GDF15 ameliorates sepsis-induced lung injury via AMPK-mediated inhibition of glycolysis in alveolar macrophage.

Growth differentiation factor 15 (GDF15) as a stress response cytokine is involved in the development and progression of several diseases associated with metabolic disorders. However, the regulatory role and the underlying mechanisms of GDF15 in sepsis remain poorly defined. Our study analyzed the levels of GDF15 and its correlations with the clinical prognosis of patients with sepsis. In vivo and in vitro models of sepsis were applied to elucidate the role and mechanisms of GDF15 in sepsis-associated lung injury. We observed strong correlations of plasma GDF15 levels with the levels of C-reactive protein (CRP), procalcitonin (PCT), lactate dehydrogenase (LDH), and lactate as well as Sequential Organ Failure Assessment (SOFA) scores in patients with sepsis. In the mouse model of lipopolysaccharide-induced sepsis, recombinant GDF15 inhibited the proinflammatory responses and alleviated lung tissue injury. In addition, GDF15 decreased the levels of cytokines produced by alveolar macrophages (AMs). The anti-inflammatory effect of glycolysis inhibitor 2-DG on AMs during sepsis was mediated by GDF15 via inducing the phosphorylation of the α-subunit of eukaryotic initiation factor 2 (eIF2α) and the expression of activating transcription factor 4 (ATF4). Furthermore, we explored the mechanism underlying the beneficial effects of GDF15 and found that GDF15 inhibited glycolysis and mitogen-activated protein kinases (MAPK)/nuclear factor-κB (NF-κB) signaling via promoting AMPK phosphorylation. This study demonstrated that GDF15 inhibited glycolysis and NF-κB/MAPKs signaling via activating AMP-activated protein kinase (AMPK), thereby alleviating the inflammatory responses of AMs and sepsis-associated lung injury. Our findings provided new insights into novel therapeutic strategies for treating sepsis.

Corticosteroid treatment in severe patients with SARS-CoV-2 and chronic HBV co-infection: a retrospective multicenter study.

BACKGROUND: The impact of corticosteroids on patients with severe coronavirus disease 2019 (COVID-19)/chronic hepatitis B virus (HBV) co-infection is currently unknown. We aimed to investigate the association of corticosteroids on these patients. METHODS: This retrospective multicenter study screened 5447 confirmed COVID-19 patients hospitalized between Jan 1, 2020 to Apr 18, 2020 in seven centers in China, where the prevalence of chronic HBV infection is moderate to high. Severe patients who had chronic HBV and acute SARS-cov-2 infection were potentially eligible. The diagnosis of chronic HBV infection was based on positive testing for hepatitis B surface antigen (HBsAg) or HBV DNA during hospitalization and a medical history of chronic HBV infection. Severe patients (meeting one of following criteria: respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 ≤ 93% on room air; or oxygen index < 300 mmHg) with COVID-19/HBV co-infection were identified. The bias of confounding variables on corticosteroids effects was minimized using multivariable logistic regression model and inverse probability of treatment weighting (IPTW) based on propensity score. RESULTS: The prevalence of HBV co-infection in COVID-19 patients was 4.1%. There were 105 patients with severe COVID-19/HBV co-infections (median age 62 years, 57.1% male). Fifty-five patients received corticosteroid treatment and 50 patients did not. In the multivariable analysis, corticosteroid therapy (OR, 6.32, 95% CI 1.17-34.24, P = 0.033) was identified as an independent risk factor for 28-day mortality. With IPTW analysis, corticosteroid treatment was associated with delayed SARS-CoV-2 viral RNA clearance (OR, 2.95, 95% CI 1.63-5.32, P < 0.001), increased risk of 28-day and in-hospital mortality (OR, 4.90, 95% CI 1.68-14.28, P = 0.004; OR, 5.64, 95% CI 1.95-16.30, P = 0.001, respectively), and acute liver injury (OR, 4.50, 95% CI 2.57-7.85, P < 0.001). Methylprednisolone dose per day and cumulative dose in non-survivors were significantly higher than in survivors. CONCLUSIONS: In patients with severe COVID-19/HBV co-infection, corticosteroid treatment may be associated with increased risk of 28-day and in-hospital mortality.

Risk factors for severe COVID-19 in middle-aged patients without comorbidities: a multicentre retrospective study.

BACKGROUND: Information regarding characteristics and risk factors of COVID-19 amongst middle-aged (40-59 years) patients without comorbidities is scarce. METHODS: We therefore conducted this multicentre retrospective study and collected data of middle-aged COVID-19 patients without comorbidities at admission from three designated hospitals in China. RESULTS: Among 119 middle-aged patients without comorbidities, 18 (15.1%) developed into severe illness and 5 (3.9%) died in hospital. ARDS (26, 21.8%) and elevated D-dimer (36, 31.3%) were the most common complications, while other organ complications were relatively rare. Multivariable regression showed increasing odds of severe illness associated with neutrophil to lymphocyte ratio (NLR, OR, 11.238; 95% CI 1.110-1.382; p < 0.001) and D-dimer greater than 1 µg/ml (OR, 16.079; 95% CI 3.162-81.775; p = 0.001) on admission. The AUCs for the NLR, D-dimer greater than 1 µg/ml and combined NLR and D-dimer index were 0.862 (95% CI, 0.751-0.973), 0.800 (95% CI 0.684-0.915) and 0.916 (95% CI, 0.855-0.977), respectively. SOFA yielded an AUC of 0.750 (95% CI 0.602-0.987). There was significant difference in the AUC between SOFA and combined index (z = 2.574, p = 0.010). CONCLUSIONS: More attention should be paid to the monitoring and early treatment of respiratory and coagulation abnormalities in middle-aged COVID-19 patients without comorbidities. In addition, the combined NLR and D-dimer higher than 1 µg/ml index might be a potential and reliable predictor for the incidence of severe illness in this specific patient with COVID-19, which could guide clinicians on early classification and management of patients, thereby relieving the shortage of medical resource. However, it is warranted to validate the reliability of the predictor in larger sample COVID-19 patients.

[Angiotensin II induces expression of inflammatory mediators in vascular adventitial fibroblasts].

Vascular adventitial fibroblasts (AF) may play an important role in vascular inflammation. This study was aimed to investigate the expression pattern of inflammatory mediators in AF induced by angiotensin II (AngII) and to explore the effects of AF-derived inflammatory mediators on the adhesion and migration of macrophages both in vitro and in vivo. We used real-time RT-PCR to detect the mRNA expression of inflammatory mediators in cultured AF. The results showed that AngII (1 × 10(-7) mol/L) up-regulated mRNA expression of 4 inflammatory mediators, including P-selectin, ICAM-1, IL-6 and MCP-1, in cultured AF. Western blot analysis or ELISA revealed that AngII up-regulated P-selectin and ICAM-1 protein expression and IL-6 secretion in cultured AF, but did not alter MCP-1 secretion. We further detected the effects of AF-derived inflammatory mediators on the adhesion and chemotaxis of RAW264.7, a macrophage cell line. We found that AF stimulated with AngII could enhance the adhesion of RAW264.7 and the conditioned medium from AngII-stimulated AF could enhance the migration of RAW264.7. Immunofluorescence study showed an enhanced accumulation of CD68 positive cells and the up-regulation of P-selectin, ICAM-1, IL-6 and MCP-1 in aortic adventitia of AngII-infused (200 ng/kg per min for 2 weeks) rats. We concluded that AF may contribute to vascular inflammation via expression of certain inflammatory mediators and the subsequent adhesion and chemotaxis of macrophages.

RhoA-Rho kinase signaling pathway mediates adventitial fibroblasts differentiation to myofibroblasts induced by TGF-ß1.

Vascular adventitial fibroblasts (AF) differentiation to myofibroblasts (MF) is the critical physiopathologic feature of vascular remodeling. This study was to investigate the role of RhoA-Rho kinase signaling pathway in AF differentiation to MF induced by transforming growth factor ß1 (TGF-ß1). The results showed that TGF-ß1 up-regulated total RhoA protein expression and RhoA activity in cultured AF by Western blotting and Rho pull-down assay, respectively. TGF-ß1 up-regulated phospho-Myosin phosphatase target subunit (MYPT1, a downstream substrate of Rho kinase) expression without altering Rho kinase protein expression, indicating TGF-ß1 induced the enhancement of activity of Rho kinase. Ad-N19RhoA-hrGFP virus infection and Y27632, a specific inhibitor of Rho kinase, dose-dependently inhibited TGF-ß1-induced α-SM-actin and Calponin expression, as markers of MF differentiation. In conclusion, the RhoA-Rho kinase pathway is involved in AF differentiation to MF induced by TGF-ß1.

[Clinical features and risk factors for secondary hemophagocytic lymphohistiocytosis in elderly patients with severe SARS-CoV-2 infection: a multicenter retrospective cohort study].

OBJECTIVE: To explore the incidence of secondary hemophagocytic lymphohistiocytosis (sHLH) in elderly patients with severe SARS-CoV-2 infection, and to analyze and summarize its clinical features and risk factors for early identification of high-risk groups. METHODS: A retrospective cohort study was conducted. From January to May 2020, No. 960 Hospital of People's Liberation Army, the Second Hospital Affiliated to Cheeloo College of Medicine of Shandong Province, the First Rehabilitation Hospital of Shandong Province, the Public Health Clinical Center Affiliated to Shandong University, and Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine received 248 patients over 60 years old who were diagnosed with severe SARS-CoV-2 infection during their assistance to Hubei or support for diagnosis and treatment of SARS-CoV-2 infection in Shandong Province. The clinical data of patients were collected. According to the hemophagocytic lymphohistiocytosis diagnosis scoring (HScore) criteria, the patients were divided into sHLH group (HScore > 169) and non-sHLH group (HScore < 98). The demographic data, clinical features, laboratory results, the proportion of organ failure and 60-day mortality of patients were collected and compared between the two groups. The risk factors of sHLH and 60-day death were evaluated through binary multivariate Logistic regression analysis in elderly patients with severe SARS-CoV-2 infection. The receiver operator characteristic curve (ROC curve) was plotted to analyze the diagnostic value of indicators only or combined for sHLH. RESULTS: Among 248 elderly patients with severe SARS-CoV-2 infection, 82 patients with incomplete data and untraceable clinical outcomes, and 35 patients with HScore of 98-169 were excluded. Finally, 131 patients were enrolled in the final follow-up and statistics, including 25 patients in the sHLH group and 106 patients in the non-sHLH group. Compared with the non-sHLH group, plasma albumin (ALB), hemoglobin (Hb), lymphocyte count (LYM), platelet count (PLT), fibrinogen (Fib) and prealbumin (PAB) in the sHLH group were significantly reduced, while alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), MB isoenzyme of creatine kinase (CK-MB), serum creatinine (SCr), C-reactive protein (CRP), D-dimer, ferritin (Fer), lactate dehydrogenase (LDH), procalcitonin (PCT), cardiac troponin I (cTnI), triglycerides (TG), interleukin-6 (IL-6), total bilirubin (TBil) were significantly higher. The fever and fatigue in the sHLH group were more severe than those in the non-sHLH group, and the patients in the sHLH group had higher rates of shock, acute kidney injury, liver dysfunction, and cardiac injury than the non-sHLH group. The 60-day mortality of patient in the sHLH group was significantly higher than that in the non-sHLH group [84.0% (21/25) vs. 40.6% (43/106), P < 0.01]. Binary multivariate Logistic regression analysis showed that high Fer [odds ratio (OR) = 0.997, 95% confidence interval (95%CI) was 0.996-0.998], D-dimer (OR = 0.960, 95%CI was 0.944-0.977), LDH (OR = 0.998, 95%CI was 0.997-0.999) and TG (OR = 0.706, 95%CI was 0.579-0.860) were independent risk factors for sHLH in elderly patients with severe SARS-CoV-2 infection (all P < 0.01), while elevated Fer (OR = 1.001, 95%CI was 1.001-1.002), LDH (OR = 1.004, 95%CI was 1.002-1.005) and D-dimer (OR = 1.036, 95%CI was 1.018-1.055) were independent risk factors for 60-day death of patients (all P < 0.01). The death risk of the sHLH patients was 7.692 times higher than that of the non-sHLH patients (OR = 7.692, 95%CI was 2.466-23.987, P = 0.000). ROC curve analysis showed that a three-composite-index composed of LDH, D-dimer and TG had good diagnostic value for sHLH in elderly patients with severe SARS-CoV-2 infection [area under the ROC curve (AUC) = 0.920, 95%CI was 0.866-0.973, P = 0.000]. CONCLUSIONS: Elderly patients with severe SARS-CoV-2 infection complicated by sHLH tend to be critically ill and have refractory status and worse prognosis. High Fer, LDH, D-dimer and TG are independent risk factors for sHLH, and are highly suggestive of poor outcome. The comprehensive index composed of LDH, D-dimer and TG has good diagnostic value, and can be used as an early screening tool for sHLH in elderly patients with severe SARS-CoV-2 infection.

Effectiveness of combining plasma exchange with continuous hemodiafiltration on acute Fatty liver of pregnancy complicated by multiple organ dysfunction.

Acute fatty liver of pregnancy (AFLP) is a rare disease of progressive hepatic insufficiency and secondary systemic complications that induce significant maternal risk. The application of combining plasma exchange (PE) and continuous hemodiafiltration (CHDF) is a novel concept for patients with AFLP. Since 2002, we have utilized the combination of PE with CHDF as adjunctive medical therapy for 11 AFLP patients with multiple organ dysfunction. Before PE and CHDF initiation, four patients had signs and symptoms of encephalopathy, four required ventilatory support, and all 11 were developing liver failure, significant renal compromise, and coagulopathy. PE combined with CHDF for patients was initiated a mean of 2 days postpartum (range, days 0-3). Daily or every other day PE combined with CHDF was undertaken on two to eight occasions for each of the 11 patients. Ten patients responded with composite clinical and laboratory improvement and were discharged to the ward, then cured and discharged from hospital; one patient died of septic shock. Average duration of hospitalization was 17 days (range, days 9-38) from time of admission to discharge; the average duration of intensive care unit was 10 days (range, days 4-23). No significant PE- and CHDF-related complications occurred. These results indicate that combing PE and CHDF in a series-parallel circuit is an effective and safe treatment for patients with severe AFLP. This finding may have important implications for the development of an effective treatment for patients with AFLP suffering multiple organ dysfunction.

[Adenovirus mediated N19RhoA gene transfer attenuates neointimal formation in rats after carotid artery balloon injury].

OBJECTIVE: To investigate the role of small G-protein RhoA in neointimal formation following rat carotid artery balloon injury and related mechanisms. METHODS: Male 3-4-month-old Sprague-Dawley rats were used in the present study (10 rats per group). Group A: control; Group B: carotid artery balloon injury; Group C: injury + Ad-CMV-eGFP + Pluronic F-127; Group D: injury + Ad-CMV-N19RhoA-eGFP + Pluronic F-127; Group E: non injury + Ad-CMV-eGFP + Pluronic F-127. Perivascular gene transfer of an adenovirus co-expressing N19RhoA was performed to rat carotid artery following balloon injury and the effect on neointimal formation and the expressions of PCNA and α-SM-actin examined. Rats were killed after 14 days. RESULTS: The protein expression of RhoA in group B was significantly higher than in group A (P = 0.001), and the positive cells rate of PCNA and α-SM-actin which were assessed by immunohistochemistry in group C (45.2% and 75.6%) was significantly higher than in group D (28.4% and 51.9%, all P < 0.01). The area of neointima was significantly smaller [(0.14 ± 0.08) mm(2) vs. (0.23 ± 0.10) mm(2), P < 0.01], the luminal area was significantly larger [(0.47 ± 0.11) mm(2) vs. (0.31 ± 0.06) mm(2), P < 0.01] in group D than in group C. CONCLUSION: Gene transfer of N19RhoA attenuates neointimal formation after balloon injury in rat carotid arteries possibly related to the modulating capacities of small G-protein RhoA on the proliferation, phenotypic differentiation and migration of vascular adventitial fibroblasts.

Pregnant outcomes of critically ill pregnant patients with pulmonary hypertension: A multicenter retrospective study.

Objective: To identify the pregnancy outcomes and risk factors of critically ill pulmonary hypertension (PH) patients with intensive care unit (ICU) admission. Methods: The multicenter, retrospective cohort study was performed on 60,306 parturients from January 2013 to December 2018 in China. Diagnosis of PH was based on the estimation of systolic pulmonary arterial pressure (sPAP) via echocardiography. Patients were stratified by sPAP into three groups, mild (30-50 mmHg), moderate (51-70 mmHg), and severe (>70 mmHg). The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of in-hospital death, heart failure, and sustained arrhythmias requiring treatment. The secondary outcome was fetal adverse clinical events (FACE), a composite of fetal/neonatal death, prematurity, small birth weight, and fetal distress. Results: A total of 181 pregnant patients were enrolled, including 101 patients with mild PH, 31 with moderate PH, and 49 with severe PH. The maternal median age was 32 (27, 35) years and 37% were nulliparous. The MACE occurred in 59 (59/181, 32.6%) women, including in-hospital death in 13 (13/181, 7.2%), heart failure in 53 (53/181, 29.3%), and sustained arrhythmias in 7 (7/181, 3.9%). The incidence of FACE was as high as 66.3% (120/181). Compared with mild and moderate PH patients, patients with severe PH had a significantly higher mortality rate (22.4 vs. 1.51%, P < 0.001) and MACE incidence (51.0 vs. 25.8%, P = 0.001). Although the incidence of FACE in severe PH was slightly higher than that in mild to moderate PH, there was no significant difference (69.4 vs. 65.1%, P = 0.724). PH complicated with left heart disease (OR = 4.365, CI: 1.306-14.591), elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) level (OR = 1.051, CI:1.015-1.088), and sPAP level estimated by echocardiography (OR = 1.021; CI: 1.003-1.040) were independently associated with MACE in multivariable regression (P < 0.05). Increased risk of FACE was noted for PH patients combined with eclampsia/preeclampsia (OR = 6.713; CI: 1.806-24.959). Conclusion: The incidence of MACE and FACE remained high in critically ill pregnant patients with PH, particularly moderate and severe PH in China. Further studies are warranted to identify subsets of women with PH at lower pregnant risks and seek more effective therapy to improve pregnancy outcomes.

[The effects of joint administration of 6% hydroxyethyl starch 130/0.4 and high-volume hemofiltration on patients with acute lung injury and acute kidney injury].

OBJECTIVE: To evaluate the effects of administration of 6% hydroxyethyl starch (6% HES 130/0.4, voluven) in combination with high volume hemofiltration (HVHF) in patients with ALI and AKI. METHODS: One hundred and eight patients with acute lung injury (ALI) and acute kidney injury (AKI) were enrolled from Department of Intensive Care Unit (ICU) of the provincial Hospital Affiliated to Shandong University between August 2006 and May 2011. The patients were randomly divided into two groups A (n = 68) and B (n = 40) to receive voluven (i.v., for volume resuscitation) and voluven+HVHF for 72 hours. The arterial blood lactate concentration (Lac), high sensitivity C-reactive protein (hs-CRP) serum concentration, pulmonary function index alveolar-arterial oxygen pressure difference [P(A-a)DO2] and oxygenation index (OI), as well as kidney function index serum cystatin C (Cyst C) and serum creatinine clearance rate (CCr) were measured at the time of admission and 72 hours after the treatment for statistical analysis. RESULTS: In comparison with group A, group B had significantly (all P < 0.01) lower mean value in the level of arterial Lac (mmol/L: 1.7 ± 0.7 vs. 2.7 ± 1.5), serum hs-CRP (mg/L: 35.8 ± 18.8 vs. 99.5 ± 20.4), P(A-a)DO2 (mm Hg, 1 mm Hg=0.133 kPa: 115.5 ± 23.1 vs. 155.4 ± 27.4), Cyst C (mg/L: 2.06 ± 1.12 vs. 3.95 ± 2.06) and significantly higher (both P < 0.01) mean value of OI (mm Hg: 295.2 ± 38.8 vs. 239.5 ± 32.7) and CCr (ml/min: 108.71 ± 31.33 vs. 90.21 ± 30.35) 72 hours after treatment. The mortality rate of group B was significantly lower than group A [10.00%(4/40) vs. 29.41%(20/68), P < 0.05] 7 days after the admission. CONCLUSION: 6% HES 130/0.4 in combination with HVHF could improve the lung and kidney function of the patients with ALI and AKI, prevent the development of multiple organ dysfunction syndrome (MODS), therefore improve the survival rate of these patients.

Sex Differences on Clinical Characteristics, Severity, and Mortality in Adult Patients With COVID-19: A Multicentre Retrospective Study.

Background: Coronavirus disease-2019 (COVID-19) epidemic is spreading globally. Sex differences in the severity and mortality of COVID-19 emerged. This study aims to describe the impact of sex on outcomes in COVOD-19 with a special focus on the effect of estrogen. Methods: We performed a retrospective cohort study which included 413 patients (230 males and 183 females) with COVID-19 from three designated hospitals in China with a follow up time from January 31, 2020, to April 17, 2020. Women over 55 were considered as postmenopausal patients according to the previous epidemiological data from China. The interaction between age and sex on in-hospital mortality was determined through Cox regression analysis. In addition, multivariate Cox regression models were performed to explore risk factors associated with in-hospital mortality of COVID-19. Results: Age and sex had significant interaction for the in-hospital mortality (P < 0.001). Multivariate Cox regression showed that age (HR 1.041, 95% CI 1.009-1.073, P = 0.012), male sex (HR 2.033, 95% CI 1.007-2.098, P = 0.010), the interaction between age and sex (HR 1.118, 95% CI 1.003-1.232, P = 0.018), and comorbidities (HR 9.845, 95% CI 2.280-42.520, P = 0.002) were independently associated with in-hospital mortality of COVID-19 patients. In this multicentre study, female experienced a lower fatality for COVID-19 than male (4.4 vs. 10.0%, P = 0.031). Interestingly, stratification by age group revealed no difference in-hospital mortality was noted in women under 55 compared with women over 55 (3.8 vs. 5.2%, P = 0.144), as well as in women under 55 compared with the same age men (3.8 vs. 4.0%, P = 0.918). However, there was significantly difference in women over 55 with men of the same age group (5.2 vs. 21.0%, P = 0.007). Compared with male patients, female patients had higher lymphocyte (P < 0.001) and high-density lipoprotein (P < 0.001), lower high sensitive c reaction protein level (P < 0.001), and lower incidence rate of acute cardiac injury (6.6 vs. 13.5%, P = 0.022). Conclusion: Male sex is an independent risk factor for COVID-19 in-hospital mortality. Although female mortality in COVID-19 is lower than male, it might not be directly related to the effect of estrogen. Further study is warranted to identify the sex difference in COVID-19 and mechanisms involved.

[The role of p38 mitogen-activated protein kinase in interleukin-6 induction by lipopolysaccharide in vascular smooth muscle cells].

OBJECTIVE: To investigate the regulation mechanism of p38 mitogen-activated protein kinase (p38MAPK) in interleukin-6 (IL-6) expression of vascular smooth muscle cell (VSMC) induced by lipopolysaccharide (LPS). METHODS: Rat VSMCs were divided into LPS group, SB203580+LPS group, SB203580 group and control group. LPS group was treated with 100 microg/L LPS for 0, 3, 6, 12, 24 hours, SB203580+LPS group was first treated with 10 micromol/L SB203580 for 2 hours and then exposed to 100 microg/L LPS for 0, 3, 6, 12, 24 hours, SB203580 group was pretreated with 10 micromol/L SB203580 for 2 hours. The level of IL-6 mRNA was determined by real-time polymerase chain reaction (PCR) and IL-6 secretion in the culture medium was measured by enzyme linked immunosorbent assay (ELISA) at different time points. RESULTS: The expression of IL-6 mRNA and the release of IL-6 were increased significantly in VSMC as early as 3 hours after being treated with LPS [mRNA: (21.3+/-3.2)x10(4), protein: (296.2+/-19.6) ng/L], peaked in 12 hours [mRNA: (131.4+/-11.2)x10(4), protein: (897.7+/-34.0) ng/L], and the elevation persisted up to 24 hours after treatment [mRNA: (15.3+/-4.7)x10(4), protein: (194.3+/-24.0) ng/L] compared with control group [mRNA: (9.4+/-1.9)x10(4), protein: (29.4+/-4.4) ng/L, all P<0.05]. On the other hand, the expression of IL-6 was significantly suppressed by p38MAPK inhibitor SB203580 at 3, 6, 12 hours [mRNA: (15.4+/-3.6)x10(4), (43.2+/-6.6)x10(4), (56.2+/-5.5)x10(4), protein: (180.3+/-23.6), (432.2+/-56.8), (546.2+/-57.9) ng/L, all P<0.05]. CONCLUSION: The release of IL-6 and the expression of IL-6 mRNA was increased significantly in LPS-challenged VSMC; however, the induction of IL-6 was significantly suppressed by p38MAPK inhibitor. p38MAPK may play an important role in the release of IL-6 induced by LPS.

A retrospective study of risk factors for severe acute respiratory syndrome coronavirus 2 infections in hospitalized adult patients.

INTRODUCTION: Coronavirus disease 2019 (COVID­19) caused by severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) infection spread worldwide. OBJECTIVES: The aim of the study was to identify the clinical characteristics and risk factors associated with severe incidence of SARS ­CoV­2 infection. PATIENTS AND METHODS: All adult patients (median [IQR] age, 52 [37-58] years) consecutively admitted to the Dabieshan Medical Center from January 30, 2020 to February 11, 2020 were collected and reviewed. Only patients diagnosed with COVID­19  according to the World Health Organization interim guidance were included in this retrospective cohort study. RESULTS: A total of 108 patients with COVID­19 were retrospectively analyzed. Twenty­five patients (23.1%) developed severe disease, and of those 12 patients (48%) died. Advanced age, comorbidities (most commonly hypertension), higher blood leukocyte count, neutrophil count, higher C­reactive protein level, D­dimer level, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Sequential Organ Failure Assessment (SOFA) score were associated with greater risk of COVID­19, and so were lower lymphocyte count and albumin level. Multivariable regress ion showed increasing odds of severe COVID­19 associated with higher SOFA score (odds ratio [OR], 2.45; 95% CI, 1.302-4.608; P = 0.005), and lymphocyte count less than 0.8 × 109/l (OR, 9.017; 95% CI, 2.808-28.857; P <0.001) on admission. Higher SOFA score (OR, 2.402; 95% CI, 1.313-4.395; P = 0.004) on admission was identified as risk factor for in­hospital death. CONCLUSIONS: Lymphocytopenia and a higher SOFA score on admission could help clinicians to identify patients at high risk for developing severe COVID­19. More related studies are needed in the future.

Perivascular gene transfer of dominant-negative N19RhoA attenuates neointimal formation via inhibition of TGF-beta1-Smad2 signaling in rats after carotid artery balloon injury.

Phenotypic differentiation of adventitial fibroblasts to myofibroblasts is an essential feature of vascular remodeling. Here, we carried out perivascular gene transfer of dominant-negative N19RhoA to investigate whether antagonism of RhoA signaling attenuates neointimal formation following rat carotid artery balloon injury and alters TGF-beta1-Smad2-induced differentiation of adventitial fibroblasts to myofibroblasts. Perivascular delivery of an adenovirus coexpressing dominant-negative N19RhoA and humanized Renilla green fluorescent protein (hrGFP) (Ad-N19RhoA-hrGFP), as demonstrated by hrGFP staining, suppressed neointimal formation at 7 and 14days post-injury. Ad-N19RhoA-hrGFP administration inhibited neointimal alpha-smooth muscle-actin and Calponin expression, as markers of myofibroblast differentiation and perivascular collagen deposition, at 14days after balloon injury. Ad-N19RhoA-hrGFP administration also inhibited adventitial Smad2 phosphorylation, but did not alter local TGF-beta1 and total-Smad2 expression after injury. Our results provide evidence that perivascular gene transfer of dominant-negative N19RhoA blocks TGF-beta1-Smad2-induced differentiation of adventitial fibroblasts to myofibroblasts, which contributes to intimal hyperplasia after balloon injury.

[Study the effects of high-volume hemofiltration and fluid resuscitation on removing blood lactic acid and pro-inflammatory cytokines in patients with refractory septic shock].

OBJECTIVE: To evaluate the effects of high-volume hemofiltration (HVHF) and fluid resuscitation on the levels of arterial lactate and inflammatory cytokines, the acute physiology and chronic health evaluation II (APACHE II) score, and sepsis-related organ failure assessment (SOFA) score in patients with refractory septic shock and multiple organ dysfunction syndrome (MODS). METHODS: Eighty-nine patients with refractory septic shock and MODS undergoing HVHF, fluid resuscitation were included in the trial, and they were randomly divided into fluid resuscitation group (group A, 41 cases) and HVHF and fluid resuscitation group (group B, 48 cases). The changes in arterial lactate, lactate clearance rate, interleukin-6 (IL-6), procalcitonin (PCT), high sensitivity C-reactive protein (hs-CRP), APACHE II score and SOFA score in patients with refractory septic shock and MODS were determined before and after the treatment. RESULTS: (1) The arterial lactate clearance rate after treatment in both groups was elevated gradually. The level of lactate clearance rate in group B at 6, 12, 24 hours [(18.8+/-10.3)%, (31.6+/-11.4)%, (39.2+/-16.4)%] were higher than that of group A, respectively [(10.7+/-7.5)%, (14.7+/-10.3)%, (16.5+/-10.2)%, P < 0.05 or P < 0.01]. (2) The levels of pro-inflammatory cytokine IL-6, PCT and hs-CRP were reduced gradually after treatment in both groups. After treatment, the serum concentration of IL-6, PCT and hs-CRP levels in group B were reduced significantly more than that in group A at 1 day and 3 days (P < 0.05 or P < 0.01). (3) The APACHE II and SOFA scores in both groups were reduced gradually on 3 days and 7 days after treatment, but the APACHE II and SOFA scores on 7 days in group B were lower compared with group A (P < 0.05 and P < 0.01). CONCLUSION: HVHF and fluid resuscitation could reduce arterial lactate and cytokines contents, at the same time lower the APACHE II score and SOFA score in patients with refractory septic shock and MODS, thus it could improve the survival rate of MODS patients.

[Incidence and mortality risk factors of acute kidney injury in critical ill pregnancies: a single center retrospective analysis].

OBJECTIVE: To evaluate the incidence and mortality risk factors of pregnancy-related acute kidney injury (PR-AKI) in intensive care unit (ICU). METHODS: A retrospective analysis was conducted. Critically ill pregnancies admitted to ICU of Shandong University Affiliated Provincial Hospital from January 1st, 2012 to December 31st, 2016 were enrolled. Based on the Kidney Disease: Improving Global Outcomes (KDIGO)-acute kidney injury (AKI) criteria, patients were divided into two groups: PR-AKI group and non-PR-AKI group. Clinical characteristics and laboratory data of two groups were compared. Risk factors of incidence and mortality of PR-AKI patients were analyzed, and the receiver operating characteristic (ROC) curve was drawn to evaluate the value of these risk factors in predicting mortality of PR-AKI patients in ICU. RESULTS: (1) A total of 219 pregnancies in ICU were included in the analysis, 85 cases (38.8%) were diagnosed with PR-AKI, with 29.4% in AKI stage 1, 27.1% in AKI stage 2 and 43.5% in AKI stage 3. (2) Nineteen of 219 critically ill pregnancies died in ICU, the total ICU mortality was 8.7%. The mortality of PR-AKI group was higher than non-PR-AKI group (16.5% vs. 3.7%, P = 0.003). The mortality was worsened with increasing severity of AKI (4.0% for AKI stage 1, 4.3% for AKI stage 2, 32.4% for AKI stage 3). (3) Acute fatty liver of pregnancy (AFLP) and lactate (Lac) were the independent risk factors for PR-AKI [AFLP: odds ratio (OR) = 6.081, 95% confidence interval (95%CI) was 1.587-23.308, P = 0.008; Lac: OR = 1.460, 95%CI was 1.078-1.977, P = 0.014]. (4) Age, Lac, acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) were the independent risk factors associated with the mortality of PR-AKI patients in ICU (age: OR = 1.130, 95%CI was 1.022-1.249, P = 0.017; Lac: OR = 1.198, 95%CI was 1.009-2.421, P = 0.039; APACHE II: OR = 1.211, 95%CI was 1.102-1.330, P < 0.001; SOFA: OR = 1.411, 95%CI was 1.193-1.669, P < 0.001). (5) ROC curve analysis showed that age, Lac, APACHE II score and SOFA score all had good predictive values for in-hospital mortality among PR-AKI patients in ICU, the cut-off value was 29 years old, 3.8 mmol/L, 16 and 8, respectively, and the AUC was 0.751, 0.757, 0.892 and 0.919, respectively (all P < 0.01). CONCLUSIONS: The incidence and mortality of PR-AKI of critically ill pregnancies in ICU are high. Increased age, Lac, APACHE II score and SOFA score are independent risk factors associated with the mortality of PR-AKI patients in ICU, and have good predictive values for prognosis.

The Effects of High-volume Hemofiltration by Different Ultrasound Directing on Extra Vascular Lung Water Index in Patients with Septic Shock.

BACKGROUND: We explored the effects of high-volume hemofiltration(HVHF) by different ultrasound directing on the plasma N-terminal pro-B-type natriuretic peptide(NT-Pro-BNP), extra vascular lung water index (EVLWI), liquid net balance quantity and prognosis in patients with septic shock. METHODS: Overall, 107 intensive patients with septic shock were enrolled by retrospective analysis from Department of Intensive Care Unit (ICU) of the Shandong Provincial Hospital affiliated to Shandong University from 2014-2017. According to HVHF by different ultrasound directing, all the patients were divided into two groups ((ultrasonic cardiac output monitor (USCOM), group A, n=51cases)) and ((critical bedside ultrasound (CBU), group B, n=56cases)). RESULTS: The value of CI in group A had a significant positive correlation with the value of PCCI by the PiCCO2 monitoring (P<0.05). The lung ultrasound water B lines in group B also had a significant positive correlation with the value of EVLWI by the PiCCO2 monitoring. The cumulative liquid net balance quantity in group B had a more significant elevation than group A after treatment 7th d. The level of EVLWI after treatment 48 h and 72 h, the level of plasma NT-Pro-BNP, the levels of P(A-a)DO2,OI and blood lactic after treatment 72 h, and the APACHE II scores and SOFA scores after treatment 7thd were reduced more significantly in group B than group A (P<0.001). The mortality at 28th day had a more significant decrease in group B than group A. CONCLUSION: It could decrease the level of NT-Pro-BNP, EVLWI, P(A-a)DO2, which then improves pulmonary oxygenation. Consequently, it decreased the APACHE II and SOFA scores and improved the 28th survival rate of patients.

Red blood cell distribution width as a risk factor for inhospital mortality in obstetric patients admitted to an intensive care unit: a single centre retrospective cohort study.

BACKGROUND: Red blood cell distribution width (RDW) has been shown to predict mortality in critically ill patients. To our knowledge, whether or not RDW is associated with clinical outcomes of obstetric patients requiring critical care has not been evaluated. METHODS: This was a single centre, retrospective, observational study of obstetric patients admitted to the intensive care unit (ICU). Patients were excluded from the analysis if they had known haematological diseases or recently underwent blood transfusion. Patients who died or were discharged from the ICU within 24 hours of admission were also excluded. Patient clinical characteristics at ICU admission were retrieved from the medical charts. Multiple logistic regression was used to estimate OR and 95% CI for inhospital mortality associated with RDW. The receiver operating characteristic curve was used to examine the performance of RDW, alone or in combination with the Acute Physiology and Chronic Health Evaluation II score (APACHE II), in predicting inhospital mortality. RESULTS: A total of 376 patients were included in the study. The hospital mortality rate was 5.32%. A significant association was found between baseline RDW levels and hospital mortality (OR per per cent increase in RDW, 1.31; 95% CI 1.15 to 1.49). Further adjustment for haematocrit and other potential confounders did not appreciably alter the result (p<0.001). The area under the curve (AUC) for inhospital mortality based on RDW was similar to that based on the APACHE II score (0.752 vs 0.766). A combination of these two factors resulted in substantial improvement in risk prediction, with an AUC value of 0.872 (p<0.001). CONCLUSIONS: The study suggests that RDW is an independent predictor for inhospital mortality among ICU admitted obstetric patients. Combining RDW and APACHE II score could significantly improve inhospital prognostic prediction among these critically ill obstetric patients.

Effects of atorvastatin combined with low-molecular-weight heparin on plasma inflammatory cytokine level and pulmonary pathophysiology of rats with sepsis.

The aim of the present study was to investigate the effect of atorvastatin combined with low-molecular-weight heparin (LMWH) on plasma early inflammatory cytokine levels as well as pulmonary pathophysiology of rats with sepsis. A total of 122 rats were randomly divided into five groups including the sham operation group (n=10), CLP group (n=10), atorvastatin group (n=34, 20 mg/kg/day), LMWH group (n=34, 100 IU/kg/day), and atorvastatin combined with LMWH group (n=34). Blood samples from 6 rats in each group were collected to detect TNF-α, IL-1ß and HMGB1 concentration in plasma by linked immunosorbent assay at baseline and postoperatively at 4, 8, 12 and 24 h. Pulmonary pathophysiology was observed postoperatively at 24 h. The remaining 10 rats in each group were used to calculate the 7-day cumulative mortality rate. Compared to the sham operation group, the scores in CLP were greater than those of the sham operation group (P<0.05). Compared to the CLP group, the sepsis severity scores of the atorvastatin, LMWH, and atorvastatin combined with LMWH groups decreased gradually. Significant difference was detected in the four groups (P<0.05 0.01). Compared to the sham operation group, at 4, 8, 12 and 24 h, the TNF-α, IL-1ß and HMGB1 levels in plasma in CLP increased significantly (P<0.01). Compared to the CLP group, the TNF-α, IL-1ß and HMGB1 levels of plasma in other groups decreased gradually, and there was a significant difference in the four groups (P<0.01). At 24 h post operation, compared to the sham operation group, the damage of pulmonary pathophysiology in CLP was more severe. Compared to the CLP group, the damage of pulmonary pathophysiology in other groups was slight. Compared to the CLP group, the 7-day cumulative mortality rate in other groups decreased significantly (P<0.05). In conclusion, atorvastatin, combined with LMWH can decrease sepsis severity, plasma inflammatory cytokine levels, pulmonary pathophysiology, and the 7-day cumulative mortality rate. Atorvastatin, and LMWH may therefore be useful for the treatment of sepsis due to its ability to inhibit the release of TNF-α, IL-1ß and HMGB1 in septic rats.

[Protective effects of combined use of atorvastatin and low molecular weight heparin on the inflammatory reaction and pulmonary functions in rats with sepsis].

Objective: To investigate the influence of combined use of atorvastatin (ATO) and low molecular weight heparin (LMWH) on the inflammatory reaction and pulmonary protection functions in rats with sepsis. Methods: A total of 122 healthy male Sprague-Dawley (SD) rats were divided into five groups using a random number table: sham-operated group (sham group, n =10),sepsis group (n =10),ATO group (n =34),LMWH group (n =34),and ATO combined with LMWH group (ATO+LMWH group, n =34).The rat model of sepsis was reproduced by cecal ligation and puncture (CLP),while in sham group, rats were only subjected to laparotomy without cecum ligation and puncture. The rats of each pretreatment group received relevant therapies for 5 days, either gastric perfusion with ATO 20 mg/kg or subcutaneous injection with LMWH 100 U/kg or both before operation. The sepsis severities of the model animals were scored according to the modified sepsis severity assessment standards of experimental animals. Ten rats in each group were calculated the 7-day cumulative mortality rate. Blood samples from 6 rats in each group were collected to determine the levels of tumor necrosis factor-α (TNF-α),interleukin-1 ß (IL-1 ß) and high mobility group protein box-1 (HMGB1) contents in plasma using enzyme linked immunosorbent assay (ELISA)before operation (0 hour) and 4,8,12,and 24 hours post operation. The lung tissue was harvested 24 hours after operation, and the pulmonary pathology was assayed by hematoxylin and eosin (HE) staining using optical microscope. Results: ① The sepsis severity grades of sepsis group were significantly higher than those of sham group at 4 hours after operation (score:12.2 ± 2.0 vs.7.2 ± 0.5,P ＜ 0.05).Furthermore, they displayed a gradually increasing tendency, with the 7-day cumulative mortality rate being 90％ (9/10).The sepsis severity grades in ATO group, LMWH group, and ATO+LMWH group showed a significant decrease compared with sepsis group at 8 hours after operation (12.2± 2.0,11.2±2.2,10.0± 1.7 vs.16.6±2.5,all P ＜ 0.05).The 7-day cumulative mortality rates in ATO group, LMWH group, and ATO+LMWH group were 60％ (6/10),60％ (6/10),and 40％ (4/10),respectively, all of which was significantly lower than that of sepsis group (all P ＜ 0.05).② The levels of TNF-α,IL-1 ß and HMGB1 have not shown much variations in the sham group after operation; the levels of pro-inflammatory cytokines in other 4 groups were significantly increased after operation compared with those before operation; the levels of TNF-α,IL-1ß,and HMGB 1 reached peak at 4,8,and 24 hours, respectively. The levels of pro-inflammatory cytokines in sepsis group were significantly higher than those in the sham group. However, the levels of pro-inflammatory cytokines in ATO group, LMWH group, and ATO+LMWH group were significantly lower than those in sepsis group [4-hour TNF-α (ng/L):668.3 ± 124.6,536.5 ± 118.5,496.5 ± 108.5 vs.783.8 ± 134.7;8-hour IL-1 ß (ng/L):2 476.7 ± 137.8,2 460.4± 171.2,2 090.0 ± 151.2 vs.2 873.9 ± 295.6;24-hour HMGB1 (µg/L):654.4± 154.4,659.0± 134.6,609.4±90.5 vs.859.3 ± 167.5,P ＜ 0.05 or P ＜ 0.01].③ It was showed by optical microscopy that the pulmonary tissue morphology was normal in sham group and that the damage of pulmonary pathology was relatively severe in sepsis group. Compared with sepsis group, the damage of pulmonary pathology in ATO group, LMWH group, and ATO + LMWH group was alleviated obviously, and the most obvious improvements were found in ATO + LMWH group. Conclusions: Either ATO or LMWH could decrease sepsis severity, suppress the release of plasma pro-inflammatory cytokines at the early and late stages, alleviate the damage of pulmonary pathology, and reduce the 7-day cumulative mortality rate. Therefore, the combined treatment of sepsis using both ATO and LMWH resulted in better outcomes than implemented individually.