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Objective To investigate the clinical characteristics,risk factors and prognosis of patients with persistent inflammation,immune-suppression and catabolism syndrome(PICS)secondary to sepsis in medical intensive care unit(MICU)in initial stage,in order to increase the understanding of PICS and provide the reference experience for the early screening of high-risk patients.Methods A total of 298 elderly patients diagnosed as sepsis admitted into MICU from Aug.2013 to Dec.2016 were retrospectively studied.Of them,97 patients meeting inclusion criteria were ultimately enrolled and separated into the PICS group and the non-PICS group.General and clinical data and laboratory indexes at first day admitted into MICU were compared between the two groups.The indexes between the two groups were analyzed statistically by multivariate logistic regression analysis.The survival-time distributions were estimated by Kaplan-Meier model,and the difference in prognosis was compared between the two groups.Results Of 97 patients,36 patients (37.1％)met the diagnosis of PICS.The acute physiological function and chronic health evaluation Ⅱ (APACHE Ⅱ) score had a significant difference between the two groups(27.7±5.8 vs.22.9±6.0,P＜0.01).The grade of acute gastrointestinal injury(AGI)were significantly higher in the PICS group than in the non-PICS group(P ＜0.05).Platelet counts,helper T cell counts and CD4+/CD8+ ratios were significantly lower in the PICS group than in the non-PICS group[(164.39 ± 84.29) × 109/L vs.(235.16 ± 126.89) × 109/L,(238.97± 181.11)/μl vs.(385.93±308.22)/μl,(1.58 ± 1.13) vs.(2.12± 1.23),all P ＜0.05)].Multivariable logistic regression analysis revealed that APACHE Ⅱ score was an independent risk factor for PICS and its optimal cut-off value for predicting PICS was 26.5.Kaplan-Meier analysis showed that the overall survival was poorer in the PICS group than in non-PICS group in the whole observation phase.The further Kaplan-Meier analysis on survival time of subdivisions showed that the survival of patients at 90-day and 180-day after admission and in stage 1-3 during one year had significant differences between the two groups (P ＜ 0.05).While the survival of patients at 28-day after admission had no significant difference between the two groups(P＞0.05).Conclusions The elderly patients with persistent inflammation,immune-suppression,and catabolism syndrome(PICS) secondary to sepsis in medical intensive care unit(MICU)show the higher levels of APACHE Ⅱ score and AGI grade,and lower values of platelet counts,CD4+ T cell counts and CD4+/CD8+ ratio in initial stage.And APACHE Ⅱ score is an independent risk factor for PICS in elderly sepsis patients,and the optimal cut-off value of APACHE Ⅱ score for predicting PICS is 26.5.The prognosis for advanced stage and long term prognosis are poor.It is essential to use APACHE Ⅱ and so on,to timely identify and intervene PICS.
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Objective To investigate the effect of thymosin α1 on immunity,metabolism and prognosis in elderly patients with sepsis followed by persistent inflammation,immunosuppression,and catabolism syndrome (PICS).Methods In this retrospective study,68 patients diagnosed with sepsis followed by PICS in medical intensive care unit (MICU) from Jan.2014 to Dec.2016 were involved.Thirty-four patients treated with thymosin α1 for 2 weeks were allotted to the observational group;other 34 patients were to the control group.Patients' clinical information and data of laboratory test were collected in addition.We compared patients' general information,and the indexes before and after treatment,then the indexes between the two groups to analyze the effect of thymosin α 1 on immunity and metabolism;moreover,we conducted survival analysis and compared the mortality of different periods to analyze the effect of thymosin α1 on prognosis.Results The number of monocytes,the levels of CD4/CD8 and HLADR/CD14 before and after treatment in the observational group were significantly higher than those in the control group [(0.11 ± 0.31)× 109/L vs.(-0.16 ± 0.36)× 109/L,(0.20 ± 0.94) vs.(-0.22 ± 0.74) and (5.8 ±16.3)％ vs.(-3.3 ± 18.2)％ respectively],which suggested that the number of monocytes and the levels of CD4/CD8 and HLADR/CD14 were significantly increased by thymosin α1 intervention,and the difference were statistically significant(P ＜ 0.05).Kaplan-meier survival analysis showed prognosis between the two groups was not statistically significant (P ＞ 0.05).The further analysis of mortality in different periods indicated that the mortality within 28 days,90 days and 120 days and overall mortality between the two groups [8 (23.5％) vs.12 (35.3％),18(52.9％) vs.25 (73.5％),20 (58.8％) vs.27 (79.4％) and 24 (70.6％) vs.28 (82.4％) respectively],were not statistically significant(P ＞ 0.05).Conclusions Thymosin α1 can be used to regulate the immunity of elderly patients with sepsis followed by PICS,but its effect on regulating metabolism and improving prognosis needs further study.
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Objective To investigate the effects of mesenchymal stem cells(MSCs)on the pathological structure and cytokine expression of lung tissue in septic model of diabetic rats. Methods Diabetic rats were ran-domly divided into control,sham-operation,sepsis and MSC-treated groups. The diabetic model was induced by high-sucrose and high-fat diet combined with streptozotocin and cecal ligation and puncture. The pathological changes of lung tissue were observed at 6,12,18 and 24 hours after operation respectively,and the expression of SP-D,TNF-α,IFN-γ and IL-10 in lungs were measured.Results The levels of SP-D,TNF-α and IFN-γ in lung tissue increased gradually with the elongation of time after CLP. The expression of IL-10 in lung tissue increased and then decreased. The trend of MSC intervention increased the content of SP-D,TNF-α and IL-10 in the lung tissue of non-diabetic septic rat model and reduced the content of IFN-γ.MSC intervention reduced the SP-D and TNF-α content.The intervention of MSC had no effect on the content of IFN-γ in the lung tissue of diabetic septic rats.However,it increased and then decreased the content of IL-10.Conclusions The model of sepsis in diabetic rats can be established by feeding combined high-sugar and high-fat diet and streptozotocin combined with cecal ligation and puncture. Mesenchymal stem cells affect sepsis inflammation and organ damage. But its specific role depends on the immune status and the timing of mesenchymal stem cell selection.
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Objective To investigate the predictive value of glycosylated serum protein (GSP) combined with glycemic variability (GV) in persistent inflammation immunosuppressive catabolic syndrome (PICS) in elderly septic patients. Methods A retrospective study was conducted. The septic patients aged≥60 years old with 28 days hospitalized duration admitted to geriatric intensive care unit (ICU) of Guangzhou General Hospital of Guangzhou Military Command from January 2014 to December 2017 were enrolled. The patients were divided into two groups according to whether PICS occurred within 14 days after ICU admission according to the PICS diagnostic criteria. General patients' data including gender, age, underlying disease, site of infection, the length of ICU stay were collected, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), GSP at 1 day after hospitalization and lymphocyte count (LYM), C-reactive protein (CRP), albumin (ALB), prealbumin (PA) levels at 1 day and 14 days were recorded. The levels of blood glucose on the 1st day and 14th day were observed, the GV was calculated. Data were cross-validated using the random forest method. Receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of glycemic parameters for PICS. Results A total of 315 elderly septic patients were included. Patients with malignant tumors, severe autoimmune diseases, and immunosuppressive therapy or dead within 28 days of hospitalization were excluded. A total of 132 patients were enrolled in the analysis, including 45 in the PICS group and 87 in the non-PICS group. The length of ICU stay in the PICS group was significantly longer than that in the non-PICS group [days: 35.0 (22.0, 49.5) vs. 8.0 (5.0, 23.0), P < 0.01]. No significant difference in the baseline data of gender, age, underlying disease, infection site or APACHE Ⅱ score between the two groups was found. ① Parameters for PICS diagnosis: with the prolongation of ICU stay, LYM and PA in the non-PICS group were increased and those in the PICS group were decreased, and CRP and ALB levels were decreased in both groups. LYM, ALB and PA levels in the PICS group were significantly lower than those in the non-PICS group at 14 days after ICU admission [LYM (×109/L): 0.6 (0.5, 0.7) vs. 1.1 (0.9, 1.6), ALB (g/L): 25.4±2.7 vs. 29.9±4.3, PA (g/L): 0.08 (0.05, 0.14) vs. 0.11 (0.10, 0.21), all P < 0.01], and CRP level was significantly higher than that in the non-PICS group (mg/L: 87.5±56.3 vs. 49.2±49.1, P < 0.01). ② Glycemic parameters: the GSP level of the PICS group at 1 day after ICU admission was significantly lower than that of the non-PICS group (mmol/L: 2.3±0.6 vs. 2.7±0.6, P < 0.01), but there was no statistically significant difference in the level of blood glucose or GV at 1 day and 14 days after ICU admission as compared with the non-PICS group [blood glucose (mmol/L): 10.0±3.3 vs. 9.4±3.3 at 1 day, 10.8±3.6 vs. 10.4±3.5 at 14 days; GV: (24.2±1.4)% vs. (23.7±1.2)% at 1 day, (24.8±7.8)% vs. (24.7±7.7)% at 14 days, all P > 0.05]. ③ ROC curve analysis: 1-day GSP as well as 1-day and 14-day GV had certain predictive value for PICS secondary to sepsis in the elderly. The predictive value of 1-day GSP combined with 14-day GV was the highest, its area under ROC curve (AUC) was 0.637, with a sensitivity of 95.8% and a specificity of 25.0%, while the positive likelihood ratio was 1.278, the negative likelihood ratio was 0.167, the positive predictive value was 71.9%, and the negative predictive value was 75.0%. Conclusion GSP combined with GV could effectively predict secondary PICS in elderly septic patients.
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Objective To investigate the changes of cardiovascular hemodynamics in elderly patients with septic shock using pulse indicator continuous cardiac output (PiCCO).Methods Fifty elderly patients with septic shock at the General Hospital of Guangzhou Military Command were enrolled from January 2015 to December 2015.We collected clinical data,including gender,age,acute physiological and chronic health evaluation (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,and the PiCCO parameters,such as cardiac index (CI),stroke volume index (SVI),systemic vascular resistance index (SVRI),cardiac function index (CFI),global ejection fraction (GEF),extravascular lung water volume index (EVLWI),etc.All clinical data were retrospectively analyzed.Results Compared with medical reference ranges,the majority of elderly patients with septic shock had low levels of CI (n=35),SVI (n=41),CFI (n =39) and GEF (n=46) and high levels of EVLWI (n =34).More patients over 75 years than those under 75 years showed lower CI (n=33,or 80.5％ vs.n =2,or 22.2％,x2 =13.511,P=0.001),lower CFI (n=35,or 85.4％ vs.n=4,or 44.4％,x-=7.236,P =0.027),and higher SVRI (n =24,or 58.5％ vs.n =0 or 0.0％,x2 =10.392,P=0.006).CI and CFI levels were negatively correlated with patient age (r=-0.460,P=0.001;r=-0.384,P=0.006).Diabetics showed lower CFI [(2.70±0.67)L/min vs.(3.64± 1.54)L/min,t =2.189,P =0.033],while patients with chronic obstructive pulmonary disease demonstrated a higher level of EVLWI[(13.83±7.60)l/min vs.(9.61±4.24)L/min,t =-2.062,P=0.045].On the third day,patients with high levels of PVPI showed an increased rate of mortality (80.0 ％,or 4 out of 5 cases to 28.9o,or 13 out of 45 cases,x2 =5.239,P=0.022),while the level of EVLWI of non-survivors was significantly higher than that of survivors on day 28[(11.10±5.57)ml/kg vs.(8.53±2.85)ml/kg,t=-2.150,P=0.037].Conclusions Elderly patients with septic shock have worse heart function,more lung water,and therefore lower volume tolerance than younger patients.The heart function of elderly patients deteriorates with age.PiCCO can provide real-time hemodynamic data and may be a prognostic index for elderly patients with septic shock.
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Terminology of persistent inflammation immunosuppression and catabolism syndrome (PICS) is developed based on the concept of multiple organ failure (MOF), which reflect that the preponderance is gradually reversed from pro-inflammation to anti-inflammation, and eventually the state of simultaneously persistent inflammation and severe immunosuppression appeared. Although the improvement of rescue technology and management increase the early survival rates of patient with critical illnesses, the long-term outcomes of most patients are not optimistic. The patients with PICS are difficult to treat or prevent, and are likely to indolent death and have a rising incidence, which is an important challenge to the intensive care unit (ICU). The paper review the understanding of PICS, summarize the specific changes of immune system in PICS, and explore the immunological markers for early recognition of PICS and judgment of immune state in order to provide new thinking for prevention and control of PICS.
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<p><b>OBJECTIVE</b>To analyze the diagnostic value of larval excretory-secretory antigen in Angiostrongylus cantonensis (LESA) infection.</p><p><b>METHODS</b>A.cantonensis larvae harvested from mice brain were cultured in vitro. The LESA and the adult worm antigens of A.cantonensis (AWA) were collected and analyzed using SDS-PAGE and Western blotting. Two ELISA systems were established using the two antigens (LESA-ELISA and AWA-ELISA) to detect the serum spectra from different sources.</p><p><b>RESULTS</b>SDS-PAGE and Western blotting displayed fewer protein and antigen bands for LESA than for the adult antigen. Two distinct bands of LESA (with relative molecular masses of 40 000 and 26 000) showed reactivity with the sera from patients with A. cantonensis infection. The serum levels of IgG and IgM antibodies to LESA increased at the beginning of infection in mice, reaching the peak on day 5 after infection and decreased on day 10. Compared with AWA-ELISA, LESA-ELISA showed a lower seropositive ratio in suspected patients with A.cantonensis, with also a lower cross-positive ratio in patients with schistosomiasis and clonorchis sinensis.</p><p><b>CONCLUSION</b>LESA possesses fewer antigen reaction bands than AWA. Although with a slightly lower positive ratio than AWA, LESA has a higher specificity for detecting serum antibodies in suspected cases of A.cantonensis infection, and therefore shows a potential for the diagnosis of angiostrongyliasis especially in the early stage and in current infection.</p>