Surgical trauma and immunosuppression: pathophysiology and potential immunomodulatory approaches

Effects of Omega-3 Polyunsaturated Fatty Acids, Docosahexaenoic Acid and Eicosapentaenoic Acid, on Post-Surgical Complications in Surgical Trauma Patients: Mechanisms, Nutrition, and Challenges

This paper aims to provide an in-depth review of the specific outcomes associated with omega-3 polyunsaturated fatty acids (PUFAs), focusing on their purported effects on post-surgical complications in trauma patients. A comprehensive investigation of omega-3 polyunsaturated fatty acids was conducted until February 2023 using the PubMed database. Surgical trauma is characterized by a disruption in immune response post surgery, known to induce systemic inflammation. Omega-3 PUFAs are believed to offer potential improvements in multiple post-surgical complications because of their anti-inflammatory and antioxidant properties. Inconsistent findings have emerged in the context of cardiac surgeries, with the route of administration playing a mediating role in these outcomes. The effects of omega-3 PUFAs on post-operative atrial fibrillation have exhibited variability across various studies. Omega-3 PUFAs have demonstrated positive effects in liver surgery outcomes and in patients with acute respiratory distress syndrome. Omega-3 is suggested to offer potential benefits, particularly in the perioperative care of patients undergoing traumatic procedures. Incorporating omega-3 in such cases is hypothesized to contribute to a reduction in certain surgical outcomes, such as hospitalization duration and length of stay in the intensive care unit. Therefore, comprehensive assessments of adverse effects can aid in identifying the presence of subtle or inconspicuous side effects associated with omega-3.

Parameters influencing health-related quality of life after severe trauma: a systematic review (part II)

INTRODUCTION

It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma.

METHODS

The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner.

RESULTS

A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability.

CONCLUSION

Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

Prospective flow cytometry analysis of leucocyte subsets in critically ill patients who develop sepsis: a pilot study

PURPOSE

Sepsis in critically ill patients with injury bears a high morbidity and mortality. Extensive phenotypic monitoring of leucocyte subsets in critically ill patients at ICU admission and during sepsis development is still scarce. The main objective of this study was to identify early changes in leukocyte phenotype which would correlate with later development of sepsis.

METHODS

Patients who were admitted in a tertiary ICU for organ support after severe injury (elective cardiac surgery, trauma, necessity of prolonged ventilation or stroke) were sampled on admission (T1) and 48-72 h later (T2) for phenotyping of leukocyte subsets by flow cytometry and cytokines measurements. Those who developed secondary sepsis or septic shock were sampled again on the day of sepsis diagnosis (Tx).

RESULTS

Ninety-nine patients were included in the final analysis. Nineteen (19.2%) patients developed secondary sepsis or septic shock. They presented significantly higher absolute monocyte counts and CRP at T1 compared to non-septic patients (1030/µl versus 550/µl, p = 0.013 and 5.1 mg/ml versus 2.5 mg/ml, p = 0.046, respectively). They also presented elevated levels of monocytes with low expression of L-selectin (CD62Lneg monocytes) (OR[95%CI] 4.5 (1.4-14.5), p = 0.01) and higher SOFA score (p < 0.0001) at T1 and low mHLA-DR at T2 (OR[95%CI] 0.003 (0.00-0.17), p = 0.049). Stepwise logistic regression analysis showed that both monocyte markers and high SOFA score (> 8) were independently associated with nosocomial sepsis occurrence. No other leucocyte count or surface marker nor any cytokine measurement correlated with sepsis occurrence.

CONCLUSION

Monocyte counts and change of phenotype are associated with secondary sepsis occurrence in critically ill patients with injury.

SULFORAPHANE ADMINISTRATION AFTER HEMORRHAGIC SHOCK/RESUSCITATION IN MICE REDUCES THE SECRETION OF INFLAMMATORY CYTOKINES AND INCREASES THE IMMUNOCOMPETENCE OF SPLENIC MACROPHAGES

ABSTRACT

Objective : The purpose of this study was to investigate the immunomodulatory effects of sulforaphane (SFN), a nuclear factor erythroid 2-related factor (Nrf2) pathway activator, on splenic macrophages' immunocompetence after hemorrhagic shock/resuscitation (HS/R). Methods : Male C57/BL6 wild-type mice (n = 6 per group) were subjected to either pressure-controlled HS (MAP, 35-45 mm Hg) or a sham procedure surgery (without HS). After 90 minutes of HS, fluid resuscitation with withdrawn blood and 0.9% NaCl was performed. Sulforaphane (50 mg/kg of body weight) was applied intraperitoneally immediately after the resuscitation phase as well as 24 and 48 h thereafter, depending on group allocation. The mice were killed at 6, 24, and 72 h after resuscitation. After killing, spleens were harvested to perform Nrf2 immunofluorescence histology. Splenic macrophages were isolated and cultured to measure cytokine secretion in the cell culture supernatant. Furthermore, macrophages isolated after 24-hour resuscitation were treated with 100 ng/mL of bacterial LPS to measure immunocompetence. Matrix-assisted laser desorption/ionization mass spectrometry imaging was performed to verify the distribution of SFN in the spleen after intraperitoneal injection. Results : We showed that administered SFN reached the spleen within the first hour after administration. Furthermore, we identified that SFN increased splenic Nrf2 activation and decreased cytokine expression in splenic macrophages after HS/R. In addition, we showed that SFN exhibited splenic anti-inflammatory properties of macrophages in vitro (IL-6/IL-10-ratio of the HS/R group: 51.79 ± 9.99 [at 6 h] and 15.70 ± 3.35 [at 24 h] vs. HS/R + SFN group: 20.54 ± 5.35 [at 6 h] and 8.60 ± 2.37 [at 24 h], P < 0.05). Furthermore, SFN improved in vitro splenic macrophage immunocompetence after HS/R, as evidenced by the increased secretion of inflammatory cytokines in response to LPS stimulation in vitro . Conclusions : Our study shows that SFN can reduce inflammatory cytokines secreted by splenic macrophages after HS/R and increase their immunocompetence toward a more anti-inflammatory profile.

Tumor regionalization after surgery: Roles of the tumor microenvironment and neutrophil extracellular traps

Surgery is unanimously regarded as the primary strategy to cure solid tumors in the early stages but is not always used in advanced cases. However, tumor surgery must be carefully considered because the risk of metastasis could be increased by the surgical procedure. Tumor surgery may result in a deep wound, which induces many biological responses favoring tumor metastasis. In particular, NETosis, which is the process of forming neutrophil extracellular traps (NETs), has received attention as a risk factor for surgery-induced metastasis. To reduce cancer mortality, researchers have made efforts to prevent secondary metastasis after resection of the primary tumor. From this point of view, a better understanding of surgery-induced metastasis might provide new strategies for more effective and safer surgical approaches. In this paper, recent insights into the surgical effects on metastasis will be reviewed. Moreover, in-depth opinions about the effects of NETs on metastasis will be discussed.

Therapies that limit the formation of web-like structures formed by white cells known as neutrophils may lower the risk of cancer spread (metastasis) following surgical tumor removal. Removing solid tumors remains a key cancer treatment, but in some cases surgery itself increases the risk of metastasis. Jong-Wan Park at Seoul National University, South Korea, and co-workers reviewed current understanding of metastasis following surgery. Surgical removal destroys the architecture supporting cancer cells but this can release tumor cells into blood vessels. The stress of deep wounds also affects immune responses, most notably neutrophil extracellular traps (NETs), web-like structures formed by neutrophils to trap and kill pathogens. NETs have previously been implicated in metastasis. In a post-surgical environment enriched in neutrophils and pro-inflammatory cytokines, NET formation may help cancer cells thrive, promoting metastasis.

Stellate Ganglion Block Improves the Proliferation and Function of Splenic CD4 + T Cells Through Inhibition of Posthemorrhagic Shock Mesenteric Lymph-Mediated Autophagy

Severe hemorrhagic shock leads to excessive inflammation and immune dysfunction, which results in high mortality related to mesenteric lymph return. A recent study showed that stellate ganglion block (SGB) increased the survival rate in rats suffering hemorrhagic shock. However, whether SGB ameliorates immune dysfunction induced by hemorrhagic shock remains unknown. The aim of the present study was to verify the favorable effects of SGB on the proliferation and function of splenic CD4 + T cells isolated from rats that underwent hemorrhagic shock and to investigate the mechanism related to the SGB interaction with autophagy and posthemorrhagic shock mesenteric lymph (PHSML). Male rats underwent SGB or sham SGB and conscious acute hemorrhage followed by resuscitation and multiple treatments. After 3 h of resuscitation, splenic CD4 + T cells were isolated to measure proliferation and cytokine production following stimulation with ConA in vitro. CD4 + T cells isolated from normal rats were treated with PHSML drained from SBG-treated rats, and proliferation, cytokine production, and autophagy biomarkers were detected. Hemorrhagic shock reduced CD4 + T cell proliferation and production of interleukin (IL)-2, IL-4, and tumor necrosis factor-α-induced protein 8-like 2 (TIPE2). SGB or administration of the autophagy inhibitor 3-methyladenine (3-MA) normalized these indicators. In contrast, administration of rapamycin (RAPA) autophagy agonist or intravenous injection of PHSML inhibited the beneficial effects of SGB on CD4 + T cells from hemorrhagic shocked rats. Furthermore, PHSML incubation decreased proliferation and cytokine production, increased LC3 II/I and Beclin-1 expression, and reduced p-PI3K and p-Akt expression in normal CD4 + T cells. These adverse effects of PHSML were also abolished by 3-MA administration, as well as incubation with PHSML obtained from SGB-treated rats. SGB improves splenic CD4 + T cell function following hemorrhagic shock, which is related to the inhibition of PHSML-mediated autophagy.

Estradiol-induced inhibition of endoplasmic reticulum stress normalizes splenic CD4 + T lymphocytes following hemorrhagic shock

The aim is to investigate that 17β-estradiol (E2)/estrogen receptors (ERs) activation normalizes splenic CD4 + T lymphocytes proliferation and cytokine production through inhibition of endoplasmic reticulum stress (ERS) following hemorrhage. The results showed that hemorrhagic shock (hemorrhage through femoral artery, 38–42 mmHg for 90 min followed by resuscitation of 30 min and subsequent observation period of 180 min) decreased the CD4⁺ T lymphocytes proliferation and cytokine production after isolation and incubation with Concanavalin A (5 μg/mL) for 48 h, induced the splenic injury with evidences of missed contours of the white pulp, irregular cellular structure, and typical inflammatory cell infiltration, upregulated the expressions of ERS biomarkers 78 kDa glucose-regulated protein (GRP78) and activating transcription factor 6 (ATF6). Either E2, ER-α agonist propyl pyrazole triol (PPT) or ERS inhibitor 4-Phenylbutyric acid administration normalized these parameters, while ER-β agonist diarylpropionitrile administration had no effect. In contrast, administrations of either ERs antagonist ICI 182,780 or G15 abolished the salutary effects of E2. Likewise, ERS inducer tunicamycin induced an adverse effect similarly to that of hemorrhagic shock in sham rats, and aggravated shock-induced effects, also abolished the beneficial effects of E2 and PPT, respectively. Together, the data suggest that E2 produces salutary effects on CD4⁺ T lymphocytes function, and these effects are mediated by ER-α and GPR30, but not ER-β, and associated with the attenuation of hemorrhagic shock-induced ERS.

Alarming Cargo: The Role of Exosomes in Trauma-Induced Inflammation

Severe polytraumatic injury initiates a robust immune response. Broad immune dysfunction in patients with such injuries has been well-documented; however, early biomarkers of immune dysfunction post-injury, which are critical for comprehensive intervention and can predict the clinical course of patients, have not been reported. Current circulating markers such as IL-6 and IL-10 are broad, non-specific, and lag behind the clinical course of patients. General blockade of the inflammatory response is detrimental to patients, as a certain degree of regulated inflammation is critical and necessary following trauma. Exosomes, small membrane-bound extracellular vesicles, found in a variety of biofluids, carry within them a complex functional cargo, comprised of coding and non-coding RNAs, proteins, and metabolites. Composition of circulating exosomal cargo is modulated by changes in the intra- and extracellular microenvironment, thereby serving as a homeostasis sensor. With its extensively documented involvement in immune regulation in multiple pathologies, study of exosomal cargo in polytrauma patients can provide critical insights on trauma-specific, temporal immune dysregulation, with tremendous potential to serve as unique biomarkers and therapeutic targets for timely and precise intervention.

Drain site enterocutaneous fistula after hyperthermic intraperitoneal chemotherapy

Spontaneous sigmoid colon perforation after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is a rare complication. It is more commonly seen with mitomycin‐based HIPEC. This case study's patient presented with pus discharge at the drain site after 4 weeks of surgery. The symptoms persisted after conservative treatment. High suspicion after the feculent smell of the discharge fluidled to the prompt diagnosis of enterocutaneous fistula. There was limitedperforation with abscess formation, followed by fistula formation. The patient was treated successfully with surgery.

A Machine Learning-Based Prediction of Hospital Mortality in Patients With Postoperative Sepsis

Introduction: The incidence of postoperative sepsis is continually increased, while few studies have specifically focused on the risk factors and clinical outcomes associated with the development of sepsis after surgical procedures. The present study aimed to develop a mathematical model for predicting the in-hospital mortality among patients with postoperative sepsis. Materials and Methods: Surgical patients in Medical Information Mart for Intensive Care (MIMIC-III) database who simultaneously fulfilled Sepsis 3.0 and Agency for Healthcare Research and Quality (AHRQ) criteria at ICU admission were incorporated. We employed both extreme gradient boosting (XGBoost) and stepwise logistic regression model to predict the in-hospital mortality among patients with postoperative sepsis. Consequently, the model performance was assessed from the angles of discrimination and calibration. Results: We included 3,713 patients who fulfilled our inclusion criteria, in which 397 (10.7%) patients died during hospitalization, and 3,316 (89.3%) patients survived through discharge. Fluid-electrolyte disturbance, coagulopathy, renal replacement therapy (RRT), urine output, and cardiovascular surgery were important features related to the in-hospital mortality. The XGBoost model had a better performance in both discriminatory ability (c-statistics, 0.835 vs. 0.737 and 0.621, respectively; AUPRC, 0.418 vs. 0.280 and 0.237, respectively) and goodness of fit (visualized by calibration curve) compared to the stepwise logistic regression model and baseline model. Conclusion: XGBoost model has a better performance in predicting hospital mortality among patients with postoperative sepsis in comparison to the stepwise logistic regression model. Machine learning-based algorithm might have significant application in the development of early warning system for septic patients following major operations.

Engagement of Posthemorrhagic Shock Mesenteric Lymph on CD4+ T Lymphocytes In Vivo and In Vitro

BACKGROUND

Immune dysfunction is associated with posthemorrhagic shock mesenteric lymph (PHSML) return. To determine the proliferation and cytokine production capacity of CD4⁺ T lymphocytes, the effect of PHSML drainage on spleen CD4⁺ T lymphocytes in a mouse model of hemorrhagic shock was assessed.

METHODS

The normal spleen CD4⁺ T lymphocytes were in vitro incubated with either drained normal mesenteric lymph (NML), PHSML during hypotension (PHSML-H), or PHSML from 0 h to 3 h after resuscitation (PHSML-R) to verify direct proliferation effects of PHSML.

RESULTS

Hemorrhagic shock led to reduction of proliferation and mRNA expression of interleukin 2 (IL-2) and IL-2 receptor in CD4⁺ T lymphocytes and to decrease in IL-2 and interferon γ (IFN-γ) levels in supernatants. In contrast, the interleukin-4 levels were increased. These effects were reversed by PHSML drainage. Moreover, NML incubation promoted CD4⁺ T lymphocyte proliferation, whereas both PHSML-H and PHSML-R treatment had a biphasic effects on CD4⁺ T lymphocyte proliferation, exhibiting an enhanced effect at early stages and an inhibitory effect at later stages. Compared with NML, PHSML-H increased IL-2 expression at 12 h, but decreased expression of both IL-2 and IFN-γ at 24 h. By contrast, PHSML-R induced significant increases in IL-2 and IFN-γ levels at 24 h. Interleukin-4 expression in CD4⁺ T lymphocytes was reduced at 12 h, but augmented at 24 h after incubation with either PHSML-H or PHSML-R.

CONCLUSIONS

The results indicate that PHSML has a direct inhibitory effect on CD4⁺ T lymphocyte proliferation that induces an inflammatory response, which is associated with cellular immune dysfunction.

Pulmonary non-tuberculous mycobacterial infections: current state and future management

Currently, there is a trend of increasing incidence in pulmonary non-tuberculous mycobacterial infections (PNTM) together with a decrease in tuberculosis (TB) incidence, particularly in developed countries. The prevalence of PNTM in underdeveloped and developing countries remains unclear as there is still a lack of detection methods that could clearly diagnose PNTM applicable in these low-resource settings. Since non-tuberculous mycobacteria (NTM) are environmental pathogens, the vicinity favouring host-pathogen interactions is known as important predisposing factor for PNTM. The ongoing changes in world population, as well as socio-political and economic factors, are linked to the rise in the incidence of PNTM. Development is an important factor for the improvement of population well-being, but it has also been linked, in general, to detrimental environmental consequences, including the rise of emergent (usually neglected) infectious diseases, such as PNTM. The rise of neglected PNTM infections requires the expansion of the current efforts on the development of diagnostics, therapies and vaccines for mycobacterial diseases, which at present, are mainly focused on TB. This review discuss the current situation of PNTM and its predisposing factors, as well as the efforts and challenges for their control.

Perioperative Nutrition Care of Orthopedic Surgery Patient

Despite evidence that malnutrition is associated with significant complications in orthopedic surgery¹, unrecognized malnutrition continues to be a "silent epidemic", effecting up to 50% of hospitalized patients. Specifically, pre-surgical malnutrition is associated with increased risk for surgical site infections, increased length of hospital stay, and increased health care costs in patients following total joint arthroplasty. Serologic markers (i.e. serum albumin and total lymphocyte count), anthropometric measurements, (i.e. calf muscle circumference and triceps skin fold) and assessment and screening tools (i.e. The Rainey-MacDonald Nutritional Index, the Mini Nutrition Assessment Short Form, the Malnutrition Universal Screening Tool and the Nutrition Risk Screening 2002) have all been used to aid in the diagnosis of malnutrition in orthopedic patients, yet there is no universal gold standard for screening or assessing nutritional risk and no accepted guideline for perioperative nutritional optimization in this patient population. Recently, the Perioperative Nutrition Screen (PONS) was introduced² as an easy and efficient way to preoperatively identify and risk stratify patients for malnutrition in order to guide perioperative nutrition optimization. Given malnutrition is associated with increased risk of surgical site infections and increased length of hospital stay, adequate assessment of perioperative risk for malnutrition and preoperative nutrition optimization, including structured weight loss in the obese population, consumption of high protein oral nutritional supplements, immunonutrition oral supplements and adequate glucose control, may improve perioperative outcomes. The presence of a Registered Dietician (RD) should be a standard of care in all pre-operative clinics to improve nutrition care and surgical outcomes.

Post-operative complications in patients with a significant post-operative decrease in γδT cells

BACKGROUND

It has previously been shown that appropriate distribution of immune cells between different tissues and organs of the body is required for proper function of the immune system. Our previous work demonstrated that surgical trauma in mice induces γδT lymphocyte migration from peripheral blood to the peritoneal lymphoid organs. These described γδT cells have immunoregulatory activity as they suppress the cell-mediated immune response in vitro. We found a similar phenomenon in patients after different surgical operations. In the current study, we analyse post-operative complications in patients with a significant post-operative decrease in γδT cells.

METHODS

We investigated the percentage of γδT cells in peripheral blood of patients undergoing standard surgical procedures (gastric resection, colorectal resection, cholecystectomy and strumectomy) before and 3 days after the operation. The percentage of γδT cells was evaluated by the fluorescence-activated cell sorting cytofluorimeter. Patients were grouped based on the decrease of γδT cells. We compared the number of septic complications in patients with a large and small decrease in γδT cells.

RESULTS

After major surgery in the peritoneal cavity (gastric and colorectal surgery), in the group that had a large decrease in γδT cells we found significantly more septic complications than in the group of patients with small γδT decrease. That effect was not visible after less traumatic surgery.

CONCLUSION

Surgery results in a decreased percentage of γδT lymphocytes in the peripheral human blood which correlates with the number of septic complications. This observation may help to predict post-operative recovery after gastroabdominal surgery.

A Population-Based Study of 90-Day Hospital Cost and Utilization Associated With Robotic Surgery in Colon and Rectal Cancer

BACKGROUND

The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies.

METHODS

Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections.

RESULTS

A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses.

CONCLUSIONS

Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.

Risk Factors for Mortality in Pediatric Postsurgical versus Medical Severe Sepsis

BACKGROUND

Sepsis is a leading cause of morbidity and mortality after surgery. Most studies regarding sepsis do not differentiate between patients who have had recent surgery and those without. Few data exist regarding the risk factors for poor outcomes in pediatric postsurgical sepsis. Our hypothesis is pediatric postsurgical, and medical patients with severe sepsis have unique risk factors for mortality.

METHODS

Data were extracted from a secondary analysis of an international point prevalence study of pediatric severe sepsis. Sites included 128 pediatric intensive care units from 26 countries. Pediatric patients with severe sepsis were categorized into those who had recent surgery (postsurgical sepsis) versus those that did not (medical sepsis) before sepsis onset. Multivariable logistic regression models were used to determine risk factors for mortality.

RESULTS

A total of 556 patients were included: 138 with postsurgical and 418 with medical sepsis. In postsurgical sepsis, older age, admission from the hospital ward, multiple organ dysfunction syndrome at sepsis recognition, and cardiovascular and respiratory comorbidities were independent risk factors for death. In medical sepsis, resource-limited region, hospital-acquired infection, multiple organ dysfunction syndrome at sepsis recognition, higher Pediatric Index of Mortality-3 score, and malignancy were independent risk factors for death.

CONCLUSIONS

Pediatric patients with postsurgical sepsis had different risk factors for mortality compared with medical sepsis. This included a higher mortality risk in postsurgical patients presenting to the intensive care unit from the hospital ward. These data suggest an opportunity to develop and test early warning systems specific to pediatric sepsis in the postsurgical population.

Postoperative lymphopenia: An independent risk factor for postoperative pneumonia after lung cancer surgery, results of a case-control study

Objective

Postoperative lymphopenia has been proposed as a risk factor for postoperative infections but has never been identified as such in a multivariate analysis. Postoperative pneumonia (POP) is one of the most common complications after lung cancer surgery and is associated with a worse outcome. We aimed to evaluate the association between postoperative lymphopenia and POP after lung cancer surgery.

Methods

Patients admitted for lung cancer surgery (lobectomy, bilobectomy, or pneumonectomy) aged ≥ 18 years and with no history of an immunosuppressive state were eligible for inclusion. Lymphocyte counts were determined in blood drawn on the day before surgery and at postoperative days 1, 3 and 7. POP diagnosis was based on clinical, biological and radiological data. A logistic regression model adjusted on currently described risk factors for POP was used to explain the onset of this condition.

Results

Two hundred patients were included, of whom 43 (21.5%) developed POP. Preoperative lymphocyte count was 1.8±0.6x10⁹ cells/L and 2.0±0.7x10⁹ cells/L in patients with and without POP, respectively (P = .091). In both groups, the lymphocyte count nadir occurred at postoperative day 1. In multivariate analysis, lymphopenia at postoperative day 1 was significantly associated with increased risk of POP (odds ratio: 2.63, 95% CI [1.03–5.40]). POP rate at postoperative day 7 was higher in patients presenting low lymphocyte counts (≤1.19x10⁹ cells/L) at postoperative day 1 (P = .003).

Conclusions

Our study showed that lymphopenia following lung cancer surgery was maximal at postoperative day 1 and was associated with POP.

HLA-DR Expression on Monocyte Subsets in Critically Ill Children

BACKGROUND

To longitudinally study blood monocyte subset distribution and human leukocyte antigen-DR (HLA-DR) expression on monocyte subsets in children with sepsis, post-surgery and trauma in relation to nosocomial infections and mortality.

METHODS

In 37 healthy children and 37 critically ill children (12 sepsis, 11 post-surgery, 10 trauma and 4 admitted for other reasons)-participating in a randomized controlled trial on early versus late initiation of parenteral nutrition-monocyte subset distribution and HLA-DR expression on monocyte subsets were measured by flow cytometry upon admission and on days 2, 3 and 4 of pediatric intensive care unit (PICU) stay.

RESULTS

Upon PICU admission, critically ill children had a higher proportion of classical monocytes (CD14++CD16-) than healthy children [PICU 95% (interquartile range [IQR] 88%-98%); controls, 87% (IQR 85%-90%), P < 0.001]. HLA-DR expression was significantly decreased within all monocyte subsets and at all time points, being most manifest on classical monocytes and in patients with sepsis. Percentage of HLA-DR expressing classical monocytes [upon PICU admission 67% (IQR 44%-88%); controls 95% (IQR 92%-98%), P < 0.001], as well as the HLA-DR mean fluorescence intensity [upon PICU admission 3219 (IQR 2650-4211); controls 6545 (IQR 5558-7647), P < 0.001], decreased during PICU stay. Patients who developed nosocomial infections (n = 13) or who died (n = 6) had lower HLA-DR expression on classical monocytes at day 2 (P = 0.002) and day 3 (P = 0.04), respectively.

CONCLUSIONS

Monocytic HLA-DR expression decreased during PICU stay and was lower compared with controls on all examined time points, especially on classical monocytes and in children admitted for sepsis. Low HLA-DR expression on classical monocytes was associated with nosocomial infections and death.

Monocyte-Dependent Suppression of T-Cell Function in Postoperative Patients and Abdominal Sepsis

INTRODUCTION

Surgical trauma causes inflammation and postoperative immunosuppression. Previous studies have shown a T-cell-dependent suppression of MHC II expression and other functions of antigen-presenting cells. The aim of this study was to determine which immune cell initiates postoperative immunosuppression and consecutive sepsis.

METHODS

We separated T-cells and monocytes in human abdominal surgery (n = 11) patients preoperatively as well as 24 h postoperatively and in patients who developed postoperative sepsis (n = 6). We analyzed their surface markers and then coincubated these cells with naïve preoperative cells of the other cell type, respectively. Cytokine secretion from naïve cells was measured by a multiplex immunoassay, serving as a bioassay for the function of the stimulating postoperative cell.

RESULTS

Surface marker analysis showed a postoperative suppression of CD3 cells and the activation marker CD28 (P = 0.02), which was further reduced in septic patients. FACS analysis revealed a significant increase in CD14 monocytes (P = 0.02) and CD14CD86, CD14HLA-DR subpopulations 2 h postoperatively. In sepsis patients, HLA-DR expression was reduced compared with postoperative levels (P < 0.01). After coincubation with postoperative T-cells, secretion of IL-6 (P < 0.01) and IL-10 (P < 0.01) from naïve monocytes was increased, whereas T-cells from sepsis patients resulted in suppressed cytokine secretion. After coincubation with postoperative monocytes, secretion of IFN-gamma (P < 0.01) and IL-10 (P < 0.01) from naïve T-cells was significantly diminished, whereas monocytes from septic patients triggered only insignificant IL-10 secretion from naïve and septic T-cells.

CONCLUSIONS

Our results show that in the early postoperative period, T-cells are suppressed but able to trigger the release of cytokines from monocytes, whereas activated monocytes seem to induce T-cell suppression. In sepsis patients, a global suppression of both cell types in terms of absolute numbers and function seems to occur.

Potential impact of invasive surgical procedures on primary tumor growth and metastasis

Surgical procedures such as tumor resection and biopsy are still the gold standard for diagnosis and (determination of) treatment of solid tumors, and are prognostically beneficial for patients. However, growing evidence suggests that even a minor surgical trauma can influence several (patho) physiological processes that might promote postoperative metastatic spread and tumor recurrence. Local effects include tumor seeding and a wound healing response that can promote tumor cell migration, proliferation, differentiation, extracellular matrix remodeling, angiogenesis and extravasation. In addition, local and systemic immunosuppression impairs antitumor immunity and contributes to tumor cell survival. Surgical manipulation of the tumor can result in cancer cell release into the circulation, thus increasing the chance of tumor cell dissemination. To prevent these undesired effects of surgical interventions, therapeutic strategies targeting immune response exacerbation or alteration have been proposed. This review summarizes the current literature regarding these local, systemic and secondary site effects of surgical interventions on tumor progression and dissemination, and discusses studies that aimed to identify potential therapeutic approaches to prevent these effects in order to further increase the clinical benefit from surgical procedures.

Gonadal hormone receptors underlie the resistance of female rats to inflammatory and cardiovascular complications of endotoxemia

The male gender is more vulnerable to immunological complications of sepsis. Here, we tested the hypotheses that female rats are protected against endotoxemia-evoked hypotension and cardiac autonomic dysfunction, and that gonadal hormone receptors account for such protection. Changes in blood pressure, heart rate, and cardiac sympathovagal balance caused by i.v. lipopolysaccharide (LPS) were determined. In male rats, LPS elevated serum TNFα together with falls in blood pressure and rises in heart rate. The spectral index of cardiac sympathovagal balance (low-frequency/high-frequency ratio, LF/HF) was reduced by LPS, suggesting an enhanced parasympathetic dominance. Remarkably, none of these LPS effects was evident in female rats. We also report that pretreatment of female rats with fulvestrant (nonselective estrogen receptor blocker), PHTPP (estrogen receptor β blocker), or mifepristone (progesterone receptor blocker) uncovered clear inflammatory (increased serum TNFα), hypotensive and tachycardic responses to LPS. However, these female rats, contrary to their male counterparts, exhibited increases in LF/HF ratio. On the other hand, LPS failed to modify inflammatory or cardiovascular states in rats pretreated with MPP (estrogen receptor α blocker). In females treated with formestane (aromatase inhibitor), LPS increased LF/HF ratio but had no effect on blood pressure. In male rats, the hypotensive and cardiac autonomic effects of LPS were (i) eliminated after treatment with estrogen, and (ii) intensified and inhibited, respectively, in flutamide (androgen receptor blocker)-pretreated rats. These findings highlight important roles for female gonadal hormones and functional estrogen receptor β and progesterone receptors in offsetting inflammatory and cardiovascular derangements caused by endotoxemia in female rats.

Frequency and perforin expression of different lymphocyte subpopulations in patients with lower limb fracture and thoracic injury

INTRODUCTION

Trauma with multiple injuries is associated with a high risk of complications, which may be related to excessive stimulation of inflammatory and anti-inflammatory responses. Although the effects of polytrauma on the immune response have been well established at the cellular and molecular levels, there is little information about the changes in the cytolytic potential of immunocompetent cells, including expression of cytotoxic molecules such as perforin. Therefore, the objective of the present study was to analyse and compare differences in the frequency and perforin expression of leukocyte subpopulations in the peripheral blood of patients with lower limb fracture, thoracic injury, and simultaneous lower limb fracture and thoracic injury.

PATIENTS AND METHODS

Forty-five patients with trauma injury (15 patients with lower limb injury, 15 patients with thoracic injury, and 15 patients with simultaneous lower limb and thoracic injury) were included in the study. Peripheral blood of 15 sex- and age-matched healthy volunteers served as the control group. Peripheral blood samples were taken from all subjects included in the study and peripheral blood mononuclear cells were isolated by gradient centrifugation. The frequency of T lymphocytes, natural killer (NK) and NK T cells, and their subsets, as well as their perforin expression levels were simultaneously detected and analysed by flow cytometry.

RESULTS

There was a statistically significant decrease in the frequency of T lymphocytes, NK and NK T cells as well as perforin expression in the patients with simultaneous lower limb and thoracic injury compared with the other two groups, with a predominantly marked decrease in NK and NK T cells.

CONCLUSION

The decrease in the frequency and cytotoxic potential of peripheral blood lymphocytes is related to the severity of trauma injury, which can explain the underlying mechanism contributing to complication occurrence.

The REAnimation Low Immune Status Markers (REALISM) project: a protocol for broad characterisation and follow-up of injury-induced immunosuppression in intensive care unit (ICU) critically ill patients

INTRODUCTION

The host response to septic shock is dynamic and complex. A sepsis-induced immunosuppression phase has recently been acknowledged and linked to bad outcomes and increased healthcare costs. Moreover, a marked suppression of the immune response has also been partially described in patients hospitalized in intensive care unit (ICU) for severe trauma or burns. It has been hypothesized that immune monitoring could enable identification of patients who might most benefit from novel, adjunctive immune-stimulating therapies. However, there is currently neither a clear definition for such injury-induced immunosuppression nor a stratification biomarker compatible with clinical constraints.

METHODS AND ANALYSIS

We set up a prospective, longitudinal single-centre clinical study to determine the incidence, severity and persistency of innate and adaptive immune alterations in ICU patients. We optimized a workflow to describe and follow the immunoinflammatory status of 550 patients (septic shock, severe trauma/burn and major surgery) during the first 2 months after their initial injury. On each time point, two immune functional tests will be performed to determine whole-blood TNF-α production in response to ex vivo lipopolysaccharide stimulation and the T lymphocyte proliferation in response to phytohaemagglutinin. In addition, a complete immunophenotyping using flow cytometry including monocyte HLA-DR expression and lymphocyte subsets will be obtained. New markers (ie, levels of expression of host mRNA and viral reactivation) will be also evaluated. Reference intervals will be determined from a cohort of 150 age-matched healthy volunteers. This clinical study will provide, for the first time, data describing the immune status of severe ICU patients over time.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the institutional review board (no 69HCL15_0379) and the French National Security agency for drugs and health-related products. Results will be disseminated through presentations at scientific meetings and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov Registration number: NCT02638779. Pre-results.

The Effect of Surgical Stress on Postoperative Tαβ and Tγδ Cell Distribution

BACKGROUND

It was previously shown that appropriate distribution of immune cells between different tissues and organs of the body is required for proper function of the immune system. Our previous experiments demonstrated that surgical trauma in mice induces Tγδ lymphocyte migration from peripheral blood to peritoneal lymphoid organs. Tγδ cells have regulatory activity as they suppress the cell-mediated immune response in vitro via TGF-β. In the current study, we aim to evaluate the influence of surgery on both Taβ and Tγδ lymphocyte distribution in patients that underwent operation.

MATERIALS AND METHODS

We investigated the percentage of Tαβ and Tγδ cells in peripheral blood of patients undergoing standard surgical procedures (gastric resection, colorectal resection, cholecystectomy, and strumectomy) before and 3 days after operation. The percentage of Tαβ and Tγδ cells was evaluated by FACS Canto II cytofluorimeter.

RESULTS

We showed that only major surgery located in the peritoneal cavity (gastric and colorectal surgery) decreases the percentage of Tγδ cells in peripheral blood as opposed to less traumatic surgery (strumectomy and cholecystectomy) which does not have such effect. However, significant reduction of Tγδ cells after operation was only observed in a group of patients that underwent gastrectomy. Additionally, we found that gastrectomy results in significant reduction of cumulative Tγδ CD4 and Tγδ CD25 lymphocyte counts.

CONCLUSION

Surgery results in decreased percentage of Tγδ lymphocytes in peripheral human blood, and this correlates with the severity and location of the surgical trauma. This observation may help to predict postoperative recovery after gastroabdominal surgery.

Postoperative Infections are Associated with Increased Risk of Cardiac Events in Vascular Patients

BACKGROUND

Despite advances in perioperative care, the rate of cardiac events in vascular patients remains high. We have previously shown that infections in trauma patients are associated with higher rates of subsequent cardiac complications, likely due to the additive effect of a second hit of an infection following the trauma. The aim of this study was to investigate whether there is an association between postoperative infections and subsequent cardiac events in vascular patients.

METHODS

A 5-year retrospective review of demographics, comorbidities, operative interventions, infectious, and cardiac events in all vascular patients who underwent an operative intervention at a single tertiary referral center was performed. In patients with clinical suspicion of myocardial injury, myocardial damage was defined as troponin >0.15 ng/mL and myocardial infarction (MI) as troponin >1 ng/mL. Pneumonia was diagnosed using bronchoalveolar lavage (BAL) and considered positive if BAL fluid culture contained >10,000 colony-forming units (cfu). Urinary tract infection (UTI) was diagnosed if the urine culture contained >100,000 cfu. All other infections were diagnosed by culture data. Regression analysis was performed to assess risk of cardiac events as a function of infections adjusting for age, gender, and comorbidities.

RESULTS

We analyzed 1,835 vascular operative interventions with the mean age of the cohort 65.5 years (65.9% male). The overall infection rate was 13.2%, with UTI being the most common (60.3%). The overall rate of myocardial damage was 8.1% and the rate of MI 3.8%. Rates of both myocardial damage (15.5 vs. 7.7%; P = 0.0015) and MI (7.1 vs. 3.4%; P = 0.018) were significantly higher in patients with infections, compared to those without infections. Adjusting for age, gender, medical comorbidities, open versus endovascular cases as well as statin and steroid use, patients with UTI were more likely to subsequently develop either myocardial damage (odds ratio [OR] = 3.57 [95% confidence interval = 1.51-8.45]) or MI (OR = 4.20 [1.23-14.3]). A similar association was noted between any infections and either myocardial damage (OR = 2.97 [1.32-6.65]) or MI (OR = 4.31 [1.44-12.94]).

CONCLUSIONS

We herein describe an association between postoperative infections, most commonly UTI, and subsequent cardiac events. Efforts should be made to minimize the risk of developing infections to ensure cardioprotection in vascular patients during perioperative period.

OXYGEN MITIGATES THE INFLAMMATORY RESPONSE IN A MODEL OF HEMORRHAGE AND ZYMOSAN-INDUCED INFLAMMATION

Sequential insults (hits) may change the inflammatory reaction that develops in response to separate single hits (e.g., injury, infection); however, their effects on the long-term clinical outcome are still only partially elucidated. Double-hit models are typically severe and fatal. We characterized in C57BL/6 mice a moderate double-hit model of hemorrhage (35%-40% of total blood volume) and resuscitation, followed by peritoneal injection of zymosan A that induced local and systemic inflammation with 58% mortality. This model allowed exploration of the inflammatory response over time in the surviving mice. We show that after 2 days, mice subjected to the double-hit model had elevated proinflammatory systemic and local peritoneal cytokine response (interleukin [IL]-1β, tumor necrosis factor-α, IL-6) and moderately elevated anti-inflammatory cytokines (IL-10, transforming growth factor-β), compared with the single-hit and sham mice. However, this dynamically changed, and by day 7, proinflammatory cytokines were reduced, and anti-inflammatory cytokines were markedly (P < 0.05) elevated in the double-hit group. Mice in the double-hit group that inhaled 100% oxygen intermittently for 6 h every day exhibited markedly reduced serum proinflammatory cytokines as early as day 2 (P < 0.05), inhibited macrophage infiltration into the peritoneum (by 13-fold; P < 0.05), and substantially increased survival rates of 85% (P = 0.00144). Oxygen mitigates the inflammatory response and exerts a beneficial effect on survival in a double-hit model of hemorrhage and zymosan-induced inflammation.

Does nephrectomy during radical adrenalectomy for stage II adrenocortical cancer affect patient outcome?

PURPOSE

To evaluate if including nephrectomy in the standard surgical approach to stage II adrenocortical cancer (i.e., adrenalectomy) might modify oncologic outcome of patients.

METHODS

We performed a retrospective analysis involving 41 patients with stage II adrenocortical cancer (ACC) who had undergone radical surgery. Patients were divided into two groups according to the surgical procedure: group A = radical adrenalectomy alone, group AN = radical adrenalectomy + radical nephrectomy. Oncologic effectiveness of the procedures was tested comparing the recurrence-free and overall survival of patients of A vs AN groups.

RESULTS

The group A consisted of 25 patients and group AN of 16 patients. No differences were noted between the two groups in terms of demographic data and ACC characteristics. During follow-up, 15/25 (60 %) patients of group A vs 14/16 (87.5 %) patients of group AN experienced a recurrence, after a median of 36 months in group A and 10 months in group AN (p = 0.06); a significant impairment of renal function was recorded in patients of AN group with respect to those of group A. Finally, 13/25 (52 %) patients of group A and 10/16 (62.5 %) patients of group AN died due to ACC-related causes. No differences in survival times were noted (p = 0.3).

CONCLUSION

Our study suggests that adjunctive nephrectomy does not modify the oncologic results of adrenalectomy in the treatment of stage II ACC in terms of recurrence-free and overall survival. Thus, when there are no signs of ACC local invasion, surgeon should make every effort to preserve the kidney.

Dementia With Lew Body: Impacts of Surgery

Patients who have dementia with Lewy bodies (DLB) and undergo surgery may develop aggravated postoperative cognitive dysfunction or postoperative delirium. Many patients with DLB respond poorly to surgery and anesthesia, and their conditions may worsen if they have other medical complications along with dementia. They may also face high risk of prolonged hospital stay, increased medical problems and/or mortality, causing significant physical, psychosocial, and financial burdens on individuals, family members, and society. Anesthesia, pain medications, old age, and surgery-related stresses are usually held responsible for the complications; however, the exact causes are still not fully understood. Literature on surgery-related complications for patients with DLB appears to be inadequate, and hence the topic merits detailed and systematic research. This article reviews postoperative complications and various surgery-related risk factors for DLB in light of other dementias such as Alzheimer's disease, as their neuropathologic features overlap with those of DLB.

Inflammatory Changes and Coagulopathy in Multiply Injured Patients

Severe tissue trauma leads to an early activation of several danger recognition systems, including the complement and the coagulation system, often resulting in an overwhelming almost synchronic pro- and anti-inflammatory response of the host. Although the immune response is associated with beneficial effects at the site of injury including the elimination of exogenous and endogenous danger molecules as well as the initiation of regenerative processes, an exaggerated systemic inflammatory response significantly contributes to posttraumatic complications such as multiple organ failure (MOF) and early death. Besides pre-existing physical conditions, age, gender, and underlying comorbidities, surgical and anesthesiological management after injury is decisive for outcome. Improvements in surgical intensive care have increased number of patients who survive the initial phase after trauma. However, instead of progressing to normal recovery, patients often pass into persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The characterization and management of PICS will require new strategies for direct monitoring and therapeutic intervention into the patient’s immune function. In this chapter, we describe various factors involved in the inflammatory changes after trauma and aim to understand how these factors interact to progress to systemic inflammation, MOF, and PICS.

Addressing the Global Burden of Trauma in Major Surgery

Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.

Treatment with a neutralising anti-rat interleukin-17 antibody after multiple-trauma reduces lung inflammation

BACKGROUND

It has been well recognised that a deficit of numbers and function of CD4(+)CD25(+)Foxp3(+) cells (Treg) is attributed to the development of autoimmune diseases and inflammatory diseases; additionally, IL-17-producing cells (Th17) have a pro-inflammatory role. The balance between Th17 and Treg may be essential for maintaining immune homeostasis and has long been thought as one of the important factors in the development/prevention of autoimmune diseases and inflammatory diseases. In our previous research, we explored that cytokines (IL-17) and the balance of Treg/Th17 had a significant relevance with tissue (lung) inflammation and injury in acute-phase after multiple-trauma.

OBJECTIVE

To more verify whether an imbalance of Treg/Th17 is characteristic of rats suffering from multiple trauma.

METHODS AND SUBJECTIVE

Using IL-17 monoclonal antibody (IL-17mAb)-treated multiple-trauma rat, we tested the pathogenic role of IL-17 in the development of multiple-trauma. Rat models were treated respectively with IL-17mAb or rat IgG 2A isotype control or phosphate-buffered solution after model was established. Normal rats only received anaesthesia and cannulation were taken as sham. Rats in each group were killed respectively at the end of 1h, 4h, 8h after injection. Collected serum and lung samples for assessment dynamically of MPO, IL-17, IL-6, and TGF-β-mRNA, and cytokine (IL-17, IL-6, TGF-β) and lung tissue for pulmonary histological analysis.

RESULTS

Neutralisation of IL-17 with anti-IL-17 can decrease serum IL-17 level and the IL-17-mRNA transcript level in lung, and ameliorate tissue inflammatory, defer disease course.

CONCLUSION

Our data suggest that IL-17 is crucially involved in the pathogenesis of multiple-trauma in rat, IL-17 inhibition might ameliorate the lung inflammation in acute-phase after multiple-trauma.

Risk factors for sepsis in Korean trauma patients

PURPOSE

Sepsis in severely injured patients is one of the leading causes of death in hospitals. The incidence of and risk factors for sepsis after trauma have been studied outside, but not within Korea. Therefore, this study investigated the incidence of sepsis and the independent risk factors for sepsis in moderately to severely injured patients in Korea.

METHODS

The electronic medical records of patients who visited the emergency department from January 2010 to December 2012 were reviewed retrospectively. Patients older than 18 years of age with an Injury Severity Score (ISS) greater than or equal to nine points were included.

RESULTS

A total of 183 patients met the study inclusion criteria. The median ISS was 14 (range 9-17) points and 15 (8 %) patients developed sepsis. The patients' age [adjusted OR, 1.053; 95 % confidence intervals (CI), 1.015-1.094], ISS (adjusted OR, 1.114; 95 % CI, 1.046-1.187), and emergency surgery (adjusted OR, 3.727; 95 % CI, 1.051-13.221) were independent risk factors for post-traumatic sepsis.

CONCLUSIONS

Among the risk factors identified in the literature, our research confirmed only the patients' age and ISS as risk factors for sepsis after trauma, and, additionally, identified emergency surgery as a risk factor in Korean patients. Therefore, trauma patients who have any of the risk factors mentioned above have a high risk of post-traumatic sepsis, which requires certain precautionary clinical measures.

The preoperative serum C-reactive protein level is a useful predictor of surgical site infections in patients undergoing appendectomy

PURPOSE

Although surgical site infections (SSI) are a major postoperative complication of appendectomy, few studies have focused on the risk factors for SSI. In this study, we investigated the risk factors for SSI in patients who had undergone appendectomy.

METHODS

Three hundred patients who had undergone open appendectomy were enrolled. The patients were divided into two groups based on the presence or absence of SSI. A statistical analysis was performed to assess the clinical features associated with SSI after appendectomy.

RESULTS

A multivariate analysis using the results of univariate analyses revealed that the serum C-reactive protein (CRP) level (≤ 65/> 65, mg/l), length of the operation (≤ 80/> 80, min) and pathology (catarrhal, phlegmonous/gangrenous) were associated with SSI. Among these three clinical features, only the CRP level was found to predict the risk of SSI prior to appendectomy (odds ratio 3.797; 95 % confidence intervals 1.305-11.04; P = 0.014).

CONCLUSION

Preoperative elevation of the serum CRP level (> 65 mg/l) is a valuable predictor of SSI in patients undergoing appendectomy.

Decreased levels of perforin-positive lymphocytes are associated with posttraumatic complications in patients with major trauma

OBJECTIVE

Posttraumatic immune disorder can cause complications including systemic inflammatory response syndrome (SIRS) and multiple-organ dysfunction syndrome (MODS). Cytotoxic granules containing perforin and granzyme-B (GrB) are released by cytotoxic CD8(+) T lymphocytes, NK and γδT cells after major trauma. This prospective clinical study was designed to analyze the association between these immune components and complications after major trauma.

METHODS

We retrospectively studied 48 patients aged between 16 and 65 years admitted within 90min of major trauma (Injury Severity Score>16) and surviving beyond 7 days, and 20 healthy controls. Blood samples were drawn on admission and after 1, 3 and 7 days. CD8(+) T, NK and γδT cell counts in peripheral blood and the levels of perforin and GrB in these cells were analyzed by flow cytometry. Clinical aspects of MODS and SIRS were recorded daily.

RESULTS

CD8(+) T cell counts were not significantly different in patients with SIRS or uncomplicated group, but were depressed in the MODS group after trauma. However, NK cell counts in patients with MODS were significantly depressed only at day 7 after injury, and γδT cell counts were significantly depressed after trauma. Perforin levels in CD8(+) T, NK and γδT cells in patients with MODS were depressed after trauma. GrB levels in NK, CD8(+) T and γδT cells in patients with MODS were significantly depressed at 3 and 7 days post trauma.

CONCLUSION

Posttraumatic MODS is associated with early, sustained, and severe depression of lymphocytes.

Electroacupuncture inhibits apoptosis of splenic lymphocytes in traumatized rats through modulation of the TNF-α/NF-κB signaling pathway

Surgical trauma leads to a severe deterioration of the immune system. Electroacupuncture (EA) may improve the immunodeficiency that occurs following surgery; however, the underlying signaling mechanisms require further study. In the present study, 40 rats were equally randomized into four groups: Control; Control + EA; Trauma; Trauma + EA. EA was applied at the 'Zusanli' (ST36) and 'Lanwei' (Extra37) acupoints, immediately following surgery. The splenic T cells were isolated from the rats 24 h after surgery. The apoptotic rate of the lymphocytes was measured by flow cytometric analysis, and western blotting was used to determine the protein expression levels of caspase-3, caspase-8, tumor necrosis factor (TNF)-α and TNF receptor 1 (TNFR1). The DNA binding activity of nuclear factor (NF)-κB was determined using Trans-AM® ELISA-based kits. The results of the present study showed that surgical trauma induced apoptosis of splenic lymphocytes, and significantly increased the protein expression levels of caspase-3 and caspase-8. This was accompanied by increased expression levels of TNF-α and TNFR1, and a marked reduction in the activity of NF-κB in splenic T cells. Administration of EA significantly decreased the expression levels of caspase-3, caspase-8, TNF-α and TNFR1, elevated the activity of NF-κB, and suppressed the apoptotic rate of the lymphocytes. The data suggests that EA may inhibit the apoptosis of splenic lymphocytes induced by surgical trauma, and ameliorate the postoperative immunosuppression. This may be mediated by the downregulation of TNF-α expression levels and upregulation of the activity of NF-κB.

Catecholamines, steroids and immune alterations in ischemic stroke and other acute diseases

The outcome of stroke patients is not only determined by the extent and localization of the ischemic lesion, but also by stroke-associated infections. Stroke-induced immune alterations, which are related to stroke-associated infections, have been described over the last decade. Here we review the evidence that catecholamines and steroids induced by stroke result in stroke-induced immune alterations. In addition, we compare the immune alterations observed in other acute diseases such as myocardial infarction, brain trauma, and surgical trauma with the changes seen in stroke-induced immune alterations.

Mitochondrial damage-associated molecular patterns released by abdominal trauma suppress pulmonary immune responses

BACKGROUND

Historically, fever, pneumonia, and sepsis after trauma are ascribed to pain and poor pulmonary toilet. No evidence supports that assertion however, and no known biologic mechanisms link injury to infection. Our studies show that injured tissues release mitochondria (MT). Mitochondrial damage-associated molecular patterns (mtDAMPs) however can mimic bacterial pathogen-associated danger molecules and attract neutrophils (PMN). We hypothesized that mtDAMPs from traumatized tissue divert neutrophils from the lung, causing susceptibility to infection.

METHODS

Anesthetized rats (6-10 per group) underwent pulmonary contusion (PC) by chest percussion. When modeling traumatic MT release, some rats had MT isolated from the liver (equal to 5% liver necrosis) injected intraperitoneally (IPMT). Negative controls had PC plus buffer intraperitoneally. Positive controls underwent PC plus cecal ligation and puncture. At 16 hours, bronchoalveolar and peritoneal lavages were performed. Bronchoalveolar lavage fluid (BALF) and peritoneal lavage fluid were assayed for PMN count, albumin, interleukin β, (IL-β), and CINC-1. Assays were normalized to blood urea nitrogen to calculate absolute concentrations.

RESULTS

PC caused alveolar IL-1β and CINC production and a 34-fold increase in BALF neutrophils. As expected, IPMT increased peritoneal IL-1β and CINC and attracted PMN to the abdomen. However, remarkably, IPMT after PC attenuated BALF cytokine accumulation and decreased BALF PMN. Cecal ligation and puncture had no direct effect on BALF PMNs but, like IPMT, blunted BALF leukocytosis after PC.

CONCLUSION

Rather than acting as a "second hit" to enhance PMN-mediated lung injury, mtDAMPs from trauma and pathogen-associated danger molecules from peritoneal infection diminish PMN accumulation in a contused lung. This may make the lung susceptible to pneumonia. This paradigm provides a novel mechanistic model of the relationship among blunt tissue trauma, systemic inflammation, and pneumonia that can be studied to improve trauma outcomes.

Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries

BACKGROUND

An outbreak of invasive fungal infections (IFI) began in 2009 among United States servicemen who sustained blast injuries in Afghanistan. In response, the military trauma community sought a uniform approach to early diagnosis and treatment. Toward this goal, a local clinical practice guideline (CPG) was implemented at Landstuhl Regional Medical Center (LRMC) in early 2011 to screen for IFI in high-risk patients using tissue histopathology and fungal cultures.

METHODS

We compared IFI cases identified after initiation of the CPG (February through August 2011) to cases from a pre-CPG period (June 2009 through January 2011).

RESULTS

Sixty-one patients were screened in the CPG period, among whom 30 IFI cases were identified and compared with 44 pre-CPG IFI cases. Demographics between the two study periods were similar, although significantly higher transfusion requirements (p<0.05) and non-significant trends in injury severity scores and early lower extremity amputation rates suggested more severe injuries in CPG-period cases. Pre-CPG IFI cases were more likely to be associated with angioinvasion on histopathology than CPG IFI cases (48% versus 17%; p<0.001). Time to IFI diagnosis (three versus nine days) and to initiation of antifungal therapy (seven versus 14 days) were significantly decreased in the CPG period (p<0.001). Additionally, more IFI patients received antifungal agent at LRMC during the CPG period (30%) versus pre-CPG period (5%; p=0.005). The CPG IFI cases were also prescribed more commonly dual antifungal therapy (73% versus 36%; p=0.002). There was no statistical difference in length of stay or mortality between pre-CPG and CPG IFI cases; although a non-significant reduction in crude mortality from 11.4% to 6.7% was observed.

CONCLUSIONS

Angioinvasive IFI as a percentage of total IFI cases decreased during the CPG period. Earlier diagnosis and commencement of more timely treatment was achieved. Despite these improvements, no difference in clinical outcomes was observed compared with the pre-CPG period.

[Preoperative management for malnourished patients in abdominal surgery. Practical treatment regimen for reduction of perioperative morbidity]

The incidence of malnutrition in oncological and visceral surgical units can be high. The screening of malnourished patients is very important, especially in the preoperative setting. The available published literature provides crucial knowledge about the risks inherent to malnutrition and subsequent perioperative morbidity and mortality. The preoperative screening of malnourished patients followed by a subsequent renutrition is the key to decreasing rates of postoperative morbidity and mortality. The data and guidelines given by the European Society of Parenteral and Enteral Nutrition (ESPEN) in 2006 for the preoperative nutritional conditioning are clear and give no doubt regarding the necessity of preparation of malnourished patients for elective abdominal surgery. Despite this fact, the observance and application of these guidelines among German surgical units remain low. To fill this void a model of systematic screening and treatment of malnutrition in the preoperative setting for elective abdominal surgery was created and implemented at the university hospital of Oldenburg. A practical treatment regimen was designed to prepare malnourished patients within 2-3 weeks before elective surgery. Initial results regarding the feasibility of preoperative home renutrition therapy were moderate but encouraging. The success of such a conditioning process depends on cooperation between the surgical unit, the general practitioner (GP) and the homecare environment. In the German healthcare system the prescription of home nutrition (i.e. enteral feeding) can lead to the prescription limits of a GP being exceeded and has to be justified to the medical insurance company in each case. This article presents a simple yet applicable way of screening and preparing malnourished patients a few weeks prior to elective surgery. Therefore, simple tools which can be promptly used in daily clinical life, especially in the outpatient surgical consultations prior to elective visceral surgery are proposed.

Major surgical trauma differentially affects T-cells and APC

Macrophages have been reported to initiate immunosuppression following trauma and hemorrhage, and recent experimental studies suggest a pivotal role of T-cells in maintaining immunosuppression. The aim of the present study was to investigate the interaction of APC and T-cells in humans following major surgery. First, APC and T-cells from 14 surgical patients were isolated, counted and characterized by their specific surface marker profile 2 and 24 h postoperatively. Then, these cells were co-incubated with cells of the other type, which had been isolated pre-operatively. Chemokine secretion from pre-operative cells as measured by enzyme immunoassay served as a bioassay for the function of the stimulating postoperative cells. CD3+ T-cells and surface marker CD28 were markedly suppressed postoperatively, while CD3+CD25+CD127−Tregs were not suppressed. CD14+APC counts were increased with the most significant increase observed in CD14+HLA-DR− myeloid-derived suppressor cells. In co-cultures, APC showed increased postoperative secretion of TNF-α and IL-6 independently of whether they had been co-incubated with pre- or postoperative T-cells. T-cells incubated with CD14+ cells 2 h postoperatively secreted diminished amounts of IFN-γ. The results of the study suggest that T-cells play a pivotal role in mediating immunosuppression after major abdominal surgery.

Gender differences in sepsis: cardiovascular and immunological aspects

During sepsis, a complex network of cytokine, immune, and endothelial cell interactions occur and disturbances in the microcirculation cause organ dysfunction or even failure leading to high mortality in those patients. In this respect, numerous experimental and clinical studies indicate sex-specific differences in infectious diseases and sepsis.

Female gender has been demonstrated to be protective under such conditions, whereas male gender may be deleterious due to a diminished cell-mediated immune response and cardiovascular functions. Male sex hormones, i.e., androgens, have been shown to be suppressive on cell-mediated immune responses. In contrast, female sex hormones exhibit protective effects which may contribute to the natural advantages of females under septic conditions. Thus, the hormonal status has to be considered when treating septic patients.

Therefore, potential therapies could be derived from this knowledge. In this respect, administration of female sex hormones (estrogens and their precursors) may exert beneficial effects. Alternatively, blockade of male sex hormone receptors could result in maintained immune responses under adverse circulatory conditions. Finally, administration of agents that influence enzymes synthesizing female sex hormones which attenuate the levels of pro-inflammatory agents might exert salutary effects in septic patients. Prospective patient studies are required for transferring those important experimental findings into the clinical arena.

The imbalance between regulatory and IL-17-secreting CD4⁺T cells in multiple-trauma rat

BACKGROUND

It has been well recognised that a deficit of numbers and function of CD4(+)CD25(+)Foxp3(+)cells (Treg) is attributed to the development of auto-immune diseases, inflammatory diseases, tumour and rejection of transplanted tissue; however, there are controversial data regarding the suppressive effect of Treg cells on the T-cell response in auto-immune diseases. Additionally, interleukin-17 (IL-17)-producing cells (Th17) have a pro-inflammatory role. The balance between Th17 and Treg may be essential for maintaining immune homeostasis and has long been thought as one of the important factors in the development/prevention of auto-immune diseases, inflammatory diseases, tumour and rejection of transplanted tissue, but their role in multiple trauma remains unclear.

OBJECTIVE

This study aims to investigate whether an imbalance of Treg and Th17 effector cells is characteristic of rats suffering from multiple trauma.

METHODS AND SUBJECTIVE

Sixty Sprague-Dawley (SD) rats were randomly divided into three groups. The control group (n=20, group I) no received procedures (normal). The sham group (n=20, group II) only received anaesthesia, cannulation and observation. The bilateral femoral shaft fractures with haemorrhagic shock groups (n=20, group III). Rats in groups II and III were killed at the end of 4h after models were established. Peripheral blood samples were collected for assessment of Treg cells, Th17 cells and cytokines (IL-17, IL-6, IL-2, transforming growth factor beta (TGF-β)) and intestine tissue was collected for intestine histological analysis.

RESULTS

We observed decreased Treg/Th17 ratios in CD4(+)T cells in rats with multiple trauma and a strong inverse correlation with disease activity (intestinal histological scores).

CONCLUSION

We suggest a role for immune imbalance in the pathogenesis and development of multiple trauma. The alteration of the index of Treg/Th17 cells likely indicates the therapeutic response and progress in the clinic.

The evolution of nutrition in critical care: how much, how soon?

Critical care is a very recent advance in the history of human evolution. Prior to the existence of ICU care, when the saber-tooth tiger attacked you had but a few critical hours to recover or you died. Mother Nature, and her survival of the fittest mentality, would never have favored the survival of the modern ICU patient. We now support ICU patients for weeks, or even months. During this period, patients appear to undergo phases of critical illness. A simplification of this concept would include an acute phase, a chronic phase, and a recovery phase. Given this, our nutrition care should probably be different in each phase, and targeted to address the evolution of the metabolic response to injury. For example, as insulin resistance is maximal in the acute phase of critical illness, perhaps we have evolved to benefit from a more hypocaloric, high-protein intervention to minimize muscle catabolism. In the chronic phase, and especially in the recovery phase, more aggressive calorie delivery and perhaps proanabolic therapy may be needed. As the body has evolved limited stores of some key nutrients, adequate nutrition may hinge on more than just how many calories we provide. The provision of adequate protein and other key nutrients at the right time may also be vital. This review will attempt to utilize the fundamentals of our evolution as humans and the rapidly growing body of new clinical research to answer questions about how to administer the right nutrients, in the right amounts, at the right time.

Infections after trauma are associated with subsequent cardiac injury

BACKGROUND

Trauma produces profound inflammatory and immune responses. A second hit such as an infection further disrupts the inflammatory cascade. Inflammatory responses, following traumatic injuries, infections, or both, are emerging as biologic mediators of cardiac disease including myocardial ischemia and infarction. Inflammation-induced and stress-related cardiac damage are increasingly recognized in patients with critical illness. It is believed that cardiac dysfunction is the result of alterations in the inflammatory and immune cascades. Urinary tract infections (UTIs) and ventilator-associated pneumonia (VAP) are associated with increased mortality in trauma patients. UTIs and VAPs induced inflammatory responses. We postulate that increased mortality seen in trauma patients with infections is caused by increased rates of cardiac injury.

METHODS

This is a retrospective review of prospectively collected data. All trauma patients admitted to the intensive care unit at our Level I trauma center during 5 years were included in the analysis. Proportional hazard regression analysis was performed to predict suspicion of cardiac injury (troponin ordered), any cardiac injury (troponin > 0.15 ng/mL), or severe cardiac injury (troponin > 1 ng/mL) using age, sex, Injury Severity Score (ISS), pulmonary disease (chronic obstructive pulmonary disease), heart failure, hypertension, diabetes, and the presence of a UTI or VAP. A similar proportion hazard regression was performed to predict mortality.

RESULTS

In the model to predict any cardiac injury, chronic obstructive pulmonary disease (hazards ratio [HR], 1.9; p = 0.02), ISS (HR, 1.01; p = 0.04), VAP (HR, 5.6; p < 0.01), and UTI (HR, 2.4; p = 0.03) were significant. Neither VAP nor UTI predicted severe cardiac injury. In the model to predict death, any cardiac injury was not associated with mortality, but severe cardiac injury and UTI were associated with mortality as age increased.

CONCLUSION

Infectious complications have been associated with increased mortality in trauma patients. Our data demonstrate that development of VAP or UTI is associated with an increased risk of developing cardiac injury in trauma patients, which may contribute to subsequent increased mortality.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Postoperative peritonitis without an underlying digestive fistula after complete cytoreductive surgery plus HIPEC

BACKGROUND/AIM

Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined.

PATIENTS AND METHODS

Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed.

RESULTS

Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%.

CONCLUSIONS

Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis.

Enhanced immunological response by dendritic cells in male hypogonadism

BACKGROUND

The effect of male hypogonadism on the immune response is poorly understood, even though testosterone has both immunosuppressive and anti-inflammatory effects in men.

DESIGN

In this study, we compared the distribution and functional status of peripheral blood (PB) monocytes, dendritic cells (DCs) [CD16(+) (monocytoid), CD33(+) (myeloid) and CD33(-) (plasmacytoid)] and CD4(+) CD25(+)CD127(-/lo) regulatory T cells from hypogonadic men and control subjects. Immunophenotypic studies were performed both on resting and in vitro-stimulated cells.

RESULTS

Overall, no significant differences were detected on the number of monocytes, DCs and CD4(+) CD25(+) CD127(-/lo) regulatory T cells between both groups of subjects. However, hypogonadic men showed slightly higher numbers of circulating CD16(+) cells expressing the CD107b activation/degranulation-associated marker than controls, such differences reaching statistical significance after in vitro stimulation with CpG oligodeoxynucleotides. Interestingly, antigen-stimulated expression of CD107b on CD16(+) cells inversely correlated with the serum concentrations of total testosterone (r(2)=-0.45; P=0.01), free testosterone (r(2)=-0.48; P=0.005), calculated free testosterone (r(2)=-0.44; P=0.01) and bioavailable testosterone (r(2)=-0.46; P=0.008) among all cases studied, as well as with both the LH (r(2)=-0.53, P=0.04) and FSH (r(2)=-0.54, P=0.04) serum levels among hypogonadic men.

CONCLUSIONS

These findings show an enhanced immunological response of circulating (activated) CD16(+) DCs to antigen stimulation, which was inversely related to testosterone and gonadotropin serum levels. Such findings suggest a modulation by the hypothalamic-hypophyseal-gonadal axis of the immune response and may have clinical implications for hypogonadic men, as regards susceptibility to autoimmune diseases and increased responses to antigenic stimuli.

Systematic review of the management of ischaemic colitis

AIM

The study reviews the literature related to ischaemic colitis (IC) to establish an evidence base for its management and to identify factors predicting severity and mortality.

METHOD

A systematic review of the English language literature was conducted according to recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE, Embase and Cochrane Library databases were searched using the keyword search 'ischaemic colitis OR colon ischaemia OR colonic ischaemia OR management ischaemic colitis'. IC is often misdiagnosed so only studies where the diagnosis was supported by histopathology in every case were included. Critical appraisal was performed of included studies using predefined quality assessment checklists and narrative data synthesis.

RESULTS

In all, 2610 publications were identified. Of these, eight retrospective case series and three case controlled studies describing 1049 patients were included. Medical management was used in 80.3% patients of whom 6.2% died. Surgery was required in 19.6% of whom 39.3% died. The overall mortality of IC was 12.7%. Lack of rectal bleeding, peritonism and renal dysfunction were commonly quoted predictors of severity; however, right sided IC appeared to be the most significant predictor of outcome.

CONCLUSION

Most patients with IC can be managed conservatively. Right sided IC may be the most significant predictor of severity.