Sepsis and Cancer: An Interplay of Friends and Foes

Early and high-volume administration of sodium bicarbonate in sepsis-associated acute kidney injury in patients with malignancies, during continuous renal replacement therapy

INTRODUCTION

Sepsis is an uncontrolled systemic response to infection that leads to life-threatening organ dysfunction. The in-hospital mortality rate remains significantly high in septic shock patients with malignancies. This study investigates whether early and high-volume administration of sodium bicarbonate during continuous renal replacement therapy (CRRT) can reduce 28-day mortality, increase shock reversal rates, and shorten the duration of CRRT, mechanical ventilation, and intensive care unit (ICU) stays. The goal is to provide valuable clinical data for the management of cancer patients with sepsis-associated acute kidney injury (SAKI).

MATERIALS AND METHODS

A retrospective study was performed on 88 patients who were admitted to the ICU and received continuous renal replacement therapy (CRRT) for acute renal failure secondary to sepsis at the Cancer Center of Sun Yat-sen University from March 2010 to October 2021. Based on the initiation time of CRRT and the volume of sodium bicarbonate infusion, patients were divided into four groups: the early high-volume group, early low-volume group, late high-volume group, and late low-volume group.

RESULTS

The results of this study showed that in the 28-day mortality model, established using the Cox proportional hazards method, early CRRT (HR 0.473; 95% CI 0.245-0.915, p = 0.026) and high-volume sodium bicarbonate infusion (HR 0.173; 95% CI 0.078-0.383, p < 0.001) were identified as two independent protective factors. The 28-day mortality rate in the early high-volume group (15.0%) was significantly lower than that of the other three groups (60.0%, 30.0%, and 75.0%, respectively; χ2 = 23.822, p < 0.001). Additionally, the shock reversal rate in the early high-volume group (80.0%) was significantly higher compared to the other groups (35.0%, 45.0%, and 35.7%; χ2 =13.576, p = 0.004). The duration of CRRT was shorter in the early high-volume group (35.0 ± 4.45 h) than in the other groups (70.0 ± 30.19 h, 48.0 ± 5.22 h, and 72.0 ± 19.84 h; χ2 =11.278, p = 0.01). Furthermore, the duration of mechanical ventilation (7.0 ± 3.33 days) was lower in the early high-volume group compared to the other groups (8.0 ± 1.12 days,10.0 ± 1.11 days, and 8.0 ± 2.65 days; χ2 =8.064, p = 0.045), as was the length of ICU stay (7.0 ± 0.89 days) compared to the other groups (13.0 ± 3.35 days, 10.0 ± 1.49 days, and10.0 ± 3.70 days; χ2 = 9.184, p = 0.027).

CONCLUSION

Early and high-volume administration of sodium bicarbonate during CRRT may reduce 28-day mortality and improve shock reversal rates in patients with sepsis-associated acute kidney injury complicated by malignancy. Prospective randomized controlled large sample studies are needed to confirm this.

Causality of genetically predicted solid cancers on risk of sepsis: insights from Mendelian randomization

OBJECTIVE

Some studies have found that solid cancer and sepsis are linked. The primary objective of this study is to explore this connection further, investigating the causal effect of solid cancer on sepsis by applying Mendelian randomization (MR).

METHODS

Using genome-wide association study (GWAS) data from the Medical Research Council-Integrative Epidemiology Unit database, we conducted a bidirectional two-sample Mendelian randomization (MR) analysis to test the causal association between solid cancers (10 GWAS, 1,345,730 samples) and sepsis (2 GWAS, 1,288,566 samples) in European ancestry. In the context of multivariable MR analysis, lifestyle risk factors such as body mass index (BMI) were incorporated, with relevant clinical interventions taken into account.

RESULTS

The two-sample MR analysis suggested a causal relationship between renal cancer and sepsis (OR = 1.051, 95% CI = 1.019-1.085, PIVW = 1.800E-03). Renal cancer (OR = 1.064, 95% CI = 1.011-1.120, PIVW = 1.60E-02), BMI (OR = 1.315, 95% CI = 1.176-1.471, PIVW = 1.25E-06), and smoking (OR = 1.139, 95% CI = 1.009-1.286, PIVW = 3.65E-02) showed a significant association with sepsis in our lifestyle multivariable MR analysis. Reverse MR analysis indicates that sepsis may prevent renal cancer. (OR = 0.924, 95% CI = 0.865 -0.988, PIVW = 2.060E-02).

CONCLUSIONS

Our findings suggest renal cancer is correlated with the occurrence of sepsis. This association is partially influenced by BMI and smoking. Unexpectedly, sepsis may act as a protective effect against renal cancer.

Clinical subtypes identification and feature recognition of sepsis leukocyte trajectories based on machine learning

Sepsis is a highly variable condition, and tracking leukocyte patterns may offer insights for tailored treatment and prognosis. We used the MIMIC-IV database to analyze patients diagnosed with Sepsis-3 within 24 h of ICU admission. Latent class mixed models (LCMM) were applied to leukocyte trajectories to identify sepsis subtypes. The primary outcome was 28-day all-cause mortality, with secondary outcomes including the need for life-support therapies. Associations between leukocyte trajectories and outcomes were assessed using multivariate regression, and findings were externally validated with the eICU database. Use the XGBoost model to identify baseline characteristics of high-risk mortality sepsis subgroups for predicting subgroup allocation upon patient admission to the ICU, and apply the SHAP method to interpret the contributing variables of the model. Among 7410 sepsis patients, eight distinct leukocyte trajectory subtypes were identified. Among those subtypes, patients with persistently high leukocyte levels had the poorest prognosis (HR 3.00; 95% CI 2.48-3.62) and a significantly greater need for life-support therapies; Patients with persistently low white blood cell levels had a higher risk of death (HR 1.68; 95% CI 1.24-2.27) but were less likely to receive invasive mechanical ventilation. Incorporating early ICU baseline variables into an XGBoost algorithm enables effective prediction of high-mortality risk subgroups (AUC > 0.8). SHAP method reveals distinct early clinical characteristics between hyperinflammatory subtypes (class 4, 7, and 8) and the hypoinflammatory subtype (class 1). In ICU-admitted sepsis patients, eight leukocyte trajectories are identified, which is the key independent predictors of prognosis, separating from single leukocyte measurements. High-mortality risk subgroups exhibit distinct clinical characteristics at ICU admission, providing valuable insights for their prediction and personalized early intervention.

Interaction between post-tumor inflammation and vascular smooth muscle cell dysfunction in sepsis-induced cardiomyopathy

Background

Sepsis-induced cardiomyopathy (SIC) presents a critical complication in cancer patients, contributing notably to heart failure and elevated mortality rates. While its clinical relevance is well-documented, the intricate molecular mechanisms that link sepsis, tumor-driven inflammation, and cardiac dysfunction remain inadequately explored. This study aims to elucidate the interaction between post-tumor inflammation, intratumor heterogeneity, and the dysfunction of VSMC in SIC, as well as to evaluate the therapeutic potential of exercise training and specific pharmacological interventions.

Methods

Transcriptomic data from NCBI and GEO databases were analyzed to identify differentially expressed genes (DEGs) associated with SIC. Weighted gene co-expression network analysis (WGCNA), gene ontology (GO), and KEGG pathway enrichment analyses were utilized to elucidate the biological significance of these genes. Molecular docking and dynamics simulations were used to investigate drug-target interactions, and immune infiltration and gene mutation analyses were carried out by means of platforms like TIMER 2.0 and DepMap to comprehend the influence of DVL1 on immune responsiveness.

Results

Through the utilization of the datasets, we discovered the core gene DVL1 that exhibited remarkable up-regulated expression both in SIC and in diverse kinds of cancers, which were associated with poor prognosis and inflammatory responses. Molecular docking revealed that Digoxin could bind to DVL1 and reduce oxidative stress in SIC. The DVL1 gene module related to SIC was identified by means of WGCNA, and the immune infiltration analysis demonstrated the distinctive immune cell patterns associated with DVL1 expression and the impact of DVL1 on immunotherapeutic resistance.

Conclusions

DVL1 is a core regulator of SIC and other cancers and, therefore, can serve as a therapeutic target. The present study suggests that targeted pharmacological therapies to enhance response to exercise regimens may be a novel therapeutic tool to reduce the inflammatory response during sepsis, particularly in cancer patients. The identified drugs, Digoxin, require further in vivo and clinical studies to confirm their effects on SIC and their potential efforts to improve outcomes in immunotherapy-resistant cancer patients.

A Qualitative Study Exploring the Rehabilitation Experience of Individuals with a Previous Diagnosis of Cancer and/or Sepsis, Their Caregivers, and Health Providers

BACKGROUND/OBJECTIVES

Survivors of cancer have more than double the risk of developing sepsis compared to those with no history of cancer. Those who develop sepsis have lasting side effects reducing their physical function and quality of life. Rehabilitation-related needs and barriers are unknown for individuals with cancer who have had sepsis. The aim of this study was to examine the rehabilitation-related experiences of patients with cancer and/or sepsis, their caregivers, and the healthcare team and the educational needs regarding the rehabilitation of patients with sepsis.

METHODS

We performed a qualitative descriptive study using interviews and focus groups for data generation. We included adults living in Canada who were English-speaking, currently or formerly diagnosed with cancer and/or sepsis, or a caregiver of someone with a current or past diagnosis of cancer and/or sepsis, or a healthcare professional working with this population. Two reviewers used NVivo software for data management and conducted a qualitative data analysis.

RESULTS

We included 30 study participants (nine patients, nine caregivers, 12 healthcare professionals; 15 for one-on-one interviews; 15 in the focus groups). We identified three overarching themes relating to rehabilitation: (1) the rehabilitation experience did not meet the patient's care expectations; (2) barriers to rehabilitation exist on multiple levels; (3) there are important gaps in education on how to improve physical and psychosocial outcomes. We identified two themes related to educational resources: (1) the educational content provided must be specific and meaningful; (2) multi-modal resources are needed to suit diverse partner needs.

CONCLUSIONS

We identified rehabilitation barriers related to healthcare settings, the pandemic, and workplace culture for those with cancer and sepsis. This study highlights the need to create diverse educational resources on rehabilitation for those with sepsis to improve outcomes and patient/caregiver satisfaction.

Advancing sepsis diagnosis and immunotherapy machine learning-driven identification of stable molecular biomarkers and therapeutic targets

Sepsis represents a significant global health challenge, necessitating early detection and effective treatment for improved outcomes. While traditional inflammatory markers facilitate the diagnosis of sepsis, the aspect of immune suppression remains poorly addressed. This study aimed to identify critical immune-related genes (IIRGs) associated with sepsis through genomic analysis and machine learning techniques, thereby enhancing diagnostic and treatment response predictions. Analyses of two extensive datasets were conducted, identifying significant immune genes using the ESTIMATE algorithm, Weighted Gene Correlation Network Analysis (WGCNA), and five machine learning methods. Prediction models were constructed and validated using six machine learning algorithms, achieving high accuracy (AUC > 0.75). Eleven key IIRGs were identified as active in immune pathways, such as the JAK-STAT signaling pathway, and were significantly correlated with immune cell infiltration in sepsis. Additionally, drug sensitivity analysis indicated that IIRGs correlated with responses to anticancer drugs. These results underscore the potential of these genes in enhancing sepsis diagnosis and treatment, highlighting the imperative for further validation across diverse populations.

Combination therapy with lipid prodrug liposomes reshapes disease-associated neutrophils to promote the cancer-immunity cycle

Neutrophils play a critical role in the cancer-immunity cycle and are associated with poor clinical outcomes. Recent research has primarily focused on the targeted delivery, phenotypic reversal, and reprogramming of tumor-associated neutrophils, while the impact of disease-associated neutrophils (DANs) on antitumor therapy remains understudied. Since liposomes, as drug delivery carriers, possess excellent biocompatibility and stability, making them particularly suitable for combination therapy, we optimized the formulation of asymmetrically branched polyethylene glycol-modified mitomycin C lipid prodrug liposomes (PEG2,5 K@MLP-L) and prepared hyaluronic acid and sialic acid ester stearate-co-modified dexamethasone palmitate liposomes (HA*SAS@DXP-L) to study DANs in normal, obese, aged, and septic mice. An increase in mitochondria and lysosomes in Ly-6G+CXCR2high DANs accelerated drug clearance, reduced CD3+CD8+ T cell activity in tumor-draining lymph nodes, and decreased CD8+ T cell infiltration in tumors. As the proportion of DANs increased, the efficacy of PEG2,5 K@MLP-L decreased. Combination therapy with PEG2,5 K@MLP-L and HA*SAS@DXP-L can reshape DANs, promote the cancer-immunity cycle, and enhance treatment efficacy. This study identifies key characteristics and functions of DANs and presents a promising strategy for improving clinical outcomes.

Role of MLIP in burn-induced sepsis and insights into sepsis-associated cancer progression

Introduction

Burn-induced sepsis is a critical clinical challenge marked by systemic inflammation, immune dysregulation, and high mortality. Macrophage-driven inflammatory pathways are central to sepsis pathogenesis, while immune cell metabolic reprogramming plays a key role in both sepsis and cancer progression.

Methods

Bioinformatics analyses using GEO, TCGA, and GTEx datasets identified MLIP-modulated genes linked to immune responses and prognosis. In vitro, LPS-stimulated HUVEC cells were used to study MLIP's effects on inflammation and macrophage function through cell viability, ROS levels, cytokine expression, qRT-PCR, and immunofluorescence assays.

Results

MLIP-modulated genes were associated with immune-related metabolic pathways in both sepsis and cancer. Epigenetic analysis showed MLIP expression is regulated by promoter methylation and chromatin accessibility. Prognostic analyses revealed MLIP's impact on survival outcomes across cancer types. In vitro, MLIP reduced inflammation, oxidative stress, and macrophage hyperactivation.

Conclusions

MLIP regulates immune-metabolic dynamics in burn-induced sepsis, influencing macrophage activity and oxidative stress. Its role in metabolic reprogramming suggests MLIP as a potential therapeutic target linking immune modulation and cancer progression. Further research on MLIP's role in immune evasion and tumor metabolism may inform novel therapeutic strategies.

What should intensivists know about immune checkpoint inhibitors and their side effects?

The pharmacological group of immune checkpoint-inhibitors (ICI) has revolutionized the field of oncology in the last ten years. The improvements in the survival of certain cancers thanks to these treatments comes at the cost of an increased morbidity and mortality due to certain immune related adverse events (irAE). This review will concentrate on the irAE that more frequently require intensive care unit (ICU) admission. The infectious burden of patients treated with ICI is also explored, shining light not only on the infections caused by the immunosuppression needed to manage the different irAE, but also on the specific infections arising from a unique immune dysregulation only seen in ICI treated patients.

The Effect of Postoperative Sepsis on 1-Year Mortality and Cancer Recurrence Following Transhiatal Esophagectomy for Esophageal-Gastric Junction Adenocarcinomas: A Retrospective Observational Study

INTRODUCTION

Transhiatal esophagectomy (THE) is used for specific gastroesophageal junction adenocarcinomas. THE is a high-risk surgical procedure. We aimed to assess the impact of postoperative sepsis (sepsis or septic shock) on the 1-year mortality after THE and to determine the risk factors associated with these outcomes. Secondly, we aimed to assess the impact of postoperative sepsis and other risk factors on 1-year cancer recurrence.

METHOD

A retrospective, observational study was undertaken at the Paoli-Calmettes Institute, Marseille, from January 2012 to March 2022.

RESULTS

Of 118 patients, 24.6% (n = 29) presented with postoperative sepsis. Their 1-year mortality was 11% (n = 13), and their 1-year cancer recurrence was 23.7% (n = 28). In the multivariate analysis, independent factors for 1-year mortality were the following: postoperative sepsis (OR: 7.22 (1.11-47); p = 0.038), number of lymph nodes removed (OR: 0. 78 (0.64-0.95); p = 0.011), recurrence at one year (OR: 9.22 (1.66-51.1); p = 0.011), mediastinitis (OR: 17.7 (1.43-220); p = 0.025) and intraoperative driving pressure (OR: 1.77 (1.17-2.68); p = 0.015). For postoperative sepsis, independent factors were low-dose vasopressors (OR: 0.26; 95% CI: 0.07-0.95; p = 0.049), a cervical abscess (OR: 5.33; 95% CI: 1.5-18.9; p = 0.01), bacterial pneumonia (OR: 11.1; 95% CI: 2.99-41.0; p < 0.001) and a high SOFA score on day 1 (OR: 2.65; 95% CI: 1.36-5.19; p = 0.04). For 1-year cancer recurrence, independent factors were the number of lymph nodes removed (sHR: 0.87; 95% CI: 0.79-0.96; p = 0.005), pTNM stages of III or IV (sHR: 8.29; 95% CI: 2.71-25.32; p < 0.001) and postoperative sepsis (sHR: 6.54; 95% CI: 1.70-25.13; p = 0.005).

CONCLUSIONS

Our study indicates that after THE, postoperative sepsis influences survival and cancer recurrence. We identified the associated risk factors, suggesting an early diagnosis might decrease mortality and recurrence.

What intensivists need to know about cytomegalovirus infection in immunocompromised ICU patients

PURPOSE

Advances in therapeutic care are leading to an increase in the number of patients living with overt immunosuppression. These patients are at risk of cytomegalovirus (CMV) infection and disease that can lead to or develop during ICU admission. This manuscript aims to describe the clinical presentation, risk factors, and management of CMV infection and disease in this patient population.

METHODS

We conducted a literature search in PubMed up to April 2024, focusing on CMV infection and disease in patients with overt immunosuppression (hematopoietic stem cell and solid organ transplantation, solid or hematologic malignancies, HIV infection, immunosuppressive drugs, including corticosteroids, and primary immunodeficiencies) admitted to the intensive care unit (ICU). As there is limited ICU-specific data on CMV in immunosuppressed patients, many of the findings were extrapolated from the general literature.

RESULTS

CMV infection and disease in immunocompromised critically ill patients is associated with increased mortality and presents significant management challenges. Clinical manifestations are diverse, shaped by the underlying immune deficiency and primary disease. Pneumonia and encephalitis are among the most severe CMV end-organ diseases. CMV infection may also increase the risk of secondary infections and induce life-threatening conditions, such as thrombotic microangiopathy. Importantly, CMV reactivation is not synonymous with CMV disease, and qPCR testing of body fluids cannot reliably differentiate between viral shedding and tissue-invasive infection, which requires histopathological confirmation. Ganciclovir is commonly the first-line anti-viral, though maribavir shows potential for patients unresponsive to other antivirals. Identifying patients who require prophylactic or preemptive antiviral therapy is essential.

CONCLUSIONS

CMV infection and disease in critically ill immunocompromised patients pose a unique challenge for intensivists. The broad spectrum of clinical presentations and the difficulty in distinguishing CMV-related symptoms from other causes require a high level of clinical suspicion. Accurate interpretation of nucleic acid load levels and careful evaluation of CMV's pathogenic role when it is found are critical. Further studies focusing specifically on CMV infection and disease in critically ill immunocompromised patients are needed to optimize management strategies.

Identification of common core genes and pathways in childhood sepsis and cancer by bioinformatics analysis

INTRODUCTION

Sepsis and cancer are both leading causes of death worldwide, and they share several pathophysiological characteristics. Some studies have suggested a possible association between sepsis and cancer; however, few have investigated the core genes involved in both diseases.

METHODS

Core genes common to both sepsis and cancer were identified using pediatric sepsis datasets (GEO: GSE26378, GSE4607, GSE8121 and GSE13904) and cancer databases (TCGA: BRCA, COADREAD, ESCA, KIRC, LIHC, LUAD, STAD). Gene Ontology (GO) and Reactome enrichment analyses, along with a protein-protein interaction (PPI) network analysis, were performed. Pharmacophore screening was applied to predict the targets of oxymatrine and ulinastatin, and potential target genes shared by both cancer and sepsis were identified. Survival analysis was performed. The association between the target genes and tumor size and number of positive lymph nodes was investigated by Pearson correlation analysis. The association between the target genes and tumor stage was investigated by Fisher's exact test. Molecular docking analysis was performed to evaluate the affinity of the candidate drugs for their targets.

RESULTS

A total of 641 common genes were identified. GO enrichment analysis showed that common genes were enriched in neutrophil degranulation, inflammatory response and innate immune response. Reactome enrichment analysis showed that common genes were enriched in neutrophil degranulation, interleukin-4 and interleukin-13 signaling, transcriptional regulation of granulopoiesis and interleukin-10 signaling. The PPI network showed that the top 10 core genes were TLR4, IL1B, IL10, ITGAM, TLR2, PTPRC, CDK1, FOS, MMP9 and ITGB2. The survival analysis showed that the high expression of BCAT1, CSAD, G6PD, GM2A, MMP9, PYGL and TOP2A was associated with poorer prognosis in several cancers. Molecular docking showed that oxymatrine and ulinastatin can bind to protein targets with highly stable binding.

CONCLUSIONS

We identified genes with common effects on both childhood sepsis and cancer, which provides new insights into the association between sepsis and cancer. In addition, two drugs with potential clinical application value were identified. Further studies are required to validate the role of these common core genes in sepsis and cancer and to evaluate the potential utility of these drugs.

Assessing the causal relationship between non-small cell lung cancer and sepsis: a Mendelian randomization study

BACKGROUND

A Two-sample Mendelian randomization (MR) Analysis was used to assess the causal relationship between non-small cell lung cancer (NSCLC) and sepsis.

METHOD

Single nucleotide polymorphisms (SNPs) closely associated with NSCLC were utilized as instrumental variables (IVs) in this study. The Inverse Variance Weighted (IVW) method was used as the primary method for MR analysis, supplemented by the Weighted median, Weighted model, and MR-Egger regression method. Sensitivity analysis was conducted to improve result robustness, and data from various sources were validated and integrated. Bonferroni tests were applied to adjust for multiple comparisons.

RESULTS

After Bonferroni tests correcting the combined results, MR analysis revealed a significant association between genetically predicted NSCLC and an increased susceptibility to sepsis (odds ratios [OR]: 1.140, 95% confidence interval [CI]: 1.085-1.199, P = 2.61 × 10- 7). The combined results demonstrated that NSCLC is associated with a heightened risk of sepsis in patients under 75 years of age (OR: 1.085, 95%CI: 1.037-1.353, P = 3.84 × 10- 4). Furthermore, lung adenocarcinoma (LUAD) was found to be potentially associated with an increased susceptibility to sepsis (OR: 1.040, 95% CI: 1.009-1.073, P = 1.16 × 10- 2). These results withstood multiple sensitivity analyses, demonstrating their robustness.

CONCLUSION

This study confirms that NSCLC can significantly increase susceptibility to sepsis at the genetic level, providing valuable insights for the early identification of individuals at risk for sepsis.

Cancer and sepsis: future challenges for long-term outcome

PURPOSE OF REVIEW

The purpose of this review is to investigate the long-term outcomes of cancer patients who experience sepsis or septic shock.

RECENT FINDINGS

Sepsis is a frequent cause of ICU admission in cancer patients, accounting for approximately 15% of such cases. Short-term mortality rates among these patients vary widely across studies, but they are consistently found to be slightly higher than those of noncancer patients. However, there is a lack of evidence regarding the long-term outcomes of cancer patients who have experienced sepsis or septic shock. The few available studies have reported relatively high mortality rates, reaching around 80% in a few cohort studies. Although several observational studies have noted a decrease in 1-year mortality rates over time, observational data also suggest that sepsis may increase the risk of cancer in the long run.

SUMMARY

As cancer is becoming a chronic disease, there is an urgent need for studies on the quality of life of cancer patients who have experienced sepsis. The relationship between sepsis and cancer extends beyond its impact on the progression of cancer, as sepsis might also contribute to the development of cancer.

Septic shock in the immunocompromised cancer patient: a narrative review

Immunosuppressed patients, particularly those with cancer, represent a momentous and increasing portion of the population, especially as cancer incidence rises with population growth and aging. These patients are at a heightened risk of developing severe infections, including sepsis and septic shock, due to multiple immunologic defects such as neutropenia, lymphopenia, and T and B-cell impairment. The diverse and complex nature of these immunologic profiles, compounded by the concomitant use of immunosuppressive therapies (e.g., corticosteroids, cytotoxic drugs, and immunotherapy), superimposed by the breakage of natural protective barriers (e.g., mucosal damage, chronic indwelling catheters, and alterations of anatomical structures), increases the risk of various infections. These and other conditions that mimic sepsis pose substantial diagnostic and therapeutic challenges. Factors that elevate the risk of progression to septic shock in these patients include advanced age, pre-existing comorbidities, frailty, type of cancer, the severity of immunosuppression, hypoalbuminemia, hypophosphatemia, Gram-negative bacteremia, and type and timing of responses to initial treatment. The management of vulnerable cancer patients with sepsis or septic shock varies due to biased clinical practices that may result in delayed access to intensive care and worse outcomes. While septic shock is typically associated with poor outcomes in patients with malignancies, survival has significantly improved over time. Therefore, understanding and addressing the unique needs of cancer patients through a new paradigm, which includes the integration of innovative technologies into our healthcare system (e.g., wireless technologies, medical informatics, precision medicine), targeted management strategies, and robust clinical practices, including early identification and diagnosis, coupled with prompt admission to high-level care facilities that promote a multidisciplinary approach, is crucial for improving their prognosis and overall survival rates.

Therapeutically Fine-Tuning Autonomic Nervous System to Treat Sepsis: A New Perspective on the Immunomodulatory Effects of Acupuncture

Recent studies have highlighted the immunomodulatory effects of acupuncture on sepsis and proposed novel non-pharmacological or bioelectronic approaches to managing inflammatory illnesses. Establishing rules for selectively activating sympathetic or vagal nerve-mediated anti-inflammatory pathways using acupuncture has valuable clinical applications. Over the years, studies have revealed the segmental modulatory role of acupuncture in regulating visceral function by targeting the autonomic nervous system (ANS). In this review, we aim to summarize recent findings on acupuncture in treating sepsis, focusing on the underlying ANS mechanism, as well as the rules of acupoint specificity, intensity, frequency, and other parameters utilized in these studies. Mechanistically, the immunomodulatory properties of the sympathetic nervous system have been highlighted. Furthermore, we explore the immunotherapeutic benefits of acupuncture in treating sepsis. A better understanding of the immunoregulatory mechanism of sympathetic nervous system may offer novel approaches for the development of therapeutics to treat or prevent a variety of inflammatory diseases.

A Case of Revelation Due to Pegfilgrastim

Pegfilgrastim is a granulocyte colony-stimulating factor used in non-myeloid cancer patients to prevent infections and neutropenic fevers. Although this medication is widely used to induce granulocytosis in pancytopenia patients, there are certain instances where such a situation can cause severe side effects. In this case, we present a patient with a history of metastatic colon cancer who is currently taking pegfilgrastim to counter the agranulocytosis caused by his chemotherapy treatment. However, the patient shortly developed localized left-sided jaw swelling, and upon further investigation, the granulocyte colony-stimulating factor revealed an underlying bacteremia. A discussion will also be held regarding the mechanism of action of how pegfilgrastim induced this patient's symptoms as well as the risks and benefits.

Causal relationships between lung cancer and sepsis: a genetic correlation and multivariate mendelian randomization analysis

Background

Former research has emphasized a correlation between lung cancer (LC) and sepsis, but the causative link remains unclear.

Method

This study used univariate Mendelian Randomization (MR) to explore the causal relationship between LC, its subtypes, and sepsis. Linkage Disequilibrium Score (LDSC) regression was used to calculate genetic correlations. Multivariate MR was applied to investigate the role of seven confounding factors. The primary method utilized was inverse-variance-weighted (IVW), supplemented by sensitivity analyses to assess directionality, heterogeneity, and result robustness.

Results

LDSC analysis revealed a significant genetic correlation between LC and sepsis (genetic correlation = 0.325, p = 0.014). Following false discovery rate (FDR) correction, strong evidence suggested that genetically predicted LC (OR = 1.172, 95% CI 1.083-1.269, p = 8.29 × 10-5, P fdr = 2.49 × 10-4), squamous cell lung carcinoma (OR = 1.098, 95% CI 1.021-1.181, p = 0.012, P fdr = 0.012), and lung adenocarcinoma (OR = 1.098, 95% CI 1.024-1.178, p = 0.009, P fdr = 0.012) are linked to an increased incidence of sepsis. Suggestive evidence was also found for small cell lung carcinoma (Wald ratio: OR = 1.156, 95% CI 1.047-1.277, p = 0.004) in relation to sepsis. The multivariate MR suggested that the partial impact of all LC subtypes on sepsis might be mediated through body mass index. Reverse analysis did not find a causal relationship (p > 0.05 and P fdr > 0.05).

Conclusion

The study suggests a causative link between LC and increased sepsis risk, underscoring the need for integrated sepsis management in LC patients.

The beneficial effects of Rosuvastatin in inhibiting inflammation in sepsis

Microbial infection-induced sepsis causes excessive inflammatory response and multiple organ failure. An effective strategy for the treatment of sepsis-related syndromes is still needed. Rosuvastatin, a typical β-hydroxy β-methylglutaryl-CoA reductase inhibitor licensed for reducing the levels of low-density lipoprotein cholesterol in patients with hyperlipidemia, has displayed anti-inflammatory capacity in different types of organs and tissues. However, its effects on the development of sepsis are less reported. Here, we found that the administration of Rosuvastatin reduced the mortality of sepsis mice and prevented body temperature loss. Additionally, it inhibited the production of inflammatory cytokines such as tumor necrosis factor (TNF-α), Interleukin-6 (IL-6), interleukin-1β (IL-1β), and migration inhibitory factor (MIF) in peritoneal lavage supernatants of animals. The increased number of mononuclear cells in the peritoneum of sepsis mice was reduced by Rosuvastatin. Interestingly, it ameliorated lung inflammation and improved the hepatic and renal function in the sepsis animals. Further in vitro experiments show that Rosuvastatin inhibited lipopolysaccharide (LPS)-induced production of proinflammatory cytokines in RAW 264.7 macrophages by preventing the activation of nuclear factor kappa-B (NF-κB). Our findings demonstrate that the administration of Rosuvastatin hampered organ dysfunction and mitigated inflammation in a relevant model of sepsis.

A Transcriptomic Approach to Understand Patient Susceptibility to Pneumonia After Abdominal Surgery

OBJECTIVE

To describe immune pathways and gene networks altered following major abdominal surgery and to identify transcriptomic patterns associated with postoperative pneumonia.

BACKGROUND

Nosocomial infections are a major healthcare challenge, developing in over 20% of patients aged 45 or over undergoing major abdominal surgery, with postoperative pneumonia associated with an almost 5-fold increase in 30-day mortality.

METHODS

From a prospective consecutive cohort (n=150) undergoing major abdominal surgery, whole-blood RNA was collected preoperatively and at 3 time-points postoperatively (2-6, 24, and 48 h). Twelve patients diagnosed with postoperative pneumonia and 27 matched patients remaining infection-free were identified for analysis with RNA-sequencing.

RESULTS

Compared to preoperative sampling, 3639 genes were upregulated and 5043 downregulated at 2 to 6 hours. Pathway analysis demonstrated innate-immune activation with neutrophil degranulation and Toll-like-receptor signaling upregulation alongside adaptive-immune suppression. Cell-type deconvolution of preoperative RNA-sequencing revealed elevated S100A8/9-high neutrophils alongside reduced naïve CD4 T-cells in those later developing pneumonia. Preoperatively, a gene-signature characteristic of neutrophil degranulation was associated with postoperative pneumonia acquisition ( P =0.00092). A previously reported Sepsis Response Signature (SRSq) score, reflecting neutrophil dysfunction and a more dysregulated host response, at 48 hours postoperatively, differed between patients subsequently developing pneumonia and those remaining infection-free ( P =0.045). Analysis of the novel neutrophil gene-signature and SRSq scores in independent major abdominal surgery and polytrauma cohorts indicated good predictive performance in identifying patients suffering later infection.

CONCLUSIONS

Major abdominal surgery acutely upregulates innate-immune pathways while simultaneously suppressing adaptive-immune pathways. This is more prominent in patients developing postoperative pneumonia. Preoperative transcriptomic signatures characteristic of neutrophil degranulation and postoperative SRSq scores may be useful predictors of subsequent pneumonia risk.

A Transcriptomic Approach to Understand Patient Susceptibility to Pneumonia After Abdominal Surgery

OBJECTIVE

To describe immune pathways and gene networks altered following major abdominal surgery and to identify transcriptomic patterns associated with postoperative pneumonia.

BACKGROUND

Nosocomial infections are a major healthcare challenge, developing in over 20% of patients aged 45 or over undergoing major abdominal surgery, with postoperative pneumonia associated with an almost 5-fold increase in 30-day mortality.

METHODS

From a prospective consecutive cohort (n=150) undergoing major abdominal surgery, whole-blood RNA was collected preoperatively and at 3 time-points postoperatively (2-6, 24, and 48 h). Twelve patients diagnosed with postoperative pneumonia and 27 matched patients remaining infection-free were identified for analysis with RNA-sequencing.

RESULTS

Compared to preoperative sampling, 3639 genes were upregulated and 5043 downregulated at 2 to 6 hours. Pathway analysis demonstrated innate-immune activation with neutrophil degranulation and Toll-like-receptor signaling upregulation alongside adaptive-immune suppression. Cell-type deconvolution of preoperative RNA-sequencing revealed elevated S100A8/9-high neutrophils alongside reduced naïve CD4 T-cells in those later developing pneumonia. Preoperatively, a gene-signature characteristic of neutrophil degranulation was associated with postoperative pneumonia acquisition ( P =0.00092). A previously reported Sepsis Response Signature (SRSq) score, reflecting neutrophil dysfunction and a more dysregulated host response, at 48 hours postoperatively, differed between patients subsequently developing pneumonia and those remaining infection-free ( P =0.045). Analysis of the novel neutrophil gene-signature and SRSq scores in independent major abdominal surgery and polytrauma cohorts indicated good predictive performance in identifying patients suffering later infection.

CONCLUSIONS

Major abdominal surgery acutely upregulates innate-immune pathways while simultaneously suppressing adaptive-immune pathways. This is more prominent in patients developing postoperative pneumonia. Preoperative transcriptomic signatures characteristic of neutrophil degranulation and postoperative SRSq scores may be useful predictors of subsequent pneumonia risk.

Causes of death and nomogram for patients with oncologic hepato-biliary-pancreatic disorders: A large-cohort study

The improvement of digestive cancer survival results in increased morbidity of noncancerous comorbidities. This study aimed at clarifying causes of death (COD) and predicting overall survival (OS) in patients diagnosed with liver cancer, gallbladder cancer, cholangiocarcinoma, and pancreatic cancer. We used the Surveillance, Epidemic, and End Results database to extract information. Nomograms of multivariate Cox regression was used to predict OS of cancer patients. The models were evaluated using the concordance indexes (C-indexes), the receiver operating characteristic curves and calibration curves. Respectively 58,895, 15,324, 30,708, and 109,995 cases with cancer of liver, gallbladder, bile duct or pancreas were retrieved between 2000 and 2020. Approximately 80% deaths occurred within 1 years after cancer diagnosis. Sequence in noncancerous COD proportion was diverse, while diseases of heart always accounted for a great part. Risks of death from most noncancerous COD were significantly higher than that of the cancer-free population. Nomograms were developed by predictors of interest such as age, therapy and TNM stage. The concordance indexes of nomograms were 0.756, 0.729, 0.763, and 0.760 respectively, well-calibrating to the reality. The 0.5-, 1-, and 2-year areas under the receiver operating characteristic curve were about 0.800, indicating good reliability and accuracy. Noncancerous COD accounted for larger part in gallbladder cancer and cholangiocarcinoma. Noncancerous COD showed an upward trend as follow-up time extended and the majorities were diseases of heart, cerebrovascular disease, chronic liver disease and cirrhosis. The novel OS-nomograms can provide personalized prognosis information with satisfactory accuracy.

Microbial profile in bile from pancreatic and extra-pancreatic biliary tract cancer

BACKGROUND

Dysbiotic biliary bacterial profile is reported in cancer patients and is associated with survival and comorbidities, raising the question of its effect on the influence of anticancer drugs and, recently, the suggestion of perichemotherapy antibiotics in pancreatic cancer patients colonized by the Escherichia coli and Klebsiella pneumoniae.

OBJECTIVE

In this study, we investigated the microbial communities that colonize tumours and which bacteria could aid in diagnosing pancreatic and biliary cancer and managing bile-colonized patients.

METHODS

A retrospective study on positive bile cultures of 145 Italian patients who underwent cholangiopancreatography with PC and EPC cancer hospitalized from January 2006 to December 2020 in a QA-certified academic surgical unit were investigated for aerobic/facultative-anaerobic bacteria and fungal organisms.

RESULTS

We found that among Gram-negative bacteria, Escherichia coli and Pseudomonas spp were the most frequent in the EPC group, while Escherichia coli, Klebsiella spp, and Pseudomonas spp were the most frequent in the PC group. Enterococcus spp was the most frequent Gram-positive bacteria in both groups. Comparing the EPC and PC, we found a significant presence of patients with greater age in the PC compared to the EPC group. Regarding Candida spp, we found no significant but greater rate in the PC group compared to the EPC group (11.7% vs 1.96%). We found that Alcaligenes faecalis was the most frequent bacteria in EPC than the PC group, among Gram-negative bacterial species.

CONCLUSIONS

Age differences in gut microbiota composition may affect biliary habitats in our cancer population, especially in patients with pancreatic cancer. Alcaligenes faecalis isolated in the culture of bile samples could represent potential microbial markers for a restricted follow-up to early diagnosis of extra-pancreatic cancer. Finally, the prevalence of Candida spp in pancreatic cancer seems to trigger new aspects about debate about the role of fungal microbiota into their relationship with pancreatic cancer.

Bone morphogenetic protein 9 is a candidate prognostic biomarker and host-directed therapy target for sepsis

Defining next-generation immune therapeutics for the treatment of sepsis will involve biomarker-based therapeutic decision-making. Bone morphogenetic protein 9 (BMP9) is a cytokine in the transforming growth factor-β superfamily. Here, circulating BMP9 concentrations were quantified in two independent cohorts of patients with sepsis. Decreased concentrations of serum BMP9 were observed in the patients with sepsis at the time of admission as compared with healthy controls. Concentrations of BMP9 at the time of admission were also associated with 28-day mortality, because patients with sepsis at a higher risk of death had lower BMP9 concentrations. The mechanism driving the contribution of BMP9 to host immunity was further investigated using in vivo murine sepsis models and in vitro cell models. We found that BMP9 treatment improved outcome in mice with experimental sepsis. BMP9-treated mice exhibited increased macrophage influx into the peritoneal cavity and more efficient bacterial clearance than untreated mice. In vitro, BMP9 promoted macrophage recruitment, phagocytosis, and subsequent bacterial killing. We further found that deletion of the type 1 BMP receptor ALK1 in macrophages abolished BMP9-mediated protection against polymicrobial sepsis in vivo. Further experiments indicated that the regulation of macrophage activation by the BMP9-ALK1 axis was mainly mediated through the suppressor of mother against decapentaplegic 1/5 signaling pathway. Together, these results suggest that BMP9 can both serve as a biomarker for patient stratification with an independent prognostic value and be developed as a host-directed therapy for sepsis.

Effects of carrimycin on biomarkers of inflammation and immune function in tumor patients with sepsis: A multicenter double-blind randomized controlled trial

Carrimycin is a potential immune-regulating agent for sepsis in patients with tumors. In this study, we investigated its effects on inflammation and immune function in tumor patients with sepsis. In total, 120 participants were randomized to receive either carrimycin treatment (400 mg/day) (n = 62) or placebo (n = 58) for 7 days. The primary outcomes were immune-related indicators. Subsequently, patients were stratified into two subgroups (CD4 < 38.25% and CD8 < 25.195%). Ninety-nine participants were analyzed: 47 and 52 in the carrimycin and placebo groups, respectively. HLA-DR levels were rapidly increased in the carrimycin group; however, the placebo group initially experienced a decline in HLA-DR level at 1 day after administration. In the subgroup with CD4 < 38.25%, the carrimycin group exhibited significantly higher HLA-DR levels than the placebo group (2.270, P = 0.023) 1 day after administration and the degree of increase in HLA-DR in the carrimycin group was higher than that in the placebo group (2.057, P = 0.040). In the CD8 < 25.195% subgroup, the carrimycin group demonstrated significantly higher levels of CD8+ T cells than the placebo group at 3 (2.300,P = 0.027) and 5 (2.106, P = 0.035) days after administration. Carrimycin intervention led to significant reductions in the SOFA, APACHE II, PCT, and CRP levels. No adverse events were observed. In tumor patients with sepsis, particularly in those experiencing immunological suppression, carrimycin effectively regulates immune responses by increasing HLA-DR and CD8+ T cell levels and plays an anti-infective role, reducing disease severity. (Chictr.org.cn, ID Number: ChiCTR2000032339).

Distinct clinical phenotypes in paediatric cancer patients with sepsis are associated with different outcomes-an international multicentre retrospective study

Background

Identifying phenotypes in sepsis patients may enable precision medicine approaches. However, the generalisability of these phenotypes to specific patient populations is unclear. Given that paediatric cancer patients with sepsis have different host response and pathogen profiles and higher mortality rates when compared to non-cancer patients, we determined whether unique, reproducible, and clinically-relevant sepsis phenotypes exist in this specific patient population.

Methods

We studied patients with underlying malignancies admitted with sepsis to one of 25 paediatric intensive care units (PICUs) participating in two large, multi-centre, observational cohorts from the European SCOTER study (n = 383 patients; study period between January 1, 2018 and January 1, 2020) and the U.S. Novel Data-Driven Sepsis Phenotypes in Children study (n = 1898 patients; study period between January 1, 2012 and January 1, 2018). We independently used latent class analysis (LCA) in both cohorts to identify phenotypes using demographic, clinical, and laboratory data from the first 24 h of PICU admission. We then tested the association of the phenotypes with clinical outcomes in both cohorts.

Findings

LCA identified two distinct phenotypes that were comparable across both cohorts. Phenotype 1 was characterised by lower serum bicarbonate and albumin, markedly increased lactate and hepatic, renal, and coagulation abnormalities when compared to phenotype 2. Patients with phenotype 1 had a higher 90-day mortality (European cohort 29.2% versus 13.4%, U.S. cohort 27.3% versus 11.4%, p < 0.001) and received more vasopressor and renal replacement therapy than patients with phenotype 2. After adjusting for severity of organ dysfunction, haematological cancer, prior stem cell transplantation and age, phenotype 1 was associated with an adjusted OR of death at 90-day of 1.9 (1.04-3.34) in the European cohort and 1.6 (1.2-2.2) in the U.S. cohort.

Interpretation

We identified two clinically-relevant sepsis phenotypes in paediatric cancer patients that are reproducible across two international, multicentre cohorts with prognostic implications. These results may guide further research regarding therapeutic approaches for these specific phenotypes.

Funding

Part of this study is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The short- and long-term readmission of four major categories of digestive system cancers: does obesity or metabolic disorder matter?

Purpose

Patients with digestive system cancers (DSCs) are at a high risk for hospitalizations; however, the risk factors for readmission remain unknown. Here, we established a retrospective cohort study to assess the association between metabolic obesity phenotypes and readmission risks of DSC.

Experimental design

A total of 142,753 and 74,566 patients at index hospitalization were ultimately selected from the Nationwide Readmissions Database (NRD) 2018 to establish the 30-day and 180-day readmission cohorts, respectively. The study population was classified into four groups: metabolically healthy non-obese (MHNO), metabolically healthy obese (MHO), metabolically unhealthy non-obese (MUNO), and metabolically unhealthy obese (MUO). Multivariate Cox regression analysis was used to estimate the effect of metabolic obesity phenotypes on DSC readmission.

Results

The MUNO phenotype had 1.147-fold (95% CI: 1.066, 1.235; p < 0.001) increased 180-day readmission risks in patients with neoplasm of the upper digestive tract. The MUNO phenotype had 1.073-fold (95% CI: 1.027, 1.121; p = 0.002) increased 30-day readmission risks and 1.067-fold (95% CI: 1.021, 1.115; p = 0.004) increased 180-day readmission risks in patients with neoplasm of the lower digestive tract. The MUNO and MUO phenotypes were independent risk factors of readmission in patients with liver or pancreatic neoplasm. Metabolic obesity status was independently associated with a high risk of severe and unplanned hospitalization within 30 days or 180 days.

Conclusion

Both obesity and metabolic abnormalities are associated with a high risk for the poor prognosis of DSC patients. The effect of metabolic categories on the short- or long-term readmission of liver or pancreas cancers may be stronger than that of obesity.

Risk of malignant disease in 1-year sepsis survivors, a registry-based nationwide follow-up study

BACKGROUND

Cancer and sepsis share risk factors, and sepsis patients may have impaired immune response and increased morbidity long after intensive care. This study aimed to assess whether sepsis survivors are at increased risk for cancer. Our objective was to assess the incidence of new cancer in 1-year sepsis survivors and test the hypothesis that it is higher than that of the general population.

METHODS

We obtained data on ICU admissions of adult patients from Swedish Intensive care registry (SICR) from 2005 to 2017. We included patients with an explicit ICD-10 code for sepsis for the primary ICU admission. We obtained data on cancer diagnoses (2001-2018), death (2005-2018) and emigration (2005-2018) from Cancer and Cause of death and National Patient Registry databases of the National Board of Health and Welfare; age and sex-specific cancer incidence rates in Sweden from NORDCAN registry from 2006 to 2018. One-year survivors formed the final cohort, that was followed for new cancer diagnoses until death, emigration, or end of 2018, whichever came first. The main outcome measure was standardized incidence rate ratio (SIR) to compare the incidence of cancer in 1-year sepsis survivors to that in the general population (NORDCAN). We also performed several sensitivity analyses.

RESULTS

In a cohort of 18,550 1-year survivors, 75,427 person years accumulated during a median follow-up (FU) of 3.36 years (IQR 1.72-5.86), 6366 (34.3%) patients died, and 1625 (8.8%) patients were diagnosed with a new cancer after a median FU of 2.51 (IQR 1.09-4.48) years. The incidence ratio of any new cancer over the whole FU was 1.31 (95% CI 1.23-1.40) for men and 1.74 (95% CI 1.61-1.88) for women. The difference in incidence rates persisted in several sensitivity analyses. The SIRs were highest in cancers of gastrointestinal tract, genital organs, and skin.

CONCLUSION AND RELEVANCE

Compared to general population, incidence of cancer is increased in 1-year sepsis survivors. Variation in the findings depending on follow-up time suggests that factors other than sepsis alone are involved. Surveillance for malignant disease may be warranted in sepsis survivors.

Clinical analysis of AN69ST membrane continuous venous hemofiltration in the treatment of severe sepsis

We aimed to investigate the clinical efficacy of blood purification technology based on cytokine adsorption in the treatment of sepsis. Sixty patients with sepsis were randomly divided into control (n = 30) and experimental (n = 30) groups. Both groups were given routine treatment and continuous venovenous hemofiltration, and on this basis, the experimental group received acrylonitrile/sodium methacrylate (AN69ST) blood purification. The levels of C-reactive protein, procalcitonin, white blood cell count, albumin, platelets, total bilirubin, creatinine, lactic acid, and APACE II score, as well as secretion of inflammatory factors interleukin (IL)-6 and tumor necrosis factor (TNF-α) were compared. The hospitalization time, mechanical ventilation (MV) time, drug use time, and mortality were analyzed. After treatment, the secretion levels of IL-6 and TNF-α were decreased, and other indicators were significantly improved compared with those before treatment (P < 0.05), especially in the experimental group (P < 0.05). The hospitalization time, MV time, and drug use time in the experimental group were significantly lower than those of the control group (P < 0.05), and the mortality was lower than that in the control group (P < 0.05). In conclusion, blood purification technology based on cytokine adsorption can significantly improve various indicators of sepsis patients, reduce hospitalization time, reduce mortality, and improve the prognosis.

A Narrative Literature Review on Sepsis: A Primary Manifestation of Colorectal Neoplasm

Sepsis and colorectal cancer (CRC) exhibit a complex relationship that warrants further exploration. This review delves into the interplay of factors between sepsis and CRC, uncovering shared pathophysiological traits and potential bacterial associations. Understanding these connections could pave the way for earlier diagnosis, improved management, and enhanced outcomes in CRC patients. The role of immune system dysfunction, hypoalbuminemia, and specific microbial imbalances, such as Streptococcus bovis and Clostridium septicum, are discussed. Recognizing sepsis in CRC patients is crucial for timely intervention, and tailored approaches encompassing antibiotic therapy, source control measures, and cancer treatment are essential for comprehensive care. Monitoring biomarkers and ratios can provide valuable insights into complications and overall health outcomes. A multidisciplinary approach involving various specialists is necessary to address the global burden of CRC and its association with sepsis while exploring novel interventions, such as fecal microbiota transplantation and personalized care. We conducted a thorough search using reputable databases such as PubMed, Scopus, and Google Scholar to investigate the connection between sepsis and CRC. We refined our search terms, utilized sidebar filters, and examined references in selected articles. This meticulous process helped us create a comprehensive literature review and gain valuable insights into this relationship.

A clinically applicable prediction model for the risk of in-hospital mortality in solid cancer patients admitted to intensive care units with sepsis

PURPOSE

To develop and validate a user-friendly model to predict the risk of in-hospital mortality in solid cancer patients admitted to the ICU with sepsis.

METHODS

Clinical data of critically ill patients with solid cancer and sepsis were obtained from Medical Information Mart for Intensive Care-IV database and randomly assigned to the training cohort and validation cohort. The primary outcome was in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) regression and logistic regression analysis were used to feature selection and model development. The performance of the model was validated and a dynamic nomogram was developed to visualize the model.

RESULTS

A total of 1584 patients were included in this study, of whom 1108 were assigned to the training cohort and 476 to the validation cohort. The LASSO regression and logistic multivariable analysis showed that nine clinical features were associated with in-hospital mortality and enrolled in the model. The area under the curve of the model was 0.809 (95% CI 0.782-0.837) in the training cohort and 0.770 (95% CI 0.722-0.819) in the validation cohort. The model exhibited satisfactory calibration curves and Brier scores in the training set and validation set were 0.149 and 0.152, respectively. The decision curve analysis and clinical impact curve of the model presented good clinical practicability in both the two cohorts.

CONCLUSION

This predictive model could be used to assess the in-hospital mortality of solid cancer patients with sepsis in the ICU, and a dynamic online nomogram could facilitate the sharing of the model.

Splenic SUMO1 controls systemic inflammation in experimental sepsis

Introduction

The recent discovery of TAK981(Subasumstat), the first-in-class selective inhibitor of SUMOylation, enables new immune treatments. TAK981 is already in clinical trials to potentiate immunotherapy in metastatic tumors and hematologic malignancies. Cancer patients have more than ten times higher risk of infections, but the effects of TAK981 in sepsis are unknown and previous studies on SUMO in infections are conflicting.

Methods

We used TAK981 in two sepsis models; polymicrobial peritonitis (CLP) and LPS endotoxemia. Splenectomy was done in both models to study the role of spleen. Western blotting of SUMO-conjugated proteins in spleen lysates was done. Global SUMO1 and SUMO3 knockout mice were used to study the specific SUMO regulation of inflammation in LPS endotoxemia. Splenocytes adoptive transfer was done from SUMO knockouts to wild type mice to study the role of spleen SUMOylation in experimental sepsis.

Results and discussion

Here, we report that inhibition of SUMOylation with TAK981 improved survival in mild polymicrobial peritonitis by enhancing innate immune responses and peritoneal bacterial clearance. Thus, we focused on the effects of TAK981 on the immune responses to bacterial endotoxin, showing that TAK981 enhanced early TNFα production but did not affect the resolution of inflammation. Splenectomy decreased serum TNFα levels by nearly 60% and TAK981-induced TNFα responses. In the spleen, endotoxemia induced a distinct temporal and substrate specificity for SUMO1 and SUMO2/3, and both were inhibited by TAK981. Global genetic depletion of SUMO1, but not SUMO3, enhanced TNFα production and metabolic acidosis. The transfer of SUMO1-null, but not wild-type, splenocytes into splenectomized wild-type mice exacerbated TNFα production and metabolic acidosis in endotoxemia.

Conclusion

These results suggest that specific regulation of splenic SUMO1 can modulate immune and metabolic responses to bacterial infection.

Cancer and sepsis

Sepsis is one of the leading causes of death worldwide. While mortality is high regardless of inciting infection or comorbidities, mortality in patients with cancer and sepsis is significantly higher than mortality in patients with sepsis without cancer. Cancer patients are also significantly more likely to develop sepsis than the general population. The mechanisms underlying increased mortality in cancer and sepsis patients are multifactorial. Cancer treatment alters the host immune response and can increase susceptibility to infection. Preclinical data also suggests that cancer, in and of itself, increases mortality from sepsis with dysregulation of the adaptive immune system playing a key role. Further, preclinical data demonstrate that sepsis can alter subsequent tumor growth while tumoral immunity impacts survival from sepsis. Checkpoint inhibition is a well-accepted treatment for many types of cancer, and there is increasing evidence suggesting this may be a useful strategy in sepsis as well. However, preclinical studies of checkpoint inhibition in cancer and sepsis demonstrate results that could not have been predicted by examining either variable in isolation. As sepsis management transitions from a 'one size fits all' model to a more individualized approach, understanding the mechanistic impact of cancer on outcomes from sepsis represents an important strategy towards delivering on the promise of precision medicine in the intensive care unit.

Long-Term Clinical Outcomes in Critically Ill Patients with Sepsis and Pre-existing Sarcopenia: A Retrospective Cohort Study

Purpose

Critically ill patients with sepsis account for significant disease morbidity and healthcare costs. Sarcopenia has been proposed as an independent risk factor for poor short-term outcomes, although its effect on long-term outcomes remains unclear.

Methods

Retrospective cohort analysis of patients treated at a tertiary care medical center over 6 years (09/2014 - 12/2020). Critically ill patients meeting Sepsis-3 criteria were included, with sarcopenia defined by skeletal muscle index at the L3 lumbar area on abdominal Computed-Tomography scan. The prevalence of sarcopenia and its association with clinical outcomes was analyzed.

Results

Sarcopenia was present in 34 (23%) of 150 patients, with median skeletal muscle indices of 28.1 cm 2 /m 2 and 37.3 cm 2 /m 2 in sarcopenic females and males, respectively. In-hospital mortality was not associated with sarcopenia when adjusted for age and illness severity. One year mortality was increased in sarcopenic patients, after adjustment for illness severity (HR 1.9, p = 0.02) and age (HR 2.4, p = 0.001). However, it was not associated with increased likelihood for discharge to long-term rehabilitation or hospice care in adjusted analyses.

Conclusion

Sarcopenia independently predicts one year mortality but is not associated with unfavorable hospital discharge disposition in critically ill patients with sepsis.

The correlation between the hemoglobin-to-red cell distribution width ratio and all-cause mortality in patients with malignant tumors and sepsis: A retrospective cohort study using the MIMIC-IV database

Objective

The aim of the study was to investigate the correlation between the hemoglobin-to-red cell distribution width ratio (HRR) and all-cause mortality in patients with malignant tumors and sepsis.

Methods

All patients who met the inclusion criteria of the Medical Information Mart for Intensive Care (MIMIC)-IV were selected and divided into four groups according to the quartile range of HRR distribution. Kaplan-Meier (K-M) analysis was used to plot the 28-day survival curve, and the log-rank test was used to compare the prognosis in each HRR group. A Cox proportional hazards regression model was used to evaluate the prognosis of HRR as both a continuous and categorical variable, and a restricted cubic spline was used to study the effect of HRR, as a continuous variable, on the mortality in patients with malignant tumors and sepsis. Interaction and subgroup analyses were performed to evaluate the consistency of correlations.

Results

A total of 3926 patients were included in the study, including 934 patients in the HRR ≤ 4.97 group, 988 patients in the 4.97 < HRR ≤ 6.26 group, 1005 patients in the 6.26 < HRR ≤ 7.84 group, and 999 patients in the HRR ≥ 7.84 group. According to the K-M analysis, the 28-day survival rate was the lowest in the HRR ≤ 4.97 group (59.53%), and there were significant differences in survival rates among different HRR levels (P < 0.001). The Cox proportional hazards regression model found that after adjusting for various potential confounding factors, HRR was negatively correlated with 28-day and 365-day mortality, and the risk of death in the HRR ≥ 7.84 group was significantly lower than that in the HRR ≤ 4.97 group (P = 0.030 and P = 0.008, respectively). The restricted cubic spline plot revealed a linear and negative relationship between the HRR and the 28-day and 365-day mortality rates. Subgroup analysis revealed an interaction between HRR, blood urea nitrogen, and SAPS II scores (P = 0.010 and P = 0.048, respectively).

Conclusion

Low HRR is an independent risk factor for all-cause mortality in patients with malignant tumors and sepsis and could be used as a prognostic indicator for these patients.

The double sides of NLRP3 inflammasome activation in sepsis

Sepsis is defined as a life-threatening organ dysfunction induced by a dysregulated host immune response to infection. Immune response induced by sepsis is complex and dynamic. It is schematically described as an early dysregulated systemic inflammatory response leading to organ failures and early deaths, followed by the development of persistent immune alterations affecting both the innate and adaptive immune responses associated with increased risk of secondary infections, viral reactivations, and late mortality. In this review, we will focus on the role of NACHT, leucin-rich repeat and pyrin-containing protein 3 (NLRP3) inflammasome in the pathophysiology of sepsis. NLRP3 inflammasome is a multiproteic intracellular complex activated by infectious pathogens through a two-step process resulting in the release of the pro-inflammatory cytokines IL-1β and IL-18 and the formation of membrane pores by gasdermin D, inducing a pro-inflammatory form of cell death called pyroptosis. The role of NLRP3 inflammasome in the pathophysiology of sepsis can be ambivalent. Indeed, although it might protect against sepsis when moderately activated after initial infection, excessive NLRP3 inflammasome activation can induce dysregulated inflammation leading to multiple organ failure and death during the acute phase of the disease. Moreover, this activation might become exhausted and contribute to post-septic immunosuppression, driving impaired functions of innate and adaptive immune cells. Targeting the NLRP3 inflammasome could thus be an attractive option in sepsis either through IL-1β and IL-18 antagonists or through inhibition of NLRP3 inflammasome pathway downstream components. Available treatments and results of first clinical trials will be discussed.

Predictive factors and prognostic value of candiduria in critically-ill patients with solid and hematological malignancies

PURPOSE

To investigate the epidemiology of candiduria in critically-ill patients with solid/hematological malignancies and to assess its predictive factors and prognostic value.

METHODS

All adult patients with confirmed solid/hematological malignancy admitted in the intensive care units (ICUs) for more than 48 h were retrospectively included. Urine cultures were sampled on admission and then whenever signs of sepsis were identified. Two groups were compared: (candiduria (+)) and (candiduria (-)).

RESULTS

One-hundred-seventy-three patients were included. Solid cancer was the underlying oncological disease for 147 patients (85%) while 26 patients (15%) had hematological malignancies. Twenty-nine patients (16.8%) were diagnosed with candiduria, and 31 urinary samples grew Candida spp. Candida spp represented 55.8% of the total urinary isolates. Fourteen isolates (45.2%) of Candida albicans were identified. Among the 17 non-albicans isolates, Candida tropicalis was the most predominant (41.9%). Six patients (3.5%) had candidemia with no significant difference between candiduria(+) and candiduria(-) groups (respectively, 6.9% and 2.8%; p = 0.264). In multivariate analysis, previous exposure to quinolones (OR = 3.8, CI95% [1.4-8.3]; p = 0.008), mechanical ventilation (OR = 4.1, CI95% [1.1-14.7]; p = 0.034) and renal replacement therapy (OR = 3.5, 95%CI [1.2-9.7]; p = 0.017) were identified as independent factors predicting candiduria. Candiduria was associated with significantly higher ICU-mortality after adjusting for SAPSII score on admission (OR = 2.9 CI95% [1.3-6.8]; p = 0.009).

CONCLUSION

Candiduria is common in cancer critically-ill patients. We reported an increased rate of non-albicans species, over albicans species. Patients with candiduria had higher ICU mortality, probably related to higher frailty and clinical severity.

O2 self-sufficient and glutathione-depleted nanoplatform for amplifying phototherapy synergistic thermodynamic therapy

Tumor hypoxia and high levels of intracellular glutathione (GSH) significantly limit the efficacy of photodynamic therapy (PDT). In addition, a single PDT treatment strategy is relatively insufficient to eliminate tumor, further limiting its application in biomedicine. Therefore, we demonstrated an omnipotent nanoplatform based on 2,2'-azobis [2-(2 imidazolin-2-yl)propane] dihydrochloride (AIPH) loaded manganese dioxide (MnO₂) nanoflower (abbreviated as MnO₂-AIPH) with simultaneously self-supplying oxygen (O₂), depleting GSH, performing PDT, photothermal (PTT) and thermodynamic therapy (TDT) for boosting antitumor effects. By 808 nm near infrared (NIR) light irradiation, MnO₂-AIPH not only reveals highly toxic reactive oxygen species (ROS) generation and excellent photothermal conversion ability for PDT and PTT, but also generates alkyl radicals by decomposing AIPH for TDT simultaneously to eliminate tumor effectively. Once internalized into the tumor, MnO₂ will be degraded to Mn²⁺ which catalyzes endogenous hydrogen peroxide (H₂O₂) into O₂ for enhanced PDT. Moreover, MnO₂ can facilitate GSH oxidation to amplify oxidative stress, further enhancing ROS and alkyl radicals mediated cancer cell killing. In brief, this study provides a paradigm of antitumor efficiency amplification by the combination of sustained oxygen supply, potent GSH depletion, and phototherapy synergistic TDT.

Immunotherapy to treat sepsis induced-immunosuppression: Immune eligibility or outcome criteria, a systematic review

Sepsis-induced immunosuppression (SIS) is the target of multiple clinical studies testing immunotherapies. To date, most trials are performed on a heterogeneous and unselected population. Without any consensual definition of immunosuppression and therapeutic goals, results from these trials remain poorly transposable. In this perspective, we conducted a systematic review aiming at 1/registering the inclusion criteria, 2/ report the outcomes evaluated in this literature. We searched Pubmed, Embase, and ClinicalTrials.gov for studies using an immunotherapy to reverse SIS. This review collected for each study: design, intervention, immune inclusion criteria, outcome, definition of sepsis, and source of infection. From the 80 studies assessed for eligibility, 29 were included: 17 RCT, 6 observational prospective studies, 6 ongoing RCT. Sepsis was defined based upon current recommendations at the time, with most patients presenting at least one organ failure. We found important heterogeneity regarding the use of immune parameters, both as inclusion and as outcome criteria. Only 13 studies selected patients suffering from immunosuppression based on immune biomarkers. Two immune criterias were commonly used: lymphocyte count and monocytic HLA-DR expression. This heterogeneity criteria in studies targeting SIS justify the conduct of a consensus process to define criteria to diagnose SIS and identify relevant outcomes markers.

Bacterial DNA involvement in carcinogenesis

The incidence of cancer is high worldwide, and biological factors such as viruses and bacteria play an important role in the occurrence of cancer. Helicobacter pylori, human papillomavirus, hepatitis B viruses and other organisms have been identified as carcinogens. Cancer is a disease driven by the accumulation of genome changes. Viruses can directly cause cancer by changing the genetic composition of the human body, such as cervical cancer caused by human papillomavirus DNA integration and liver cancer caused by hepatitis B virus DNA integration. Recently, bacterial DNA has been found around cancers such as pancreatic cancer, breast cancer and colorectal cancer, and the idea that bacterial genes can also be integrated into the human genome has become a hot topic. In the present paper, we reviewed the latest phenomenon and specific integration mechanism of bacterial DNA into the human genome. Based on these findings, we also suggest three sources of bacterial DNA in cancers: bacterial DNA around human tissues, free bacterial DNA in bacteremia or sepsis, and endogenous bacterial DNA in the human genome. Clarifying the theory that bacterial DNA integrates into the human genome can provide a new perspective for cancer prevention and treatment.

Therapeutic Effect of Continuous Blood Purification Combined with Humanized Nursing in Patients with Severe Sepsis

This work aimed to explore the effect of humanized nursing on the patients' recovery from severe sepsis based on continuous blood purification (CBP). 90 patients with severe sepsis were randomly and equally divided into a control group (basic intensive nursing + CBP) and a therapy group (humanized nursing + CBP). Before treatment and on the 7th and 14th days after treatment, indicators of patients were compared, including white blood cell (WBC), tumor necrosis factor (TNF-α), hepatic and renal function, C-reactive protein (CRP), brain natriuretic peptide (BNP), procalcitonin (PCT), and erythrocyte sedimentation rate (ESR). The mortality and nursing satisfaction were compared. After treatment, the saturation of pulse oxygen (SPO₂) in the therapy group (85 ± 20 and 91 ± 9) was higher than that in the control group (78 ± 28 and 82 ± 18, respectively), and the lactic acid level (LAL) was greatly lower (2.8 ± 2.4 and 1.6 ± 0.9 vs. 4.3 ± 2.3 and 2.3 ± 2.7). The Acute Physiology and Chronic Health Evaluation II (APACHE-II) score after treatment was lower (13.67 ± 4.28 and 8.45 ± 5.12 vs. 17.34 ± 6.4 and 11.46 ± 4.23). The BNP, blood urea nitrogen (BUN), and CRP levels were decreased, and so did inflammatory indicators. The survival rate reached 71% and 47% in the therapy group and control group, respectively; and the nursing satisfaction was 97.80% and 26.67%, respectively. Humanized nursing combined with CBP could improve the therapeutic effect and speed up the recovery from severe sepsis.

Of mice and men: Laboratory murine models for recapitulating the immunosuppression of human sepsis

Prolonged immunosuppression is increasingly recognized as the major cause of late phase and long-term mortality in sepsis. Numerous murine models with different paradigms, such as lipopolysaccharide injection, bacterial inoculation, and barrier disruption, have been used to explore the pathogenesis of immunosuppression in sepsis or to test the efficacy of potential therapeutic agents. Nonetheless, the reproducibility and translational value of such models are often questioned, owing to a highly heterogeneric, complex, and dynamic nature of immunopathology in human sepsis, which cannot be consistently and stably recapitulated in mice. Despite of the inherent discrepancies that exist between mice and humans, we can increase the feasibility of murine models by minimizing inconsistency and increasing their clinical relevance. In this mini review, we summarize the current knowledge of murine models that are most commonly used to investigate sepsis-induced immunopathology, highlighting their strengths and limitations in mimicking the dysregulated immune response encountered in human sepsis. We also propose potential directions for refining murine sepsis models, such as reducing experimental inconsistencies, increasing the clinical relevance, and enhancing immunological similarities between mice and humans; such modifications may optimize the value of murine models in meeting research and translational demands when applied in studies of sepsis-induced immunosuppression.

Early administration of dobutamine in the treatment of septic shock patients with tumor-a retrospective comparative cohort study

Background

Studies have found that dobutamine may be beneficial to protect organs function in patients with septic shock, but there is still a lack of relevant research in septic shock patients with tumor. The study sought to explore the role of the early administration of dobutamine in the treatment of septic shock patients with tumors.

Methods

We retrospectively collected the data of tumor patients who developed septic shock at Sun Yat-sen University Cancer Center between June 2008 and November 2021. All the patients were divided into the following 3 groups: (I) the early administration group (<3 days, n=15); (II) the late administration group (≥3 days, n=22); and (III) the non-administration group (n=85). The primary observation indicator was 28-day mortality, and the secondary observation indicators included the shock reversal rate, the length of stay in the intensive care unit (ICU) and the duration of mechanical ventilation. There was no statistical difference in the basic data of the three groups.

Results

The early administration group had a significant decrease in 28-day mortality compared to the late and non-administration groups (log-rank P=0.018). The comparison between the groups showed that the 28-day mortality of the early administration group was significantly lower than that of the non-administration group [20.0% vs. 58.8%, P=0.013, hazard ratios (HRs) =0.248, 95% confidence intervals (CIs): 0.077-0.796]. There was no statistically significant difference in 28-day mortality between the late administration group and the non-administration group (63.6% vs. 58.8%, P=0.682, HR =0.983, 95% CI: 0.543-1.778). Additionally, the early administration group had a significantly increased shock reversal rate (P=0.014), shortened length of stay in the ICU (P<0.001), and reduced duration of mechanical ventilation (P=0.049).

Conclusions

Early use of dobutamine may be beneficial to reduce the in-hospital mortality of septic shock patients with tumor, but the sample size of this study was small, which still needs to be confirmed by a multi-center randomized controlled clinical study.

Causes of death following small cell lung cancer diagnosis: a population-based analysis

PURPOSE

To examine the distribution of causes of death (CODs) in patients with small cell lung cancer (SCLC).

METHODS

Patients diagnosed with SCLC were identified from the Surveillance, Epidemiology, and End Results Program database during 2004-2015. Standardized mortality rates (SMRs) were performed for each COD to present changes in risk for a particular COD following SCLC diagnosis.

RESULTS

A total of 44,506 patients diagnosed with SCLC were identified in this study, and 42,476 patients died during the follow-up. Of total deaths, 69.5% occurred within the first years after diagnosis, 26% occurred from 1 to 3 years, and 4.5% individuals survived longer than 3 years. In addition, 88.7% of deaths were caused by SCLC, followed by non-cancer causes (7.1%) and other cancers (4.2%). Moreover, non-cancer CODs increased from 6.3 to 30% over time after 3 years of diagnosis. As for non-cancer CODs, cardiovascular diseases, COPD, and septicemia were the most common in SCLC.

CONCLUSION

Non-cancer CODs, such as cardiovascular events, COPD and septicemia, contribute to a considerable proportion of deaths among long-term SCLC survivors, supporting the involvement of multidisciplinary care for the follow-up strategy in SCLC.

TRPM7 promotes lipopolysaccharide-induced inflammatory dysfunction in renal tubular epithelial cells

BACKGROUND

Sepsis-associated acute kidney injury (S-AKI) has been reported to affect 30%-50% of all sepsis patients; this condition is associated with a notable fatality rate. Following lipopolysaccharide (LPS) stimulation, the expression of transient receptor potential cation channel subfamily M member 7 (TRPM7), a nonselective cation channel expressed by the renal tubular epithelial cells (RTECs) was found to be upregulated. We aimed to determine how TRPM7 functions in S-AKI.

METHODS

To establish an in vitro model of S-AKI, RTECs were treated with LPS. The effect of TRPM7 knockdown on cell viability, lactate dehydrogenase (LDH) release, apoptosis, inflammation, and oxidative stress was studied. The binding site between Kruppel-like factor 2 (KLF2) and TRPM7 was predicted using JASPAR. The influence of KLF2 on the regulatory roles of TRPM7 in cells, as well as the effect of their knockdown on the MAPK signaling pathway, was investigated.

RESULTS

TRPM7 was upregulated in LPS-treated cells, and knocking improved cell viability, reduced LDH levels, and minimized apoptosis, inflammation, and oxidative stress. KLF2 was shown to be associated with TRPM7 and its level decreased in LPS-treated cells. KLF2 knockdown increased TRPM7 expression and reversed the effects of TRPM7 knockdown in LPS-treated cells, including suppression of p38 MAPK, ERK1/2, and JNK activation.

CONCLUSION

Taken together, our results show that TRPM7 is negatively regulated by KLF2 and promotes LPS-induced inflammatory dysfunction by activating the MAPK pathway in RTECs. The theoretical foundation for the prevention and management of S-AKI is laid out in this article.

Risk of nonpulmonary infections requiring hospitalization in spondyloarthritis

Objectives

To compare the risk of five nonpulmonary infections leading to hospitalization between spondyloarthritis (SpA) and nonspecific back pain (NSBP), and to identify the risk factors.

Methods

A total of 3018 patients with SpA and 2527 patients with NSBP were identified. Data from December 1995 to June 2019 was retrieved from a centralized electronic medical record system. The date of onset of five types of nonpulmonary infections including: urinary tract infection (UTI), skin infection, gastroenteritis (GE), septic arthritis, and pancreato‐hepatobiliary tract infection were identified. Demographic data, comorbidities, and medications used were also retrieved. Comparative risk of each type of infection between SpA and NSBP was determined using propensity score adjustment method. Cox regression model was used to identified risk factors.

Results

Patients with SpA were younger in age, predominantly male, with fewer comorbid diabetes mellitus (DM), renal impairment, and depression. Compared with NSBP, patients with SpA had higher risk of UTI (hazard ratio [HR] 1.91; p < .001), skin infection (HR 1.79; p < .001), and septic arthritis (HR 4.57; p = .04). Risk of GE (HR 1.42; p = 1.00), and pancreato‐hepatobiliary tract infection (HR 1.67; p = .06) were not increased. Infliximab was an independent risk factor for UTI (HR 2.21; p = .04). Duration of steroid therapy >6 months (HR 2.22; p < .001), smoker (HR 1.81; p < .001), and psoriasis (HR 2.47; p < .001) were risk factors for skin infection.

Conclusion

SpA was associated with increased risk of UTI, skin infection, and septic arthritis. Infliximab, prolonged steroid therapy, smoking, and psoriasis were associated risk factors.