The Role of Programmed Cell Death 1/Programmed Death Ligand 1 (PD-1/PD-L1) Axis in Sepsis-Induced Apoptosis.

Background and Objectives: Sepsis involves a dysregulated host response, characterized by simultaneous immunosuppression and hyperinflammation. Initially, there is the release of pro-inflammatory factors and immune system dysfunction, followed by persistent immune paralysis leading to apoptosis. This study investigates sepsis-induced apoptosis and its pathways, by assessing changes in PD-1 and PD-L1 serum levels, CD4+ and CD8+ T cells, and Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) severity scores. Materials and Methods: This prospective, observational, single-centre study enrolled 87 sepsis patients admitted to the intensive care unit at the County Emergency Clinical Hospital in Târgu Mureș, Romania. We monitored the parameters on day 1 (the day sepsis or septic shock was diagnosed as per the Sepsis-3 Consensus) and day 5. Results: Our study found a statistically significant variation in the SOFA score for the entirety of the patients between the studied days (p = 0.001), as well as for the studied patient groups: sepsis, septic shock, survivors, and non-survivors (p = 0.001, p = 0.003, p = 0.01, p = 0.03). On day 1, we found statistically significant correlations between CD8+ cells and PD-1 (p = 0.02) and PD-L1 (p = 0.04), CD4+ and CD8+ cells (p < 0.0001), SOFA and APACHE II scores (p < 0.0001), and SOFA and APACHE II scores and PD-L1 (p = 0.001 and p = 0.01). On day 5, we found statistically significant correlations between CD4+ and CD8+ cells and PD-L1 (p = 0.03 and p = 0.0099), CD4+ and CD8+ cells (p < 0.0001), and SOFA and APACHE II scores (p < 0.0001). Conclusions: The reduction in Th CD4+ and Tc CD8+ lymphocyte subpopulations were evident from day 1, indicating that apoptosis is a crucial factor in the progression of sepsis and septic shock. The increased expression of the PD-1/PD-L1 axis impairs costimulatory signalling, leading to diminished T cell responses and lymphopenia, thereby increasing the susceptibility to nosocomial infections.

Immune profile of patients­a new approach in management of sepsis and septic shock?

The present study was a prospective observational single center study, enrolling 102 patients with sepsis, admitted in the Intensive Care Unit of the County Emergency Clinical Hospital in Târgu Mureș (Mureș, Romania). The main goal of the present study was to compare the changes of the following parameters on day 1 compared with day 5, in sepsis compared with septic shock, as well as in survivors compared with non-survivors: Cell blood count parameters, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and systemic inflammation index, C reactive protein (CRP), ferritin, procalcitonin (PCT), CD 3+ T cells, CD4+ T cells, CD8+ T cells, CD16+CD56+/CD3-NK cells and CD19+ B cells. The relationship between the subcategories of lymphocytes with the inflammatory markers was evaluated. The serum concentration of CRP and PCT was significantly lower on day 5 compared with day 1 and serum ferritin was significantly higher in patients with septic shock. The percentage of cytotoxic T lymphocytes was significantly decreased and the percentage of NK lymphocytes was significantly increased in patients who developed septic shock. The results indicated a negative significant correlation between the proportion of T lymphocytes and PCT concentration and a positive significant correlation between the proportion of B lymphocytes and PCT concentration.

Is Carboxyhaemoglobin an Effective Bedside Prognostic Tool for Sepsis and Septic Shock Patients?

Introduction: Proper management of sepsis poses a challenge even today, with early diagnosis and targeted treatment being the most important steps. Easy, cost-effective bedside tools are needed in order to pinpoint towards the outcome of sepsis or septic shock. Aim of study: This study aims to find a correlation between Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) severity scores, the Neutrophil-Lymphocytes Ratio (NLR) and carboxyhaemoglobin (COHb) levels in septic or septic shock patients with the scope of establishing a bed side cost-effective prognostic tool. Materials and methods: A pilot, prospective, observational, and ongoing study was conducted on 61 patients admitted with sepsis or septic shock according to the SEPSIS 3 Consensus definition. We followed clinical and paraclinical parameters on day 1 (D1) and day 5 (D5) after meeting the inclusion criteria. Results: On D1 we found a statistically significant positive correlation between each severity score (p <0.0001), r = 0.7287 for SOFA vs. APACHE II with CI: 0.5841-0.8285, r = 0.6862 for SOFA vs. SAPS II with CI: 0.5251-0.7998 and r = 0.8534 for APACHE II vs. SAPS II with CI: 0.7663 to 0.9097. On D5 we observed similar results: a significant positive correlation between each severity score (p <0.0001), with r = 0.7877 for SOFA vs. APACHE II with CI: 0.6283 to 0.8836, r = 0.8210 for SOFA vs. SAPS II with CI: 0.6822 to 0.9027 and r = 0.8880 for APACHE II vs. SAPS II., CI: 0.7952 to 0.9401. Nil correlation was found between the severity scores, NLR and COHb on D1 and D5. Conclusion: Cost-effective bedside tools to pinpoint towards the outcome of sepsis are yet to be found, however the positive correlation between the severity scores point out to a combination of such tools for prognosis prediction of septic or septic shock patients.

Endogenous Carboxyhemoglobin Level Variation in COVID-19 and Bacterial Sepsis: A Novel Approach?

BACKGROUND: The increased production of carbon monoxide (CO) in sepsis has been proven, but the blood level variations of carboxyhemoglobin (COHb) as a potential evolutionary parameter of COVID-19 and sepsis/septic shock have yet to be determined. This study aims to evaluate the serum level variation of COHb as a potential evolutionary parameter in COVID-19 critically ill patients and in bacterial sepsis. MATERIALS AND METHOD: A prospective and observational study was conducted on two groups of patients: the bacterial sepsis group (n = 52) and the COVID-19 group (n = 52). We followed paraclinical parameters on Day 1 (D1) and Day 5 (D5) of sepsis/ICU admission for COVID-19 patients. RESULTS: D1 of sepsis: statistically significant positive correlations between: COHb values and serum lactate (p = 0.024, r = 0.316), and total bilirubin (p = 0.01, r = 0.359). In D5 of sepsis: a statistically significant positive correlations between: COHb values and procalcitonin (PCT) (p = 0.038, r = 0.402), and total bilirubin (p = 0.023, r = 0.319). D1 of COVID-19 group: COHb levels were statistically significantly positively correlated with C-reactive protein CRP values (p = 0.003, r = 0.407) and with PCT values (p = 0.022, r = 0.324) and statistically significantly negatively correlated with serum lactate values (p = 0.038, r = -0.285). CONCLUSION: COHb variation could provide rapid information about the outcome of bacterial sepsis/septic shock, having the advantages of a favorable cost-effectiveness ratio, and availability as a point-of-care test.

Severe Acute Motor Axonal Neuropathy associated with Influenza-A (H1N1) Infection and Prolonged Respiratory Failure - A Case Report.

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

Perioperative Risk Stratification: A Need for an Improved Assessment in Surgery and Anesthesia-A Pilot Study.

Background and Objectives: Numerous scoring systems have been introduced into modern medicine. None of the scoring systems assessed both anesthetic and surgical risk of the patient, predict the morbidity, mortality, or the need for postoperative intensive care unit admission. The aim of this study was to compare the anesthetic and surgical scores currently used, for a better evaluation of perioperative risks, morbidity, and mortality. Material and Methods: This is a pilot, prospective, observational study. We enrolled 50 patients scheduled for elective surgery. Anesthetic and surgery risk was assessed using American Society of Anesthesiologists (ASA) scale, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM), Acute Physiology and Chronic Health Evaluation (APACHE II), and Surgical APGAR Score (SAS) scores. The real and the estimated length of stay (LOS) were registered. Results: We obtained several statistically significant positive correlations: ASA score-P-POSSUM (p < 0.01, r = 0.465); ASA score-SAS, (p < 0.01, r = -0.446); ASA score-APACHE II, (p < 0.01 r = 0.519); predicted LOS and ASA score (p < 0.01, r = 0.676); predicted LOS and p-POSSUM (p < 0.01, r = 0.433); and predicted LOS and APACHE II (p < 0.01, r = 0.454). A significant negative correlation between predicted LOS, real LOS, ASA class, and SAS (p < 0.05) was observed. We found a statistically significant difference between the predicted and actual LOS (p < 001). Conclusions: Anesthetic, surgical, and severity scores, used together, provide clearer information about mortality, morbidity, and LOS. ASA scale, associated with surgical scores and severity scores, presents a better image of the patient's progress in the perioperative period. In our study, APACHE II is the best predictor of mortality, followed by P-POSSUM and SAS. P-POSSUM score and ASA scale may be complementary in terms of preoperative physiological factors, providing valuable information for postoperative outcomes.

The role of interleukin-6 as an early predictor of sepsis in a murine sepsis model.

AIM: Evaluating the role of interleukin-6 (IL-6) as an early predictor of sepsis in a murine model. MATERIALS AND METHODS: The study divided 26 Wistar rats into two experimental groups in which sepsis was induced through the intraperitoneal injection of different Escherichia coli cultures [Group 1: Extended-spectrum beta-lactamase (ESBL)-producing culture and Group 2: Standardized ATCC35218 culture] and a control group. IL-6 levels were determined at 5 and 24 hours post-inoculation and immunohistochemistry (IHC) was performed on tissue samples from the sacrificed animals. RESULTS: Mean plasma IL-6 levels in Group 1 peaked at 5 hours [37.4 pg∕mL; standard deviation (SD) = 2.4 pg∕mL] and decreased at 24 hours (34 pg∕mL; SD=3.2 pg∕mL) after inoculation. IL-6 levels in Group 1 were elevated compared to Group 2, at 5 hours (33.7 pg∕mL; SD=3.3 pg∕mL; p=0.019) and non-significantly so at 24 hours (32.5 pg∕mL; SD=2.4 pg∕mL; p=0.233). The results did not show an increase over control levels at either 5 hours (37.6 pg∕mL; SD=3.4 pg∕mL) or 24 hours (40.8 pg∕mL; SD=2.9 pg∕mL) after inoculation. The IHC shows a varying degree of IL-6 expression across all organ types studied. No statistically significant correlations were found between the tissue level quantification of IL-6 and serum values at 24 hours in either group. CONCLUSIONS: For an early stage of infection/inflammation, serum levels of IL-6 are not correlated with tissue-level inflammation disproving a potential role of IL-6 as a very precocious diagnostic and predictor test. Accumulation of IL-6 in lung, kidney and spleen tissue can be observed from the beginning of inflammation.

The Relevance of Coding Gene Polymorphysms of Cytokines and Cellular Receptors in Sepsis.

Sepsis is an injurious systemic host response to infection, which can often lead to septic shock and death. Recently, the immune-pathogenesis and genomics of sepsis have become a research topic focusing on the establishment of diagnostic and prognostic biomarkers. As yet, none have been identified as having the necessary specificity to be used independently of other factors in this respect. However the accumulation of current evidence regarding genetic variations, especially the single nucleotide polymorphisms (SNPs) of cytokines and other innate immunity determinants, partially explains the susceptibility and individual differences of patients with regard to the evolution of sepsis. This article outlines the role of genetic variation of some serum proteins which have the potential to be used as biomarker values in evaluating sepsis susceptibility and the progression of the condition.

Caspase 3 expression and plasma level of Fas ligand as apoptosis biomarkers in inflammatory endotoxemic lung injury.

OBJECTIVE: The objective of this study is to evaluate if the immunohistochemical expression of a pulmonary apoptosis marker and plasma level of Fas ligand (FasL) correlates with the dose- and time-dependent severity of lung injury, induced by the administration of lipo-polysaccharide (LPS) in an endotoxemic rat model. MATERIALS AND METHODS: Our study included 30 male Wistar rats, randomly divided into three groups: one control group (n=6) and two experimental groups (n=12÷group), in whom we induced endotoxemia by intraperitoneal injection of progressively increasing doses of LPS (5, 10 mg÷kg). We measured FasL plasma levels of the rats at different time points and analyzed the relationships with markers of lung injury. To investigate the level of caspase 3-protein expression, the immunohistochemistry of the lung tissue was assessed. RESULTS: The median percentage of caspase 3-stained cells for the 5 mg÷kg LPS dose was 0.36%, for the 10 mg÷kg LPS dose was 0.4% and for the control group was 0.03% (p<0.0001). The elevated expression levels of caspase 3 were consistent with the altered lung morphologies observed (rs=0.88). LPS administration in rats resulted in a significant dose-dependent increase in the levels of plasma FasL (p<0.0001). These levels correlated with markers of lung injury: degree of hypoxemia (rs=-0.42), histological measured lung injury score (rs=0.72), the density of the caspase 3 staining cells in the immunohistochemistry assessment of apoptosis (rs=0.81) and with the plasma RAGE (receptor for advanced glycated end-products) values (rs=0.70). CONCLUSIONS: Apoptosis is increased in edotoxemia induced lung injury and is likely to contribute to alveolar injury.

Factors Favouring the Development of Clostridium Difficile Infection in Critically Ill Patients.

Clostridium difficile, an anaerobic, spore-forming, toxin-forming, gram-positive bacillus present in the bacterial flora of the colon is the principal cause of nosocomial diarrhoea in adults. AIM: Assessment of favouring factors of Clostridium difficile infections as well as the interactions between them, in critically ill hospitalized patients undergoing complex medical and surgical treatments. MATERIAL AND METHODS: A retrospective case-control study involving eighty patients admitted in the Intensive Care Unit (ICU) of the County Clinical Emergency Hospital Tîrgu-Mures was conducted between January and October 2014. Patients aged eighteen years and over, who had undergone complex medical and surgical treatment, were divided into two subgroups. Group 1 included patients who developed diarrhoea but were not diagnosed as having a Clostridium difficile infection (CDI). Group 2 included patients who developed diarrhoea due to CDI as indicated by a positive culture and the expression of exotoxin. The assessed parameters were age, length of stay (LOS), antibiotic spectrum, association with proton pump inhibitors (PPI) or H2-receptor antagonists, immunological status, the presence or lack of gastrointestinal tract surgery. RESULTS: The mean age was 64.6 years with an average LOS of 10 days. Fifty-six percent of patients came to the ICU from internal medicine wards and forty-three percent from surgical wards. 20.5% of them were immunosuppressed. Co-association of ceftriaxone and pantoprazole significantly increased the risk of CDI compared to co-administration of any other antibiotic or pantoprazole (p=0.01). The odds ratio for Pantoprazole together with any antibiotic versus antibiotic therapy alone was significantly higher (p=0.018) with a sevenfold increase in the risk of positive exotoxin increase. CONCLUSIONS: Antibiotic use is associated with "no risk to develop CDI" in the first five days of administration. PPIs associated therapy increased the risk of CDI in first seventy-two hours regardless of the antibiotic type, and contributes to an active expression of CD exotoxin.

Ischemic preconditioning and inflammatory response syndrome after reperfusion injury: an experimental model in diabetic rats.

Quantification of local ischemia and inflammatory response syndrome correlated with histological changes associated with ischemia-reperfusion injury (IRI) after revascularization techniques. We included 12 adult male Wistar rats, aged eight weeks that were randomly divided into two groups. The first group acted as the control and at the second group, we induced diabetes by intraperitoneal streptozotocin administration (60 mg/kg). After eight weeks, the rats were subject to ischemic preconditioning for 10 minutes at three regular intervals. Twenty-four hours post-preconditioning, both groups were subject to ischemia for 20 minutes, followed by 30 minutes of reperfusion. Oxygen extraction was higher in Group 1, the arterio-venous CO2 gradient was higher in the control group, but not significant. The lactate production was higher in Group 1. The second group had a higher Na+ and also a significant difference in K+ values. Receptor for Advanced Glycation End (RAGE) values were higher in the second group but with no significant difference (RAGE1=0.32 ng/mL versus RAGE2=0.40 ng/mL). The muscle samples from the control group displayed significant rhabdomyolysis, damage to the nucleus, while the preconditioned group showed almost normal morphological characteristics. The lungs and kidneys were most damaged in the control group, with damage expressed as thickened alveolar septa, neutrophil infiltrates, eosinophilic precipitates in the proximal convolute tubule. Ischemic preconditioning significantly attenuates the ischemic reperfusion injury.

Time- and dose-dependent severity of lung injury in a rat model of sepsis.

Different animal models of experimental lung injury have been used to investigate mechanisms of lung injury. Lipopolysaccharide (LPS) administration is the most often used approach to model the consequences of bacterial sepsis. We created an endotoxemia rat model, simulating sepsis-related lung injury, in order to quantify the time and dose dependent severity lesions induced by the administration of lipopolysaccharide. Our study included 42 male Wistar rats, randomly divided into four groups: one control group (n=6) and three experimental groups (n=12/group) in whom we induced sepsis by intraperitoneal injection of progressively increasing doses of LPS (3, 5, 10 mg/kg). At six hours, the animals included in the groups with higher doses of LPS developed thrombocytopenia, elevated lactate levels, and liver and renal injury in a dose and time dependent manner. The severity of hypoxemia at six hours correlated with the increasing doses of LPS, with a slight improvement at 24 hours. Lung injury scores became more severe with increased dose and time of exposure to LPS without reaching the level of hyaline membranes formation. We also demonstrated translocation of a protein from the airspaces into plasma (RAGE - receptor for advanced glycation end products). Induction of sepsis using LPS is a known experimental model, but LPS treatment in rats does not cause the severe endothelial and epithelial injury that occurs in humans with acute respiratory distress syndrome (ARDS). In our study, the clinical, laboratory and histopathological findings confirmed sepsis and the damage of the alveolar-capillary membrane in a dose-dependent manner.

Evaluation of O-POSSUM vs ASA and APACHE II scores in patients undergoing oesophageal surgery.

BACKGROUND AND AIMS: Risk and prognostic scores quantify the patient's risk of death or complication according to the severity of his illness. The aim of this study was to evaluate the predictive accuracy of O-POSSUM vs ASA and APACHE II models on patients undergoing oesophageal surgery. MATERIAL AND METHOD: In this observational retrospective study 55 patients were enrolled who had undergone surgical interventions of excision and reconstruction of the oesophagus for neoplastic oesophageal stenosis, in the Surgical Clinics (I and II) of the Clinical County Emergency Hospital Mures, between January 2011 and January 2014. By using patients file records after extracting the data we calculated the predictive mortality, according to the prognostic scores O-POSSUM, ASA and APACHE II and we analyzed its correlations with the postoperative evolution. We evaluated the discriminatory power of the three scores using the ROC (receiver-operating characteristic) curves. According to the cut-off value corresponding to each score, we compared the Kaplan Meier survival curves during the hospitalization period. RESULTS: ROC curves analysis revealed that O-POSSUM had a better discriminatory power for mortality compared to the other two scores: AUC = 0.73 for O-POSSUM, AUC = 0.57 for APACHE II and AUC = 0.64 for ASA (p < 0.001). The cut-off value was statistically significant only in case of O-POSSUM, as it derives from the statistical analysis of the survival curves (p = 0.035). CONCLUSION: O-POSSUM predicts mortality more accurately compared to ASA or APACHE II in patients undergoing oesophageal surgery.

Blood sampling as a cause of anemia in a general ICU - a pilot study.

OBJECTIVE: The objective of our pilot study was to evaluate the influence of daily phlebotomy on patients' haemoglobin levels from our general intensive care unit. METHODS: We prospectively enrolled 35 patients who did not present with acute haemorrhage or developed it during the study period. For each patient we recorded: the diagnosis, age, sex, haemoglobin, hematocrit, SOFA and APACHE II score, blood volume drawn in standardized vials, number of blood tests ordered per day, fluid balance per day, number of ICU days. The collected data were analyzed using the linear regression model, paired t-test, receiver operating characteristic curves, and descriptive analysis. Statistical analysis was performed with SPSS v.17 trial version (IBM, NY, USA). RESULTS: The mean volume of blood drawn per day was 18.1 (SD ± 14.4) ml and the number of blood tests was 3.8 (SD ± 1.75) per day. On univariate linear regression analysis both the blood volume drawn daily (p = 0.04) and the number of blood tests per day (p = 0.009) correlated with a drop in mean haemoglobin concentration. The difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality (p = 0.03). The sensitivity of admission haemoglobin equal to 10.6 g/dL in predicting mortality was 82.4% with a specificity of 50%, (p = 0.019, AUC = 0.732). CONCLUSIONS: We evidenced the predictive power of blood sampling and number of blood tests done on haemoglobin concentration. Besides the main objective of the study we noticed that the difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality. Considering that blood sampling contributes to anemia among ICU patients, we should limit the daily tests undertaken, to the tests absolutely necessary for guiding our therapy.

Plasma Neutrophil Gelatinase Associated Lipocalin (NGAL) - Early Biomarker for Acute Kidney Injury in Critically Ill Patients.

INTRODUCTION: NGAL (Neutrophil Gelatinase Associated Lipocalin) is a biomarker recently introduced into clinical practice for the early diagnosis of acute kidney injury (AKI). The aim of this study was to correlate the plasmatic NGAL value determined at admission with clinical progression and severity of AKI in critically ill patients. MATERIAL AND METHOD: Thirty two consecutive critically ill adult patients at risk of developing AKI (trauma, sepsis), admitted in Intensive Care Unit of the Clinical County Emergency Hospital Mures, between January to March 2015 were enrolled in the study. For each patient included in the study plasma NGAL levels were determined on admission, and these were correlated with the degree of AKI development (according to AKIN criteria) at 48 hours and 5 days post admission. The discriminatory power of NGAL, creatinine, creatinine clearance and corrected creatinine (depending on water balance) were determined using the ROC (receiver-operating characteristic) and likelihood ratios. RESULTS: ROC curve analysis showed a better discriminatory capacity in terms of early diagnosis of AKI for NGAL (AUC=0.81 for NGAL, AUC=0.59 for creatinine, AUC=0.62 for corrected creatinine, AUC=0.29 for creatinine clearance). The value of likelihood ratio was also significantly higher for NGAL (3.01±2.73 for NGAL, 1.27±1.14 for creatinine, 1.78±1.81 for corrected creatinine, and 0.48±0.33 for creatinine clearance). CONCLUSIONS: NGAL biomarker has a better discrimination capacity for early prediction of acute kidney injury compared to previously used markers.