The association between on-scene blood pressure and early neurological deterioration in patients with spontaneous intracerebral haemorrhage.

OBJECTIVE: To determine whether on-scene BP is associated with early neurological deterioration (END) in patients with spontaneous intracerebral haemorrhage (SICH). METHODS: This retrospective cohort study enrolled consecutive ambulance-transported adult SICH patients treated at our emergency department (ED) from January 2007 through December 2012. END was defined as a ≥2-point decrease in GCS within 24 h of ED arrival. The exact relationship between on-scene BP and END was assessed using multiple logistic regression analyses for adjusting age, gender, Charlson Index, aspirin use, smoking, elapsed time, consciousness level on ED arrival, haematoma size, intraventricular extension, midline shift and infratentorial ICH. We further calculated the -2 log-likelihood decrease for each regression model incorporated with the BP values measured at different times to compare model fitness. RESULTS: After adjusting for the covariates, on-scene systolic BP (by 10 mm Hg incremental: OR = 1.126, 95% CI 1.015 to 1.265), diastolic BP (by 10 mm Hg incremental: OR=1.146, 95% CI 1.019 to 1.303) and mean arterial pressure (MAP) (by 10 mm Hg incremental: OR=1.225, 95% CI 1.057 to 1.443) were significantly associated with END; adding on-scene MAP into the regression model yielded the highest model fitness increase. Adding on-scene BPs into the regression model yielded higher model fitness increase than adding ED and admission BPs. CONCLUSIONS: Few on-scene BP indices were associated with neuroworsening within 24 h after ED arrival in non-comatose SICH patients. Compared with BP measured on ED arrival or admission, on-scene BP had a stronger correlation with END.

How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia.

OBJECTS: The purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED). METHOD: We retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT. RESULTS: The mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007). CONCLUSION: Abdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.

The role of autonomic nervous system function in hypothermia-mediated sepsis protection.

OBJECTIVE: The objective of this study is to determine whether hypothermia will lessen decreases in heart rate variability and improve outcome in a rat model of sepsis. METHODS: Thirty-six male Sprague-Dawley rats were randomized into 3 groups: control, low sepsis, and high sepsis groups. These groups were each subdivided into a normothermia (37°C) (n = 6) and a hypothermia group (34°C) (n = 6). Cyclophosphamide (100 mg/kg) was administered 5 days before Staphylococcus aureus injection to produce conditions in which sepsis could be induced reliably. Hypothermic rats received temperature reduction for 1 hour post injection. Electrocardiogram was recorded before, after, and 1 day after staphylococcal injection, and the low frequency, high frequency (HF), and LF/HF ratio measurements of heart rate variability and the frequencies of arrhythmia were recorded. The effects of time, sepsis severity, and hypothermia on these variables were analyzed using a multivariate generalized estimation equation mode. RESULTS: Four deaths occurred in the normothermic group, and none, in the hypothermic group. Sepsis of both low and high severity increased low frequency and HF 1 day after sepsis induction. Hypothermia significantly decreased HF in low, but not high sepsis severity. CONCLUSIONS: Hypothermia decreased mortality in septic rats. The influence of hypothermia on HF depended on the severity of the sepsis.

An unusual case of silent acute ST-elevation myocardial infarction following amphetamine use.

We report a case of silent acute ST-elevation myocardial infarction associated with amphetamine use in a 62 years old diabetic man. The patient was devoid of chest pain and had a normal cardiac enzyme analysis at the initial presentation. A routine electrocardiogram demonstrated acute inferior wall ST-elevation myocardial infarction. Coronary angiography confirmed a total occlusion of the posterior lateral branch of right coronary artery. The patient underwent successful percutaneous transluminal coronary angioplasty with stent placement. Amphetamine abuse may play a role in acute myocardial infarction. Adverse cardiovascular manifestations of amphetamine can occur with sudden overt chest pain or present insidiously. In view of the potential association of amphetamine and myocardial infarction, physicians should not rely only upon clinical symptoms. This report highlights the diabetic patients with amphetamine abuse should undergo a routine electrocardiogram in such circumstances.

Magnolol attenuates the lung injury in hypertonic saline treatment from mesenteric ischemia reperfusion through diminishing iNOS.

BACKGROUND: Hypertonic saline (HTS) administration can decrease the inflammation following ischemia reperfusion. Magnolol is a potent antioxidant. The present study investigated whether combined treatment of magnolol and HTS could provide further protection in mesenteric ischemia reperfusion injury. METHODS: Male C3H/HeOuJ mice were randomly segregated into the following groups: sham-operated (sham), vehicle treatment and mesenteric ischemia reperfusion (MSIR) (vehicle-treated), magnolol treatment and MSIR (magnolol-treated), HTS treatment and MSIR (HTS-treated), as well as co-administration of magnolol plus HTS and MSIR (combined-treated). In MSIR, mice were subjected to mesenteric ischemia for 60 min followed by reperfusion for 30 min. Lung injury was evaluated by lung edema (water ratio) and myeloperoxide (MPO) activity; RNA expression of inducible nitric oxide synthetase (iNOS), TNF-α, and IL-6 were assayed by real time RT-PCR. The formation of peroxynitrite in plasma was assayed by the peroxynitrite-dependent oxidation of dihydrorhodamine 123 (DHR 123) to rhodamine. RESULTS: Compared with those in the sham-treated group, lung edema and MPO activity, expressions of iNOS, TNF-α and IL-6, and plasma peroxynitrite were significantly increased in the vehicle-treated group. Significant attenuations of these parameters were found in the magnolol-treated or HTS-treated animals. Combined treatment of magnolol and HTS further suppressed the lung edema, iNOS, and TNF-α expressions, and plasma peroxynitrite, compared with the results of a single treatment of magnolol or HTS. CONCLUSIONS: Compared with single-agent use, co-administration of magnolol and HTS further decreases iNOS expression and plasma peroxynitrite as well as the degree of lung injury from MISR. These results may provide another treatment measure for post-injury immunomodulation.

Relation of signal in mononuclear cell with endotoxin response and clinical outcome after trauma.

BACKGROUND: We investigated the correlation of proinflammatory transcript nuclear factor κB (NF-κB) and antioxidative gene transcript nuclear factor-erythroid 2-related factor 2 (Nrf2) expressions in peripheral blood mononuclear cells (PBMCs) with the tumor necrosis factor α (TNF-α) response after endotoxin stimulation and the clinical outcome of severely injured patients. METHODS: Thirty-two severe blunt trauma patients (injury severity score>16) with systemic inflammatory response syndrome were enrolled. Age- and sex-matched healthy persons were the controls. Patients' blood samples were obtained at 24 and 72 hours after injury. Peripheral blood mononuclear cells were isolated, and measurements for NF-κB p65 translocation, Nrf2 and phosphorylated inhibitory κB-α expressions, and TNF-α levels were assayed after endotoxin stimulation. RESULTS: In the trauma patients, TNF-α hyporesponse, depressed NF-κB p65 translocation, and phosphorylated inhibitory κB-α expression in PBMCs were found at 24 and 72 hours after injury; the Nrf2 expressions in PBMCs were not significantly different between patients and controls. The TNF-α levels had significant correlation with the NF-κB translocation and the trend of negative correlation with Nrf2 expression. Fifteen patients had critical injury (injury severity score≥25). Patients with critical injury had a lower NF-κB signal and a lower TNF-α response than did the counter group. Twelve patients developed organ failure; their Nrf2 expressions were significantly lower than those of patients without organ failure. CONCLUSIONS: The endotoxin hyporesponse associated with NF-κB and Nrf2 signal alternations in PBMCs of injured patients develops early after injury. The hyporesponse of PBMCs with a lower TNF-α level correlates with a lower NF-κB signal and is associated with critical injury, whereas a depressed Nrf2 expression in PBMCs is associated with later organ failure in trauma patients.

The effects of lazaroid U-74389G in a rat sepsis model.

OBJECTIVE AND DESIGN: To examine the protective effects of a lazaroid, 21-aminosteroid U-74389G, in a rat septic shock model. MATERIALS OR SUBJECTS: Male Sprague-Dawley rats (n = 60) aged 6-8 months. TREATMENT: Groups were exposed to 500 cGy radiation followed by E. coli inoculation, and either placebo or lazaroid injection (10 mg/kg intraperitoneal) 5 days after irradiation. METHODS: Hemodynamic measurements, arterial blood gases, serum lactate, total antioxidative capacity, and cytokine levels were measured at specific time intervals. RESULTS: Treatment with the lazaroid U-74389G maintained cardiac output and mean aortic pressure. Lazaroid treatment also prevented the increase in serum lactate seen in placebo-treated rats. Cytokine serum levels in lazaroid-treated rats were not significantly different from those in placebo-treated rats at any time point. CONCLUSIONS: Lazaroid treatment of E. coli-inoculated septic animals lessens the hemodynamic deterioration seen in sepsis.

Persistently high serum carcinoembryonic antigen levels after surgery indicate poor prognosis in patients with stage I non-small-cell lung cancer.

BACKGROUND: The aim of this study is to evaluate the prognostic significance of preoperative and postoperative serum carcinoembryonic antigen (CEA) levels in patients with stage I non-small-cell lung cancer. MATERIAL AND METHODS: A retrospective review of the medical records of 257 patients with stage I lung cancer undergoing surgical resection was performed. The clinical data of each patient was collected for analysis including age, smoking habits, gender, preoperative and postoperative serum CEA levels, tumor diameter, histologic type, visceral pleural invasion, pathologic stage, and type of operation. RESULTS: Adenocarcinoma was more often associated with elevated preoperative CEA level compared with non-adenocarcinoma. Tumor histology, however, did not influence postoperative CEA levels. In the univariate analysis, age, serum CEA level, and pathologic stage were prognostic factors. Patients with normal preoperative serum CEA levels had better 5-y survival than patients with high preoperative serum CEA levels (71.1% versus 54.6%, P = 0.016). The patients with a persistently high serum CEA level after surgery had worst prognosis. Multivariate analysis demonstrated that older age (≥65) and persistently high serum CEA levels were independent significant prognostic factors in patients with stage I lung cancer. CONCLUSIONS: Age (≥65 years) and preoperative and postoperative serum CEA levels are independent prognostic factors in patients with stage I lung cancer. Patients with a persistently high serum CEA level after surgery had worst survival, and may be good candidates for adjuvant chemotherapy.

Spleen artery embolization aggravates endotoxin hyporesponse of peripheral blood mononuclear cells in patients with spleen injury.

BACKGROUND: : Spleen artery embolization (SAE) increases the success of nonoperative management of spleen injury; however, the immune alternation after SAE is unclear. This study searched the endotoxin responses of peripheral blood mononuclear cells (PBMCs) in injured patients who received SAE. METHODS: : Patients were subsequently enrolled when their spleen injuries were confirmed by computed tomographic scan. Peripheral blood samples were obtained within first, at third, fifth, and seventh postinjury days. PBMCs were isolated; nuclear factor (NF)-kB translocations, phosphorylated I-kB expressions, and in vitro tumor necrosis factor (TNF)-alpha levels were assayed after endotoxin stimulation (ES). RESULTS: : Sixteen patients who received nonoperative managements were enrolled. Five patients received SAE (embolized patients) and 11 patients did not (nonembolized patients). Compared with those in controls, NF-kB translocations, phosphorylated I-kB expressions, and TNF-alpha levels after ES decreased significantly early in injured patients. NF-kB translocation and TNF-alpha levels after ES were indifferent at seventh day between nonembolized patients and controls, whereas significantly lower NF-kB p65 translocation and TNF-alpha levels after ES were found at seventh postinjury day in embolized patients than in controls. Compared with nonembolized patients, embolized patients had significantly lower levels of NF-kBp50 translocations after ES from first to third postinjury days and lower levels of NF-kB p65 translocations, TNF-alpha, and phosphorylated I-kB expressions after ES from first to fifth postinjury days. CONCLUSIONS: : SAE dysregulates the NF-kB system and aggravates the cytokine hyporesponse upon ES of PBMCs in patients with spleen injury. These results implicate that SAE alters immune response and may increase susceptibility to infections in injured patients.

Effects of epinephrine on heart rate variability and cytokines in a rat sepsis model.

Catecholamines have both anti-inflammatory and vasoactive properties. A decreased cardiac response to catecholamines has been associated with a high risk of death in sepsis and septic shock. The aim of this study was to investigate the effects of epinephrine (EPI) on heart rate variability (HRV) and autonomic balance, as well as cytokine levels, in a rat sepsis model. Thirty-six male Sprague-Dawley rats were assigned to 4 experimental groups and 2 control groups of 6 rats each. The rats in the experimental groups were inoculated with a lipopolysaccharide (LPS, endotoxin) to establish a sepsis model. Group A received only LPS; group B received LPS, antecedent EPI and the nonselective ß-blocker propranolol; group C received LPS and antecedent EPI; and group D received LPS, antecedent EPI and the selective ß1-blocker esmolol. One control group received EPI and the other received saline placebo. Heart rate variability (HRV) was analyzed and tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and interleukin-1ß (IL-1ß) levels were measured. Measurements were carried out at baseline, at 0 hour after EPI infusion, and at 0.5, 2, and 4 hours after LPS inoculation. There were significant differences in HRV and cytokine levels between the groups, indicating that LPS infusion caused autonomic imbalance. Antecedent EPI significantly decreased the level of TNF-α in group C compared with group A in which TNF-α level peaked at 2 hours and then declined. Propranolol (group B) but not esmolol (group D) administration resulted in elevated TNF-α levels, comparable to those observed in group A. In conclusion, antecedent administration of EPI in a rat sepsis model inhibits the production of TNF-α possibly via the ß2-adrenoceptor.

Hemoperitoneum increases the incidence of bacterial translocation.

BACKGROUND/AIMS: Severe hemorrhage may induce bacterial translocation (BT) from the bowel. Presence of hemoperitoneum is supposed to further increase the incidence of BT. METHODOLOGY: Blood was drawn from the femoral artery of rats and hemoperitoneum was created by replacing the drawn blood. Rats were randomly segregated into 5 groups. Control group rats received a sham operation. Rats in groups 1 and 2 received mild hemorrhage (15mL blood/kg body weight withdrawn) with and without hemoperitoneum respectively. Rats in groups 3 and 4 received severe hemorrhage (25mL blood/kg body withdrawn) with and without hemoperitoneum respectively. Twenty-four hours after the above manipulation, mesentery lymph nodes, livers, spleens, and finally cecums were removed for bacterial cultures. RESULTS: Rats that received severe hemorrhage had a significantly higher incidence of BT, both in tissues and in individuals, than rats that received mild hemorrhage did. group 1 rats had a higher incidence of BT in tissues compared with group 2, although the difference in individuals was not significant. On the other hand, group 3 had a higher incidence of BT either in tissues or in individuals compared with group 4. Cecal populations of bacteria assessment showed that groups with hemoperitoneum had higher levels of bacteria in comparison with groups without hemoperitoneum. CONCLUSIONS: Severe hemorrhage in rats increases the incidence of BT and the incidence is even greater in the presence of hemoperitoneum.

Emergency department critical care unit for critically ill cardiovascular patients: An observation study.

BACKGROUND: We investigated an intensive care model for acute critically cardiovascular emergency patients in the emergency department (ED) as compared with those in the coronary care unit (CCU) after ED visits. METHODS: We performed a retrospective cohort analysis of patients with acute cardiovascular emergency admitted to the intensive care unit in the ED (EICU) or CCU from January 1, 2010 to March 31, 2011 in an university-affiliated medical center. All clinical characteristics or predictors possibly related to in-hospital mortality were documented, completed, and measured via electronic medical records review. The clinical independent variables with p < 0.1 in univariate analysis were further analyzed by using multiple logistic regression. Survival analysis of the predictors for hospital mortality was assessed by Kaplan-Meier survival curves. RESULTS: A total of 964 patients were recruited in this study. Of all patients, 328 were enrolled in the EICU group, whereas 636 were enrolled in the CCU group. Multiple regression analysis of both EICU and CCU mortality demonstrated that Acute Physiology and Chronic Health Evaluation II scores were common predictors of mortality in both groups of patients. Based on these scores, Kaplan-Meier survival curves showed no statistically significant differences of cumulative survival rates in both the 7-day and in-hospital survival between both groups. CONCLUSION: Our study demonstrated a feasible and qualified model of intensive care delivery accomplished by collaboration of emergency physicians and cardiologists for acute critically ill cardiovascular emergency patients after initial ED management. Our results suggest that an expanded multicenter study should be conducted to further test and confirm this intriguing model.

Analysis of the causes of surgery-related medical disputes in Taiwan: Need for acute care surgeons to improve quality of care.

BACKGROUND: This study investigated surgery-related medical disputes and analyzed disease etiologies and the main causes of disputes in order to identify key points for the purpose of improving the quality of surgical patient care in Taiwan. METHODS: Reports on all surgery-related cases appraised by the Taiwan Witness Examiner Committee of the Department of Health between 2004 and 2008 were reviewed retrospectively by three senior physicians from the emergency department who specialize in both trauma and emergency general surgery. The causes of the various medical disputes were categorized under the following descriptions: operation- or procedure-related complication, anesthesia complication, inappropriate management or decision, delayed diagnosis or misdiagnosis, and unsatisfactory result. RESULTS: A total of 154 cases were reviewed, of which 39 were trauma-related and 115 were disease-related. The two leading causes of disputes in this review were found to be operation- or procedure-related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications. Among these, 74 cases (48.1%) required the care of an acute care surgeon and 40 cases (26.0%) required emergency general surgery intervention. CONCLUSION: Surgery- or procedure-related complications and unsatisfactory treatment results constituted the major causes of medical disputes in Taiwan. The majority of these cases involved acute care surgery; thus, the establishment of an acute care surgery system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training.

Trends in computed tomography utilisation in the emergency department: A 5 year experience in an urban medical centre in northern Taiwan.

BACKGROUND: Steady increase in computed tomography (CT) utilisation in the ED was observed in countries such as the USA, Canada, China and Korea; however, limited empirical data are available regarding Taiwan. OBJECTIVE: The objective of the present study is to quantify and compare trends in CT utilisation in the ED over a 5 year period in a medical centre in Taiwan. METHODS: Electronic chart review was performed in a medical centre with an annual ED census of 80 000 patients. Subjects >20 years of age who underwent CT scans during ED visits from 1 January 2005 to 31 December 2009 were identified. RESULTS: Among the 333 673 adult ED visits, 43 635 received CT scans, with a utilisation rate of 131 per 1000. Within the 5 year span, patient volume increased by 7.7%, whereas CT utilisation increased by 42.7%. The rates of increase in patient volume and CT utilisation were 5.0% and 32.4% in non-trauma; 19.7% and 97.8% in trauma. CT scans were mostly performed on the head (47%), abdomen (36%), followed by chest (10%) and miscellaneous (7%). An increase of 168% in spinal CTs for trauma patients was observed. An increase in CT utilisation was found in all age groups with a proportionate increase with increasing age in both trauma and non-trauma. CONCLUSION: ED CT utilisation has increased at a rate far exceeding the growth in ED patient volume. This may be attributed to the improved utility of CT in diagnosing serious pathology, more diagnostic indications for CT, ready availability and the necessity for diagnostic certainty in the ED.

Prognostic factors for survival outcome after in-hospital cardiac arrest: An observational study of the oriental population in Taiwan.

BACKGROUND: In-hospital cardiac arrest (IHCA) is a catastrophic complication for patients while admitted in a medical institution. The outcome of IHCA remains poor, and understanding of the prognostic factors for survival outcome after IHCA is lacking, specifically in an oriental population. METHODS: A retrospective observational cohort study of 382 patients with IHCA who required resuscitation was conducted in an urban tertiary hospital in Taiwan. Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures. RESULTS: The incidence of IHCA was 3.25 per 1000 admissions. These patients had a mean age of 67.2 ± 21.7 years and were mostly men (66.5%). The rate of successful ROSC was 66%, and the rate of survival to hospital discharge was 11.8%. A stepwise decrease in ROSC was observed with additional resuscitation efforts. Independent predictors for survival to hospital discharge were being female, a resuscitation duration of <20 minutes, and no use of epinephrine during resuscitation. A 68% ROSC success rate and an 84% survival to discharge rate was recorded in patients receiving resuscitation for <30 minutes. Young patients seemed the most likely to benefit from longer resuscitation attempts (>30 minutes), as observed in survival to hospital discharge. CONCLUSION: Based on data from a single hospital registry in East Asia, a shorter duration of resuscitation was demonstrated to be a predictor of immediate survival with ROSC and survival to hospital discharge.

Spontaneous Intramural Intestinal Hemorrhage versus Acute Mesenteric Ischemia by CT Evaluation.

Objective The purpose of our study was to differentiate the imaging findings of patients with spontaneous intramural intestinal hemorrhage (SIIH) from those with acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department. Methods We retrospectively included 83 patients diagnosed with SIIH or AMI after abdominal CT. Results The mean ages of 30 SIIH patients and 53 AMI patients were 74.4±14.6 years and 75.8±11.2 years, respectively. Patients with SIIH had significantly thicker maximal intestinal wall thickening (14.8±3.9 vs. 10.9 ±4.1, p<0.001), a lower rate of ileum involvement (26.7% vs. 77.4%, p<0.001) and a higher rate of ascites (96.7% vs. 64.2%, p<0.001) compared with patients with AMI. Neither pneumatosis intestinalis (p<0.001) nor portomesenteric gas (p<0.01) were detected in SIIH patients but were observed in AMI patients. A receiver-operating characteristic (ROC) curve analysis showed that the optimal cut-off value for maximal intestinal wall thickening between groups was 10.4 mm and the area under the ROC curve between groups was 0.752 (p<0.0001). A multiple logistic regression analysis showed that the independent predictors of SIIH were non-involvement of the ileum (odds ratio, OR, 6.998; p=0.001), maximal intestinal wall thickening ≥10.4 mm (OR, 5.748; p=0.040) and ascites (OR, 13.348; p=0.023). The area under the ROC curve for the model was 0.854 (p<0.001). Conclusion The independent predictors of SIIH from AMI after abdominal CT in acute abdominal patients include non-involvement of the ileum, intestinal wall thickening ≥10.4 mm, and ascites.

The role of diagnostic algorithms in the management of blunt splenic injury.

BACKGROUND: Diagnostic algorithms for patients with blunt abdominal trauma have been in use since 1995. This study investigated the role of diagnostic algorithms in the management of adult patients with blunt splenic injury at our institution. METHODS: A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about injury severity, diagnostic methods, management and final outcomes were evaluated. Patients were separated into an early and late group according to the year that diagnostic algorithms were used (1990-1994 or 1995-1999). RESULTS: One hundred and twenty-one patients were enrolled. Initially, 71 patients had an operation (OP group), whereas 50 received non-operative management (NOM group). Patients in the OP versus NOM group had lower blood pressure and greater transfusion volumes in the emergency room, higher grade splenic injury, and a greater rate of intra-abdominal-related injury. NOM failed in 7 patients (14%). Early- versus late-group patients were less likely to have NOM and high grade splenic injury; however, the rate of NOM failure was not different between the early and late groups. CONCLUSION: Diagnostic algorithms using sonograms for screening provide an initial means of selecting patients for NOM. Patients with higher grades of splenic injury can then be managed non-operatively.

Expression profile of MicroRNAs in gram-negative bacterial sepsis.

Bacterial lipopolysaccharide (LPS) is an effective trigger of the inflammatory response during infection with gram-negative bacilli (GNB), which implicates the pathogenesis of sepsis and septic shock. MicroRNAs (miRNAs) are shown to have a significant role in the fine-tuning of toll-like receptor (TLR)-mediated inflammatory response. We profiled miRNA expression levels in peripheral leukocytes of GNB urosepsis patients and compared them with those of healthy controls. We further explored the regulatory mechanism of endotoxin-responsive miRNAs in TLR and cytokine signaling by using human monocytic cell line (THP-1 cells) treated with LPS antigen stimulation. The expression of two miRNAs, that is, let-7a (P < 0.001) and miR-150 (P < 0.001), were confirmed to be significantly downregulated in GNB urosepsis patients compared with healthy controls. The expression of let-7a is first to be identified as a biomarker of GNB sepsis. By using an in vitro model with the human monocytic cell line, we demonstrated that LPS stimulation downregulated the THP-1 cell expression of let-7a. The downregulation of let-7a is correlated with the induced expression of cytokine-inducible Src homology 2-containing protein without change in cytokine-inducible Src homology 2-containing protein mRNA levels in THP-1 cells via TLR signaling pathway activation. Moreover, gain of function by overexpression of let-7a revealed that let-7a significantly decreased tumor necrosis factor-α and interleukin-1ß production in response to LPS. Reduced let-7a and miR-150 levels in peripheral leukocytes correlate with GNB urosepsis patients. Furthermore, let-7a is relevant to the regulation of TLR-mediated innate immune response.

Induced pluripotent stem cells alleviate lung injury from mesenteric ischemia-reperfusion.

BACKGROUND: Mesenteric ischemia-reperfusion (I/R) injury is a serious pathophysiologic process that can trigger the development of multiorgan dysfunction. Acute lung injury is a major cause of death among mesenteric I/R patients, as current treatments remain inadequate. Stem cell-based therapies are considered novel strategies for treating several devastating and incurable diseases. This study examined whether induced pluripotent stem cells (iPSCs) lacking c-myc (i.e., induced using only the three genes oct4, sox2, and klf4) can protect against acute lung injury in a mesenteric I/R mouse model. METHODS: C57BL/6 mice were randomly divided into the following groups: sham/no treatment, vehicle treatment with phosphate-buffered saline, treatment with iPSCs, and treatment with iPSC-conditioned medium. The mice were subjected to mesenteric ischemia for 45 minutes followed by reperfusion for 24 hours. After I/R, the lungs and the ileum of the mice were harvested. Lung injury was evaluated by histology, immunohistochemistry, and analyses of the levels of inflammatory cytokines, cleaved caspase 3, and 4-hydroxynonenal. RESULTS: The intravenously delivered iPSCs engrafted to the lungs and the ileum in response to mesenteric I/R injury. Compared with the phosphate-buffered saline-treated group, the iPSC-treated group displayed a decreased intensity of acute lung injury 24 hours after mesenteric I/R. iPSC transplantation significantly reduced the expression of proinflammatory cytokines, oxidative stress markers, and apoptotic factors in injured lung tissue and remarkably enhanced endogenous alveolar cell proliferation. iPSC-conditioned medium treatment exerted a partial effect compared with iPSC treatment. CONCLUSION: When considering the anti-inflammatory, antioxidant, and antiapoptotic properties of iPSCs, the transplantation of iPSCs may represent an effective treatment option for mesenteric I/R-induced acute lung injury.