prognostic value. The expression of CD64 on neutrophils and HLA-DR on monocytes was analyzed in the peripheral blood and mini-bronchoalveolar lavage fluid cells by flow cytometry. Twenty-seven patients with septic shock were enrolled into the study. The fluorescence intensity of HLA-DR on circulating monocytes was 3.5-fold lower than on the pulmonary monocytes (p = 0.01). The expression of CD64 on circulating and airway neutrophils was similar (p = 0.47). Only the expression of CD64 on circulating neutrophils was higher in nonsurvivors versus survivors (2.8-fold; p = 0.031). Pulmonary monocytes display a higher level of HLA-DR activation compared to peripheral blood monocytes but the expression of neutrophil CD64 is similar on lung and circulating cells. Death in septic patients was effectively predicted by neutrophil CD64 but not monocytic HLA-DR. Prognostic value of cellular activation markers in septic shock appears to strongly depend on their level of compartmentalization.

Quality of life considering patients with chronic inflammatory bowel diseases - natural and parenteral nutrition.

UNLABELLED: One of the elements of treatment considering inflammatory bowel diseases is nutritional therapy. The duration of the above-mentioned depends on the prevalence of such symptoms as fever, bowel movements, length of the functioning gastrointestinal tract, stoma and intestinal fistula presence. Nutritional therapy is an essential element of successful treatment alongside pharmacological, surgical, and biological therapy, as well as other methods. Crohn's disease and ulcerative colitis considered as chronic diseases, lead towards physical and biopsychosocial disability, being responsible for the reduction in the quality of life. The aim of the study was to determine the quality of life after surgical procedures in case of patients diagnosed with Crohn's disease and ulcerative colitis, subjected to natural and parenteral nutrition. MATERIAL AND METHODS: The study group comprised 52 patients from the Department of Gastroenterology, Military Medical Institute, and Department of Surgery and Clinical Nutrition, Clinical Hospital in Warsaw. The study was performed between October, 2011 and April, 2012. The World Health Organization Quality of Life Instrument - Bref (WHOQOL-BREF) questionnaire was used to deter-mine the patients' quality of life. CONCLUSIONS: A lower quality of life was observed in case of patients subjected to parenteral nutrition, poor education, disease symptoms exacerbation, in the majority-rural inhabitants. The quality of life does not depend on gender, type of disease, family status, and additional medical care.

Liver disease in patients qualified for home parenteral nutrition - a consequence of a failure to adjust RTU bags in the primary centre?

UNLABELLED: If planned improperly, parenteral nutrition may result in a number of severe metabolic complications caused by insufficient or excessive delivery of individual nutrients. One of the most common and the most dangerous complication is parenteral nutrition-associated liver disease (PNALD). Such a complication may also result from using RTU (ready-to-use) bags that are not adjusted adequately to individual patients. The aim of the study was the analysis of prevalence and determining the cause of liver disease in patients who had been receiving parenteral nutrition in primary centres prior to the implementation of home parenteral nutrition in the specialist centre. MATERIAL AND METHODS: The study enrolled 146 patients who were referred to the Clinic in the period of 2006-2012 in order to be qualified for home parenteral nutrition. Interview and medical documentation revealed that 100 patients had been receiving parenteral nutrition by means of ready-to-use (RTU) bags in their primary centres. In the remaining 46 patients, such feeding had not been implemented. Upon admission, the following parameters were evaluated: bilirubin, aspartate aminotransferase (AspAT), alanine aminotransferase (AlAT), lactate dehydrogenase (LDH), gamma-glutamyltranspeptidase (GGTP), alkaline phosphatase (AP), triglycerides (TG), cholesterol, protein, albumins, amylase, urea, creatinine and C-reactive protein (CRP). The analysis of the results was conducted with the use of the Student's T-test. RESULTS: The patients who had been receiving parenteral nutrition manifested significantly increased (p < 0.05) levels of total bilirubin, TG, AlAT, LDH, GGTP, AP and CRP. 23% of patients were diagnosed with jaundice, in 70%, GGTP > 100 i.u. and a half manifested biochemical features of cholestasis. No correlation was observed between the CRP level and results of liver function tests. CONCLUSIONS: It was found that there is a correlation between parenteral nutrition with RTU bags and liver disease. The probable cause of liver disease associated with parenteral nutrition received prior to the transfer to the Clinic is excessive administration of lipids. It can be accompanied by excessive administration of glucose. Modification of parenteral nutrition helped to compensate for liver disorders in all patients.

Absolute counts of peripheral blood leukocyte subpopulations in intraabdominal sepsis and pneumonia-derived sepsis: a pilot study.

The leading pathophysiological changes during sepsis include systemic abnormalities in the immune response. Due to the general character of these disturbances, sepsis is usually studied as a homogenous clinical condition. We aimed to compare the immune response in intraabdominal sepsis (IAS) and pneumonia-derived sepsis (PDS). The following cell populations were examined: white blood cell count (WBC), monocytes, lymphocytes:CD3⁺, CD4⁺ and CD8⁺ T cells, B cells, and NK cells. In both studied groups (i.e. IAS and PDS), the WBC was elevated. However, it was significantly higher in the IAS group than in the PDS group. The difference was due to a lower granulocyte count, as well as a lower monocyte count in PDS. We found no significant correlation between the total lymphocyte number and CD3⁺CD8⁺ T cells in either form of sepsis. Similarly, we observed no correlation between the total lymphocyte number and the NK cells subset in IAS. However, the numbers of CD3⁺CD8⁺ and NK cells correlated similarly in both types of sepsis. Both studied types of sepsis induced profound lymphocytopenia, with marked loss of CD8⁺ T cells and the NK cells. However, the similarrelation between them, which was independent of the infection type, suggests that the NK and CD3⁺CD8⁺ cellshave shared mechanisms of regulation. The primary site of infection has an impact on the global immune reaction. These alternations include especially myeloid cells: granulocytes and monocytes which disappear from peripheral blood during PDS, but increase in IAS.

[Wilson disease as the significant risk factor of surgical treatment--clinical case report]. / Choroba Wilsona jako znaczacy czynnik ryzyka leczenia chirurgicznego--opis przypadku klinicznego.

Wilson Disease (W ) is a rare inborn disorder of cooper metabolism. In approximately 40% of cases signs and symptoms of abnormal liver functions are observed due to hepatic inflammation, cirrhosis or insufficiency. The mainstay treatment is the conservative treatment with zinc (eg Zincteral) or penicillamine. The Authors present a patient with WD who underwent surgery because of an advanced rectal prolapse (laparotomy, rectal mobilization, rectopexy, the partial sigmoid colon resection with the primary anastomosis). The postoperative course was complicated by anastomotic leakage and a subsequent diffuse peritonitis. The patient required relaparotomy and three weeks treatment in the intensive therapy unit. The Authors consider the WD as a significant risk factor for surgical patients. Surgical treatment of patients with WD should be least invasive.

[Infection with multidrug-resistant pathogens]. / Zakaienie szczepami wieloopornymi u chorych leczonych w oddziale intensywnej terapii.

BACKGROUND: Intensive therapy units are the places where pathogens can easily spread. Improper antibiotic therapy contributes to the selection of new strains called multidrug-resistant, extensively drug-resistant or pandrug-resistant. For ITU patients, such pathogens are particularly dangerous. CASE REPORT: The case of a 50-year-old man diagnosed with septic shock after repeated surgeries due to Vater's ampulla tumour was described. In blood and peritoneal fluid cultures, Enterobacter cloacae ESBL and Klebsiella pneumoniae were first isolated; then Acinetobacter baumannii was also detected. The targeted antibiotic therapy instituted did not bring the expected results. On day 5, tigecycline and imipenem were started and continued over 10 days. After 4 days of combined therapy, bacterial strains were eradicated. The patient was sent to the referring ward in good condition. CONCLUSION: Combined use of imipenem and a new antibiotic - tigecycline provides effective treatment of septic shock in the course of intra-abdominal infection.

[Procalcitonin in diagnosis and monitoring of surgical infections]. / Prokalcytonina w diagnostyce i monitorowaniu zakazen chirurgicznych.

The procalcitonin (PCT) is a sensitive and reliable biochemical marker used in diagnosing and monitoring of bacterial infections. The procalcitonin assay allows for effective evaluation of the patient's health status. Elevated PCT serum level is correlated with progression and generalization of the infection. In severe infections, such as sepsis or septic shock, the PCT may reach concentrations even up to 1000 ng/ml (with a normal range below 0.1 ng/ml). High PCT levels in the first hours of the developing infection advocates for the bacterial etiology. Therefore, procalcitonin is used in differential diagnosis of severe bacterial and viral infections. Rapid and accurate diagnosis facilitates introduction of the effective therapy. Rapid decrease in PCT level after applying the therapy confirms its efficacy (control assay may be performed after 24 hours since the therapy has been applied). The usefulness of the PCT is supported by the fact, that in pathologic conditions, such as trauma (including surgery procedures), viral infections or autoimmunologic diseases, the PCT level is only slightly increased or remains in a normal range. The PCT level assay enables the detection of the developing infection already in the latent stadium, before characteristic clinical symptoms appear. Therefore, it is very important to monitor the PCT serum level. Further research will allow to determine the accurate diagnostic value and the clinical application of the PCT level as a marker of infection.