Systemic Inflammatory Response Syndrome After Surgery: Mechanisms and Protection

Detection and Evaluation of Procalcitonin Variants As Diagnostic Tools in Systemic Inflammation

BACKGROUND

Procalcitonin is an indicator of systemic inflammation associated with major surgery or sepsis. Procalcitonin exists in a full-length and truncated variant as a result of dipeptidylpeptidase-4 (DPP4)-cleavage. We recently identified differential biological activity of both variants. Here, we present an immunoassay-based method for the separate detection of procalcitonin variants and correlation to clinical data in patients with severe systemic inflammation.

METHODS

Rabbits were immunized with peptides of N-terminal sequences of both human procalcitonin variants and polyclonal antibodies purified from rabbit plasma. Antibodies were used for the detection of procalcitonin variants in an indirect sandwich enzyme-linked immunosorbent assay (ELISA) using a commercially available monoclonal anti-procalcitonin antibody as capture. Serum was collected from 19 septic patients exhibiting hyperprocalcitonemia as part of a cross-sectional study; clinical data were analyzed and correlated with procalcitonin variant measurements. DPP4 activity was determined by a DPP4 activity assay.

RESULTS

Purified antibodies allowed for the separate detection of both procalcitonin variants in all patients. Levels of truncated procalcitonin (truncPCT) correlated with DPP4-activity (Pearson's R = 0.85, P < .001) and negatively correlated with patients' Sequential Organ Failure Score (SOFA) scores (Pearson's R = -0.56, P = .013). In contrast, the correlation between full-length procalcitonin (fullPCT) and SOFA scores was positive (Pearson's R = 0.56, P = .013). Separation of the patient collective into groups with higher amounts of fullPCT versus truncPCT revealed higher SOFA scores in patients with fullPCT > truncPCT (mean ± standard error of the mean; 11. 3 ± 0.8 vs 6. 1 ± 1.5, P = .003). Patients with fullPCT > truncPCT showed a tendency towards higher doses of vasopressor (0. 2 ± 0.1 vs 0. 1 ± 0.03 µg/kg/min norepinephrine within the first 24 hours after sepsis diagnosis, P = .062) and exhibited higher creatinine (2. 0 ± 0.2 vs 1. 4 ± 0.3mg/dL, P = .019) and leukocyte levels (31. 0 ± 5.4 vs 12. 8 ± 1.9cells/µL, P = .012). In addition, patients with fullPCT > truncPCT were more often subjected to treatment with hydrocortisone (49.0 vs 0%, P = .018).

CONCLUSIONS

Polyclonal antibodies generated using procalcitonin N-terminal variant peptides as immunogens are suitable for procalcitonin variant assessment. The separate detection of procalcitonin variants may offer additional diagnostic value and can be correlated with organ dysfunction and clinical outcomes in patients with systemic inflammation.

Biodegradable Poly(d,l-lactide-co-ε-caprolactone) Electrospun Scaffolds Outperform Antifibrotic-Loaded Meshes in an in Vivo Tissue Regeneration Model

Wound healing is a complex and dynamic process of replacing missing cellular structures and tissue layers. Clinical practice includes the application of a sterile bandage to promote healing and to restrain infection, like the commercial nonbiodegradable meshes. However, while inert, nontoxic, and nonimmunogenic, they can cause calcification, fibrosis, and inflammation, potentially hindering the healing process in the long term. To address this challenge and enhance wound healing, we developed a totally biodegradable electrospun poly(d,l-lactide-co-ε-caprolactone) (PDLLCL) drug delivery system that incorporates two already FDA-approved antifibrotics, pirfenidone (PIRF) and triamcinolone acetonide (TA). The PDLLCL meshes, fabricated via electrospinning, exhibited homogeneity and complete degradation after 120 days, consistent with the wound healing process. In vitro, functional analysis on RAW 264.7 macrophages revealed no cytotoxicity and an immunomodulatory effect of PIRF and TA compared with the positive control (lipopolysaccharides, LPS) and the PDLLCL meshes alone. Lastly, subcutaneous in vivo assessment on a rabbit model, following the ISO 10993-6 standard, showed that our tailored made PDLLCL meshes were able to lower both irritation and fibrosis indexes from 2 weeks to 4 weeks of implantation, highlighting the beneficial effect of biodegradable polymers. However, we saw no significant positive effect on the incorporation of antifibrotics in vivo for irritation and fibrosis indexes. This underscores the potential of PDLLCL meshes as a possible alternative for wound healing, reducing the use of intermittent antifibrotic agents during the healing process.

Review of the recent advances of pyrazole derivatives as selective COX-2 inhibitors for treating inflammation

Pyrazole heterocycle is regarded as an extremely significant agent for the therapy of inflammation. Celecoxib, lonazolac, deracoxib, and phenylbutazone are examples of commercially approved pyrazole drugs with COX-2 inhibitory potential for curing inflammation. There have been recently many reviews for the biological significance of pyrazole derivatives. This review talks about pyrazole derivatives with anti-inflammatory activity and also sheds the light on the recent updates on pyrazole research with an emphasis on some synthetic pathways utilized to construct this privileged scaffold and structure activity relationship that accounts for the anti-inflammatory activity in an attempt to pave the opportunity for medicinal chemists to develop novel anti-inflammatory agents with better COX-2 selectivity.

Perioperative Nutritional Optimization in Spine Surgery

Although spine surgery has been shown to be an effective treatment for many spinal disorders, perioperative complications can increase patient morbidity and lead to poorer surgical outcomes. Nutritional status is a modifiable factor that affects spine surgery results. Malnutrition can negatively influence inflammatory pathways and can change circulating stress hormones. Perioperative nutrition status can be evaluated by both clinical and laboratory parameters, with nutritional indices allowing for determination of perioperative risk. Perioperative nutritional optimization has been attempted and has been associated with improved outcomes, for patients undergoing spine surgery. Additional investigation is needed to determine effective perioperative nutritional protocols.

Associations Between Base Excess, Alactic Base Excess, and Kidney Function Deterioration in Patients Undergoing Coronary Artery Bypass Grafting Surgery: A Retrospective Cohort Study

OBJECTIVES

To explore the relationship between base excess (BE), alactic BE (aBE), and the deterioration of kidney function in patients undergoing coronary artery bypass grafting (CABG) surgery.

DESIGN

A retrospective cohort study.

SETTING

The Medical Information Mart for Intensive Care IV (MIMIC-IV) database.

PARTICIPANTS

Patients undergoing CABG surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The outcome was kidney function deterioration, including new-onset acute kidney injury (AKI) and increased severity of AKI. Univariate and multivariate logistic regression models were conducted to explore the associations between baseline BE, aBE levels, and kidney function deterioration in patients undergoing CABG surgery. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Covariates were adjusted for, including sepsis, weight, pulse oximetry-derived oxygen saturation, Simplified Acute Physiology Score II, Charlson Comorbidity Index, partial thromboplastin time, vasopressor use, loop diuretics, blood infusions, and acetaminophen use. In total, 5,634 individuals were included who underwent CABG surgery. BE ≤2.61 (OR= 1.22, 95% CI: 1.05-1.41) and aBE ≤1.038 (OR = 1.19, 95% CI: 1.02-1.38) were related to the higher incidence of kidney function deterioration. aBE ≤1.038 (OR = 1.26, 95% CI: 1.01-1.57) was linked to a higher incidence of new onset of AKI. In patients who had AKI at baseline, BE ≤2.61 (OR = 1.88, 95% CI: 1.47-2.41) and aBE ≤1.038 (OR = 1.82, 95% CI: 1.42-2.33) were also related to increased odds of AKI recovery. The relationships between lower BE and aBE and higher odds of kidney function deterioration were also found in those aged ≥65 years, males, patients without chronic kidney disease, patients given vasopressors, and those not administered loop diuretics, nephrotoxic antibiotics, blood infusions, and acetaminophen.

CONCLUSION

Lower BE and aBE values are associated with an increased risk of kidney function deterioration in patients undergoing CABG surgery. BE and aBE could serve as early markers of kidney injury.

Multimodal monitoring of neutrophil activity during cardiac surgery

Cardiac surgery and the associated ischemia-reperfusion injury trigger an inflammatory response, which, in turn, can contribute to organ damage, prolonged hospitalization, and mortality. Therefore, the present study performed comprehensive monitoring of neutrophil-related inflammation in patients who underwent aortic valve surgery, including extracorporeal circulation. Neutrophil-related inflammation, as well as alterations in cellular physiology, phenotype, and function, were analyzed by flow cytometry, ELISA, and microscopy. Neutrophil activation occurred intraoperatively and preceded the upregulation of conventional inflammatory markers such as C-reactive protein and interleukin-6. Perioperatively, neutrophils maintained a stable response to platelet-activating factor (PAF) with regard to CD11b and CD66b expression but showed a decreased response in CD10. Postoperatively, neutrophils exhibited marked alterations in PAF-induced depolarization, while reactive oxygen species generation and phagocytic activity remained largely stable. Surprisingly, platelet-neutrophil complex formation was severely impaired intraoperatively but returned to normal levels postoperatively. Further studies are needed to elucidate the implications of these intraoperative and postoperative changes in neutrophil and platelet activity with respect to a potential immune dysfunction that temporarily increases susceptibility to infectious or hemostatic complications.

Procalcitonin: Infection or Maybe Something More? Noninfectious Causes of Increased Serum Procalcitonin Concentration: Updated Knowledge

Procalcitonin (PCT) is a precursor of calcitonin, and its determination is used in daily clinical practice. It is a good marker for bacterial infection and can help diagnose sepsis. In this review, we summarize recent findings on the utility of PCT serum concentration measurement in noninfectious conditions. We found that elevated PCT levels may help in diagnosing or monitoring the course of cancer or inflammatory diseases. An increase was observed in emergency care such as acute renal failure or injuries, which may be promising in estimating the risk of complications. PCT has the potential to become a useful and clinically relevant marker beyond the assessment of bacterial infection. Due to its limited specificity, therapeutic decisions should be based on an individual evaluation of each clinical case.

Impact of surgical site infection on short- and long-term outcomes of robot-assisted rectal cancer surgery: a two-center retrospective study

PURPOSE

Robot-assisted surgery has increasingly gained recognition in the treatment of rectal cancer. This study aimed to assess the incidence of surgical site infection (SSI) that underwent robot-assisted radical rectal cancer surgery and to evaluate their influence on patient outcomes.

METHODS

A retrospective analysis was conducted on 360 patients who underwent robot-assisted radical rectal cancer surgery between 2017 and 2024 at Fujian Medical University Union Hospital and Longyan First Affiliated Hospital of Fujian Medical University. The patients were categorized into surgical site infection and non-surgical site infection groups based on the presence of surgical site infection. Baseline clinicopathological characteristics, perioperative details, and follow-up data were analyzed. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of surgical site infection, and Cox proportional hazards regression models were utilized to evaluate factors influencing overall survival.

RESULTS

The study found that 44 out of 360 patients (12.2%) developed surgical site infection. Multivariate analysis indicated that positive perineural invasion (OR 3.59, 95% CI 1.50-8.62, P = 0.004) is an independent risk factor for SSI. Low anterior resection (OR 0.26, 95% CI 0.09-0.73, P = 0.011), preservation of the left colonic artery (OR 0.20, 95% CI 0.09-0.44, P < 0.001), and neoadjuvant therapy (OR 0.45, 95% CI 0.23-0.89, P = 0.021) were associated with reduced risks of SSI. The presence of SSI was significantly associated with a reduction in overall survival (HR 3.43, 95% CI 1.30-9.04, P = 0.012). The risk of developing surgical site infection increases with the number of risk factors, and patients with two or more risk factors have a much higher risk of developing SSI.

CONCLUSIONS

This study identified perineural invasion as an independent risk factor for the development of SSI that underwent robot-assisted radical rectal cancer surgery. Low anterior resection, preservation of the left colonic artery, and neoadjuvant therapy emerged as protective factors. Moreover, the presence of surgical site infection was significantly correlated with poorer overall survival.

Quantitative Evaluation of Changes in Retinal and Choroidal Blood Flow Following Strabismus Surgery

Purpose

This study aimed to investigate the effects of extraocular muscle recession performed as part of strabismus surgery on posterior retinal and choroidal blood flow.

Methods

A single-center prospective study was conducted on patients who underwent strabismus surgery. Optical coherence tomography, optical coherence tomography angiography, and laser speckle flowgraphy of the macula were performed before surgery and at one week, one month, and four months after surgery. Preoperative and postoperative ratios were calculated, and longitudinal changes in retinal blood flow, choroidal thickness, and choroidal blood flow were analyzed. Furthermore, the changes based on the types of resected muscle were examined.

Results

In total, 254 eyes from 127 patients were included. The subfoveal choroidal thickness increased significantly at one week and one month after surgery, with no significant change at four months after surgery. The choroidal blood flow increased significantly at one week after surgery, with no significant changes at one and four months after surgery. The retinal vessel density significantly decreased at one week after surgery, with no significant changes at one and four months after surgery. Analysis of groups that had various muscles excised showed no significant changes in any measurements. Choroidal thickness and blood flow were significantly correlated at one week after surgery.

Conclusions

Strabismus surgery decreased retinal blood flow but increased choroidal thickness and blood flow in the early postoperative period. Moreover, no significant changes were observed in the long term compared to the preoperative period.

Translational Relevance

Strabismus surgery affects the retina and choroid in the early postoperative period but not in the long term.

Personalized nutritional care for immune function recovery in postoperative gastrointestinal surgery patients: An observational study

BACKGROUND

Gastrointestinal (GI) surgery can significantly affect the nutritional status and immune function of patients. This study aimed to investigate the effects of personalized nutritional care on the recovery of immune function in patients who underwent postoperative GI surgery.

AIM

To study examines personalized nutritional care’s impact on immune function recovery, nutritional status, and clinical outcomes after GI surgery.

METHODS

This observational study included 80 patients who underwent GI surgery between 2021 and 2023. Patients received personalized nutritional care based on their individual needs and surgical outcomes. Immune function markers including lymphocyte subsets, immunoglobulins, and cytokines were measured preoperatively and at regular intervals postoperatively. Nutritional status, clinical outcomes, and quality of life were assessed.

RESULTS

Patients receiving personalized nutritional care showed significant improvements in immune function markers compared to baseline. At 4 weeks postoperatively, CD4+ T-cell counts increased by 25% (P < 0.001), while interleukin-6 levels decreased by 40% (P < 0.001). Nutritional status, as measured by prealbumin and transferrin levels, improved by 30% (P < 0.01). Postoperative complications reduced by 35% compared to historical controls. The quality-of-life scores improved by 40% at 3 months postoperatively.

CONCLUSION

Personalized nutritional care enhances immune function recovery, improves nutritional status, and reduces complications in patients undergoing postoperative GI surgery, highlighting its crucial role in optimizing patient outcomes following such procedures.

Development and validation of a nomogram predicting multidrug-resistant tuberculosis risk in East China

Objective

Multidrug-resistant tuberculosis (MDR-TB) is a global health threat. Our study aimed to develop and externally validate a nomogram to estimate the probability of MDR-TB in patients with TB.

Methods

A total of 453 patients with TB in Anhui Chest Hospital between January 2019 and December 2020 were included in the training cohort. In addition, 116 patients with TB from Anhui Provincial Hospital Infection District between January 2015 and November 2023 were included in the validation cohort. Multivariable logistic regression analysis was applied to build a predictive model by combining the feature selected in the least absolute shrinkage and selection operator regression model. The C-index, calibration plot, and decision curve analysis were implemented to evaluate the predictive model's discrimination, calibration, and clinical practicality. Then, logistic regression and least absolute shrinkage and selection operator (LASSO) models were constructed using R software, and the accuracy, goodness of fit, and stability of the models were verified using the validation cohort.

Results

Eight variables of patients with TB were selected using the best penalization parameter of the LASSO regression method, and the nomogram was established. The model displayed good discrimination with a C-index of 0.752 and good calibration. A high C-index value of 0.825 could still be reached in the validation cohort. The decision curve analysis demonstrated the clinical value of the model.

Conclusion

In this study, we constructed the LASSO regression model based on eight clinical traits and outcomes of laboratory tests, providing a novel insight for evaluating MDR-TB.

Development of a Clinical and Laboratory-Based Predictive Nomogram Model for Unfavorable Functional Outcomes Among Patients Who Undergo Interventions for Aneurysmal Subarachnoid Hemorrhage

Objective: This study elucidates the prognostic significance of perioperative changes in laboratory indicators for aneurysmal SAH and develops a nomogram model for outcome prediction. Methods: Aneurysmal SAH patients who received clipping or coiling at our institution between January 2016 and December 2022 were included. All patients were randomly assigned to derivation and validation cohorts. Independent predictors of unfavorable outcomes were identified by multivariate analyses. Three models were conducted to evaluate whether perioperative laboratory changes improve prediction performance. A nomogram including all independent predictors was developed in the derivation cohort and verified in both cohorts. Results: Diabetes mellitus [OR (95% CI) = 2.84 (1.44-5.59)], WFNS grade 3-5 [OR: (95% CI), 9.17 (5.49-15.33)], clipping [OR (95% CI) = 1.71 (1.03-2.85)], perioperative changes in white blood cell count [OR (95% CI) = 2.15 (1.17-3.96)], and concentrations of ALT [OR (95% CI) = 1.41 (1.04-1.91)], sodium [OR (95% CI) = 5.40 (3.01-9.71)], and glucose [OR (95% CI) = 2.18 (1.05-4.53)] were independent predictors of an unfavorable outcome. The predictive nomogram incorporated the aforementioned predictors and performed well in the derivation cohort (AUC, 0.839; 95% CI: 0.810-0.866) and the validation cohort (AUC, 0.797; 95% CI: 0.734-0.850). Conclusions: Perioperative changes in laboratory indicators can be predictors of unfavorable outcomes in aneurysmal SAH patients. The nomogram based on clinical and laboratory risk factors can be used as a convenient tool to facilitate individualized decision making.

Patients with Mood Disorders Have Higher Rates of Healthcare Utilization, Medical Complications, Opioid Prescriptions, and Subsequent Knee Surgery after Arthroscopic Partial Meniscectomy

PURPOSE

To compare rates of post-operative complications, healthcare utilization, opioid prescribing patterns, and secondary knee surgery in patients with versus without a preexisting anxiety or depressive disorder (ADD) undergoing isolated primary arthroscopic partial meniscectomy (APM).

METHODS

The TriNetX database was queried from inception to compare patients over 18-years-old who underwent isolated primary APM with versus without a pre-existing ADD. Patients were matched in a 1:1 ratio based on demographic factors and comorbidities, including diabetes and hypertension. The following outcomes were collected: 1) post-operative complications and healthcare utilization within ninety days, 2) proportion of patients prescribed an opioid within one year, and 3) subsequent knee surgery within two years, specifically ipsilateral or contralateral meniscus surgery or total knee arthroplasty. Two subgroup analyses were conducted. Opioid naive patients with and without an ADD were compared based on the proportion of patients prescribed an opioid within one year of APM. Rates of revision meniscus surgery on the ipsilateral knee were also compared within two years of APM.

RESULTS

Within 90 days, patients with a pre-existing ADD (n=26,507), compared to those without (n=26,507), had higher rates of healthcare utilization, including readmission (p<0.001), and medical complications, like cerebrovascular accident (p=0.002). A greater proportion of patients with an ADD were prescribed opioids at all chosen time points within one year of APM. Similarly, a greater proportion of opioid naive patients with an ADD were prescribed opioids within six months (p<0.001) and one year (p<0.001). Patients with an ADD also had higher rates of total knee arthroplasty (p=0.001) and ipsilateral revision meniscus surgery (left knee: p=0.020; right knee: p=0.019) within two years.

CONCLUSION

Patients with an anxiety or depressive disorder have higher rates of healthcare utilization, medical complications, opioid prescriptions, and subsequent knee surgery after isolated primary arthroscopic partial meniscectomy.

LEVEL OF EVIDENCE

III, retrospective cohort study.

The Role of Cytokines in Perioperative Neurocognitive Disorders: A Review in the Context of Anesthetic Care

Perioperative neurocognitive disorders (PNDs), including postoperative delirium, delayed neurocognitive recovery, and long-term postoperative neurocognitive disorders, present significant challenges for older patients undergoing surgery. Inflammation is a protective mechanism triggered in response to external pathogens or cellular damage. Historically, the central nervous system (CNS) was considered immunoprivileged due to the presence of the blood-brain barrier (BBB), which serves as a physical barrier preventing systemic inflammatory changes from influencing the CNS. However, aseptic surgical trauma is now recognized to induce localized inflammation at the surgical site, further exacerbated by the release of peripheral pro-inflammatory cytokines, which can compromise BBB integrity. This breakdown of the BBB facilitates the activation of microglia, initiating a cascade of neuroinflammatory responses that may contribute to the onset of PNDs. This review explores the mechanisms underlying neuroinflammation, with a particular focus on the pivotal role of cytokines in the pathogenesis of PNDs.

Inflammation-based Scores in Patients With Pheochromocytoma

BACKGROUND

Pheochromocytoma is associated with systemic inflammation but the underlying mechanisms are unclear. Therefore, we investigated the relationship between plasma metanephrine levels and hematological parameters-as a surrogate of inflammation-in patients with pheochromocytoma and the influence of preoperative α-blockade treatment.

DESIGN AND METHODS

We retrospectively studied 68 patients with pheochromocytoma who underwent adrenalectomy (median age, 53 years; 64.7% females) and 2 control groups matched for age, sex, and body mass index: 68 patients with nonfunctioning adrenocortical tumors and 53 with essential hypertension. The complete blood count and several inflammation-based scores (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], lymphocyte-to-monocyte ratio [LMR], systemic-immune-inflammation index [SII], prognostic-nutrition index) were assessed in all patients and, in a subset of pheochromocytomas, after adrenalectomy (n = 26) and before and after preoperative α-blockade treatment (n = 29).

RESULTS

A higher inflammatory state, as indicated by both complete blood count and inflammation-based scores, was observed in patients with pheochromocytoma compared with nonfunctioning adrenocortical tumors and essential hypertension. Plasma metanephrine levels showed a positive correlation with NLR (r = 0.4631), PLR (r = 0.3174), and SII (r = 0.3709) and a negative correlation with LMR (r = 0.4368) and prognostic-nutrition index (r = 0.3741), even after adjustment for age, sex, ethnicity, body mass index, and tumor size (except for PLR). After adrenalectomy, we observed a reduction in NLR (P = .001), PLR (P = .003), and SII (P = .004) and a concomitant increase in LMR (P = .0002). Similarly, α-blockade treatment led to a reduction in NLR (P = .007) and SII (P = .03).

CONCLUSION

Inflammation-based scores in patients with pheochromocytoma showed pro-inflammatory changes that correlated with plasma metanephrine levels and are ameliorated by adrenalectomy and α-blockade.

Pathogen Distribution, Drug Resistance, and Postoperative High-Quality Nursing Intervention Effectiveness in Knee Osteoarthritis Patients After Knee Arthroplasty With Postoperative Infection

Objective

To analyze the distribution and drug resistance of pathogens in patients with postoperative infection following knee arthroplasty (TKA) for knee osteoarthritis (KOA) and to explore the effectiveness of high-quality nursing interventions postoperatively.

Methods

A retrospective analysis was conducted on clinical data from 87 KOA patients who underwent TKA and developed postoperative wound infections (infection group) at the first Affiliated Hospital of Harbin Medical University from July 2022 to September 2024. Another 87 patients without postoperative infection during the same period were selected as the control group. Deep wound exudate samples were collected from the infection group for pathogen culture, isolation, and identification. Drug susceptibility testing was performed using the K-B disk diffusion method. Additionally, venous blood samples were collected from both the infection and control groups one week after surgery, and serum levels of inflammatory markers [interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), procalcitonin (PCT)] were measured using enzyme-linked immunosorbent assay (ELISA). According to the type of nursing interventions received, the infection group was divided into the conventional care group (n=43, receiving standard orthopedic perioperative care) and the high-quality care group (n=44, receiving comprehensive high-quality care based on routine care). The pain levels [Visual Analog Scale (VAS) scores], knee joint function [Hospital for Special Surgery (HSS) knee scores], activities of daily living (modified Barthel index), and patient satisfaction [Newcastle Satisfaction with Nursing Service (NSNS) scale] were compared between the two groups.

Results

Among the 87 KOA patients with postoperative infection after TKA, 83 patients had a single pathogen infection, and 4 patients had mixed infections with two pathogens, resulting in the cultivation and isolation of 91 pathogens. Of these, 63 (69.23%) were Gram-positive bacteria, primarily Staphylococcus aureus (29.67%) and Staphylococcus epidermidis (17.58%). There were 25 (27.47%) Gram-negative bacteria, primarily Escherichia coli (9.89%) and Pseudomonas aeruginosa (6.59%). Three (3.30%) fungal strains were isolated, all identified as Candida albicans. Gram-positive bacteria showed high resistance to penicillin, benzylpenicillin, ampicillin, erythromycin, clindamycin, ciprofloxacin, and gentamicin, but low resistance to gatifloxacin, and no resistance to vancomycin or teicoplanin. Gram-negative bacteria showed high resistance to ciprofloxacin, levofloxacin, gentamicin, and tobramycin, but low resistance to cefepime, imipenem, meropenem, gatifloxacin, and amikacin. The infection group had significantly higher serum levels of IL-6, TNF-α, and PCT compared to the control group (P<0.05). The VAS scores at 24 hours, 3 days, and 7 days postoperatively were significantly lower in the high-quality care group compared to the conventional care group (P<0.05). The HSS scores and modified Barthel index scores at 3 months postoperatively were higher than preoperative values in both groups, with a greater improvement observed in the high-quality care group (P<0.05). The satisfaction rate in the high-quality care group (93.18%) was significantly higher than in the conventional care group (74.42%) (P<0.05).

Conclusion

The primary pathogens causing postoperative wound infections in KOA patients after TKA are Gram-positive bacteria, with Staphylococcus aureus and Staphylococcus epidermidis being predominant. Serum levels of inflammatory markers are significantly higher in infection patients compared to non-infection patients. High-quality nursing interventions can effectively alleviate postoperative pain, promote recovery of knee joint function, enhance activities of daily living, and improve patient satisfaction.

Oncologic surgical complications: Imaging approach and characteristics

Cancer is a disease that has multisystemic facets in its diagnosis and management. The treatment of choice with curative intent in many sites is surgery for early disease, commonly combined with neoadjuvant or adjuvant treatment. Oncologic surgery can have both locoregional and systemic complications, occasionally accentuated by multimodality treatment. While complications are of concern in any surgical setting, they may have specific intricate implications in the care of a cancer patient. Diagnostic imaging provides a non-invasive means of detecting complications and communicating the findings to the rest of the team for decision-making. Clinical clues, site-specific considerations and visual characteristics can aid the radiologist in arriving at a diagnosis of a locoregional oncologic surgical complication. Knowledge of systemic or distant complications, their clinical and imaging characteristics is a must-know following oncologic surgery. This article as an educational narrative review addresses imaging approach and characteristics of oncologic surgical complications, by pairing clinical considerations and imaging aspects.

Effect of total intravenous-based immediate extubation on patient outcomes in adult liver transplantation: A retrospective cohort study

Background

Although step-down emergence and extubation are universally practiced after liver transplantation (LT), prolonged mechanical ventilation and positive end-expiratory pressure may enhance predisposition to ventilator-associated complications and may be associated with inferior outcomes.

Methods

We screened 339 patients who underwent LT in this retrospective cohort study. After propensity score matching, 35 patients in Group F (total intravenous-based immediate extubation, TIIE) and 107 patients in Group C (balanced anesthesia with step-down extubation) with balanced and comparable pre- and intraoperative profiles were selected for analysis. Patients in Group F received propofol- and remifentanil-based total intravenous anesthesia, followed by immediate tracheal extubation. Patients in Group C received sevoflurane-based balanced anesthesia and were step-down extubated in the intensive care unit. The primary outcomes were postoperative respiratory support time and length of postoperative ICU stay. Other postoperative outcomes were compared between the two groups.

Results

Group F had significantly shorter postoperative respiratory support time than Group C (median, 0.08 vs 17 h; P < 0.001). The duration of postoperative intensive unit care stay in Group F was significantly shorter than that in Group C (mean, 5.84 vs 7.08 days; P = 0.019). Group F had a lower incidence of bacterial infection (20.0 % vs 42.1 %; P = 0.019) than Group C. No significant differences in continuous renal replacement therapy use (2.86 % vs 13.08 %; odds ratio, 0.195; P = 0.088), early mortality rate, percentage reduction of bilirubin, the incidence of exploratory laparotomy, pneumonia, or thrombosis were observed between groups.

Conclusion

TIIE is safe, effective, and associated with a lower incidence of postoperative bacterial infection.

Comparison of postoperative inflammatory response between natural orifice specimen extraction surgery and conventional laparoscopy in the treatment of colorectal cancer: a meta-analysis and systematic review

PURPOSE

Natural orifice specimen extraction surgery (NOSES) has attracted attention because of its minimal invasiveness. This meta-analysis compared inflammatory response profiles and infectious complications between colorectal cancer patients treated with NOSES and those treated with conventional laparoscopy.

METHODS

Seven medical databases were searched up to February 2024. The authors included studies that examined changes in the inflammatory response and outcomes in the patients after NOSES surgery. The Cochrane tool and the Newcastle-Ottawa Scale were used to evaluate the quality of the studies. Pooled standardized mean differences and odds ratios with 95% CIs were calculated using either fixed- or random-effects models. Review Manager 5.4 (RevMan 5.4) and the R project were used for the meta-analysis.

RESULTS

This meta-analysis included 22 studies. Pooled analyses revealed lower tumor necrosis factor-α levels (SMD=-1.34,95% CI [-2.43, -0.25]; Z=2.40, P =0.02 and SMD =-1.49,95% CI [-2.15, -0.82]; Z=4.36, P <0.0001) and C reactive protein levels (SMD=-0.56, 95% CI [-4.17, -2.50]; Z=2.19, P =0.03 and SMD =-1.24,95% CI [-1.77, -0.71]; Z=4.56, P <0.00001) on postoperative day 1 and postoperative day 3 for NOSES than for conventional laparoscopy. Pooled analysis revealed significantly lower interleukin-6 levels in the NOSES group (SMD=-1.88,95% CI [-2.84, -0.93]; Z=3.88, P =0.0001) on postoperative day 3. There were no significant differences in white blood cell count, procalcitonin levels, or the incidence of infectious complications between the two groups.

CONCLUSIONS

NOSES has a superior inflammatory profile and does not increase the incidence of postoperative infectious diseases. The reported results should be validated in a larger population of colorectal cancer patients.

The Effect of Intravenous Lidocaine, Ketamine, and Lidocaine-Ketamine Combination in Colorectal Cancer Surgery: A Randomized Controlled Trial

BACKGROUND

Colorectal resections are associated with a pronounced inflammatory response, severe postoperative pain, and postoperative ileus. The aim of this study was to evaluate the main effects of lidocaine and ketamine, and their interaction in colorectal cancer (CRC) patients after open surgery. The interaction could be additive if the effect of 2 drugs given in combination equals the sum of their individual effects, or multiplicative if their combined effect exceeds the sum of their individual effects. We hypothesized that the combination of lidocaine and ketamine might reduce the inflammatory response additively or synergistically.

METHODS

Eighty-two patients undergoing elective open colorectal resection were randomized to receive either lidocaine or placebo and either ketamine or placebo in a 2 × 2 factorial design. After induction of general anesthesia, all subjects received an intravenous bolus (lidocaine 1.5 mg/kg and/or ketamine 0.5 mg/kg and/or a matched saline volume) followed by a continuous infusion (lidocaine 2 mg·kg -1 ·h -1 and/or ketamine 0.2 mg·kg -1 ·h -1 and/or a matched saline volume) until the end of surgery. Primary outcomes were serum levels of white blood cell (WBC) count, interleukins (IL-6, IL-8), and C-reactive protein (CRP) measured at 2 time points: 12 and 36 hours after surgery. Secondary outcomes included intraoperative opioid consumption; visual analog scale (VAS) pain scores at 2, 4, 12, 24, 36, and 48 hours postoperatively; cumulative analgesic consumption within 48 hours after surgery; and time to first bowel movement. We assessed the main effects of each of lidocaine and ketamine and their interaction on the primary outcomes using linear regression analyses. A Bonferroni-adjusted significance level was set at .05/8 = .00625 for primary analyses.

RESULTS

No statistically significant differences were observed with either lidocaine or ketamine intervention in any of the measured inflammatory markers. No multiplicative interaction between the 2 treatments was confirmed at 12 or 36 hours after surgery: WBC count, P = .870 and P = .393, respectively; IL-6, P = .892 and P = .343, respectively; IL-8, P = .999 and P = .996, respectively; and CRP, P = .014 and P = .445, respectively. With regard to inflammatory parameters, no evidence of additive interactions was found. Lidocaine and ketamine, either together or alone, significantly reduced intraoperative opioid consumption versus placebo, and, except for lidocaine alone, improved pain scores. Neither intervention significantly influenced gut motility.

CONCLUSIONS

Our study results do not support the use of an intraoperative combination of lidocaine and ketamine in patients undergoing open surgery for CRC.

Effects of Oral Nutritional Supplement on Postoperative Orthognathic Surgery Patients' Nutritional Status: A Randomised Clinical Trial

Purpose

Orthognathic surgery often leads to decreased nutrient intake and increased metabolic demands, potentially resulting in muscle mass loss and delayed recovery. The use of oral nutritional supplements (ONS) alongside nutritional counselling has been proposed to mitigate these effects. This study aimed to investigate the impact of ONS on the postoperative nutritional status of patients undergoing orthognathic surgery.

Patients and methods

A 12-week randomized controlled trial was conducted at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand. The recruitment period was extended from July to December 2022 due to unforeseen delays. Patients aged 18 or older, undergoing orthognathic surgery involving at least one jaw, and without metabolic diseases or allergies were included. The intervention group received nutritional counselling and ONS for one-month post-surgery, while the control group received only nutritional counselling. The primary outcome was nutritional status, assessed through anthropometric, biomarker, and muscle strength measurements at various time points.

Results

A total of 28 participants completed the study (control group: n=12, intervention group: n=16). Both groups experienced postoperative weight and muscle mass loss. While the intervention group showed a significantly lower weight loss at two- and four-weeks post-surgery, no significant differences were found in other nutritional status parameters or oral health-related quality of life between the groups after 12 weeks.

Conclusion

The addition of ONS to nutritional counselling did not significantly improve the overall nutritional status of orthognathic surgery patients in the long term. Further research is needed to explore more personalized and intensive nutritional interventions to enhance postoperative recovery in this population.

Trial Registration

Thai Clinical Trials Registry, TCTR20220624006. Registered 24 June 2022.

Growth Differentiation Factor 15 as a Biomarker for Risk Stratification in the Cardiothoracic Surgery Intensive Care Unit

Growth Differentiation Factor 15 (GDF15) is an emerging biomarker that significantly increases during acute stress responses, such as infections, and is moderately elevated in chronic and inflammation-driven conditions. While evidence suggests that high levels of GDF15 in cardiac surgery are associated with worse outcomes, its utility as an evaluator of early postoperative complications remains unclear. This study aims to characterize the postoperative profile of GDF15 in patients undergoing isolated surgical aortic valve replacement, evaluating its association with short-term outcomes. Serum samples from patients undergoing cardiac surgery were collected preoperatively and at defined postoperative time points (1 h, 6 h, 12 h, 24 h, and 48 h) to measure GDF15 levels. GDF15 levels significantly increased after surgery, peaking at 6 h. A positive correlation was observed between GDF15 levels and both cardiopulmonary bypass and aortic cross-clamp times. Notably, patients who developed postoperative acute kidney injury (AKI) or required prolonged hemodynamic support had significantly higher GDF15 levels, with increased mechanical ventilation time and extended intensive care unit length of stay. Furthermore, GDF15 levels correlated with postoperative SOFA scores at 24 h after surgery. GDF15 may be a valuable biomarker for risk stratification and guiding therapeutic decisions in cardiac surgery patients. Higher GDF15 levels were significantly associated with prolonged hemodynamic support, postoperative AKI, and measures of illness severity.

Effects of Continuous Erector Spinae Plane Block on the Postoperative Sleep Quality for Patients Undergoing Thoracoscopic Lung Lobe Resection Surgery: A Prospective, Randomized Controlled Trial

Purpose

To investigate the effect of continuous erector spinae plane block (ESPB) on postoperative sleep in patients undergoing thoracoscopic lung lobe resection surgery.

Patients and Methods

Eighty-six patients were randomly assigned into two groups: ESPB group (Group E) or control group (Group P). Group E received ESPB before induction, followed by continuous ESPB analgesia, while Group P received postoperative intravenous controlled analgesia. The Pittsburgh Sleep Quality Index (PSQI) questionnaire was used to assess postoperative sleep disturbance (PSD) on the postoperative day 3 (POD3). The St. Mary's Hospital Sleep Questionnaire (SMH) evaluated sleep quality on the day of surgery and postoperative day 1 (POD1) and postoperative day 2 (POD2). The Identity Consequence Fatigue Scale-10 (ICFS-10) was utilized to evaluate postoperative fatigue status. Numeric Rating Scale (NRS) scores at resting and coughing were recorded at extubation, 6 h, 24 h, 48 h, 72 h after surgery. Consumption of propofol, remifentanil, and remedial analgesics (bucinazine), hospital duration, occurrence of postoperative adverse reactions were documented. Interleukin-6 (IL-6) and interleukin-10 (IL-10) serum levels were measured before surgery, 12 h, 24 h, 48 h after surgery.

Results

The incidence of PSD in group E on POD3 was significantly lower than group P (75% vs 25%). Patients in group E had higher SMH scores than group P on the day of surgery and POD2. Compared with group P, the NRS scores of resting and coughing at all time points, remifentanil and bucinazine consumption, postoperative ICFS-10 scores, the incidence of nausea and vomiting, IL-6 serum levels in group E were significantly decreased. The IL-10 serum levels in group E were significantly higher than those in group P.

Conclusion

The continuous ESPB can improve postoperative sleep quality, alleviate pain, fatigue and inflammation, and reduce the incidence of postoperative nausea and vomiting.

Optimizing debridement and implant retention in acute periprosthetic joint infections

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Effects of postoperative glucocorticoids on mitigation of organ dysfunction in patients with type A aortic dissection: a randomized controlled trial

OBJECTIVES

This study aims to evaluate the organ-protective efficacy of postoperative glucocorticoid in patients with type A aortic dissection.

METHODS

Postoperative type A aortic dissection patients were randomly allocated to receive either postoperative glucocorticoid or standard-of-care treatment. Intravenous methylprednisolone was administered for 3 days. The primary outcome was the reduction of Sequential Organ Failure Assessment score on postoperative day 4 compared to baseline (on postoperative day 1 before methylprednisolone administration).

RESULTS

Two hundred twelve patients were included in the intention-to-treat analysis. The primary outcome was significantly different between groups: 3.16 ± 2.52 in the control group versus 4.36 ± 2.82 in the glucocorticoid group (absolute difference 1.20 [95% CI 0.52-1.93], P = 0.001). The glucocorticoid group showed markedly lower median high-sensitivity C-reactive protein levels compared to the control group (91.0 mg/l vs 182.0 mg/l; absolute difference: -91 (95% CI -122 to -57), P = 0.009) on postoperative day 4. Fewer patients in the glucocorticoid group required continuous renal replacement therapy (8.5% vs 19.8% in the control group; absolute difference: -10.4 [95% CI -19.1 to -1.3], P = 0.03).

CONCLUSIONS

This trial demonstrates that postoperative glucocorticoid in patients with type A aortic dissection significantly reduces postoperative inflammation and improves recovery of early organ dysfunction. These findings advocate for the implementation of glucocorticoid in the early phase after surgery for enhanced organ protection.

Impact of remimazolam on postoperative inflammatory markers and complications in thoracoscopic pulmonary lobectomy patients: A retrospective analysis

Remazolam is widely used for procedural sedation in intensive care units. It has been shown to have anti-inflammatory and organ-protecting properties. However, the changes in inflammatory markers and analgesic effects of remazolam after thoracoscopic pulmonary lobectomy remain unclear. This study aims to assess the effects of the novel drug remimazolam on inflammatory factor levels and postoperative complications in thoracoscopic pulmonary lobectomy patients, providing a scientific basis for clinical use. This retrospective study analyzed 200 thoracoscopic pulmonary lobectomy patients, who were divided into a control group and a remimazolam group based on their anesthesia method. Patients in ramazolam group were anesthetized with ramazolam, while patients in control group were anesthetized with propofol. All patients were performed by the same physician team and anesthesia team. Inflammatory factors (including interleukin-6 [IL-6], C-reactive protein [CRP], including interleukin-8) were measured preoperatively and postoperatively, and postoperative complication rates were compared between the 2 groups. The levels of IL-6 and CRP were significantly higher in the remimazolam group at 7 days postoperatively compared to the control group. No significant differences were observed in preoperative inflammatory factors or postoperative including interleukin-8 levels between the 2 groups. Additionally, there were no significant differences in the overall incidence of postoperative complications or in specific complications such as pulmonary infection, atelectasis, subcutaneous emphysema, pneumothorax, surgical site infection, and arrhythmia. Patients receiving remimazolam had higher postoperative IL-6 and CRP levels compared to the control group, without an increase in postoperative complications. In clinical use, attention should be paid to the control of inflammatory indicators in patients using remazolam. However, due to potential confounding factors and the retrospective design, we cannot establish a causal relationship between remimazolam and elevated inflammatory markers. These findings suggest a possible association that requires cautious interpretation. Further research is needed to assess the clinical relevance and explore the underlying mechanisms.

Oxaliplatin lipidated prodrug synergistically enhances the anti-colorectal cancer effect of IL12 mRNA

Colorectal cancer (CRC) is the fourth most common cancer in the world, with the second highest incidence rate after lung cancer. Oxaliplatin (OXA) is a broad-spectrum anti-tumor agent with significant therapeutic efficacy in colorectal cancer, and as a divalent platinum analog, it is not selective in its distribution in the body and has systemic toxicity with continued use. Interleukin-12 (IL12) is an immunostimulatory cytokine with cytokine monotherapy that has made advances in the fight against cancer, limiting the clinical use of cytokines due to severe toxicity. Here, we introduced a long alkyl chain and N-methyl-2,2-diaminodiethylamine to the ligand of OXA to obtain OXA-LIP, which effectively reduces its toxicity and improves the uptake of the drug by tumor cells. We successfully constructed IL12 mRNA and used LNPs to deliver IL12 mRNA, and in vivo pharmacodynamic studies demonstrated that OXA-LIP combined with IL12 mRNA had better tumor inhibition and higher biosafety. In addition, it was investigated by pharmacokinetic experiments that the OXA-LIP drug could accumulate in nude mice at the tumor site, which prolonged the half-life and enhanced the anti-tumor efficiency of OXA. It is hoped that these results will provide an important reference for the subsequent research and development of OXA-LIP with IL12 mRNA, as well as provide new therapeutic approaches for the treatment of colon cancer.

Identification of host endotypes using peripheral blood transcriptomics in a prospective cohort of patients with endocarditis

OBJECTIVES

Host responses to infection are a major determinant of outcome. However, the existence of different response profiles in patients with endocarditis has not been addressed. Our objective was to apply transcriptomics to identify endotypes in patients with infective endocarditis.

METHODS

A total of 32 patients with infective endocarditis were studied. Clinical data and blood samples were collected at diagnosis and RNA sequenced. Gene expression was used to identify two clusters (endocarditis endotype 1 [EE1] and endocarditis endotype 2 [EE2]). RNA sequencing was repeated after surgery. Transcriptionally active cell populations were identified by deconvolution. Differences between endotypes in clinical data, survival, gene expression, and molecular pathways involved were assessed. The identified endotypes were recapitulated in a cohort of COVID-19 patients.

RESULTS

A total of 18 and 14 patients were assigned to EE1 and EE2, respectively, with no differences in clinical data. Patients assigned to EE2 showed an enrichment in genes related to T-cell maturation and a decrease in the activation of the signal transducer and activator of transcription protein family pathway, with higher counts of active T cells and lower counts of neutrophils. A total of 14 patients (nine in EE1 and five in EE2) were submitted to surgery. Surgery in EE2 patients shifted gene expression toward a EE1-like profile. In-hospital mortality was higher in EE1 (56% vs 14%, P = 0.027), with an adjusted hazard ratio of 12.987 (95% confidence interval 3.356-50). Translation of these endotypes to COVID-19 and non-COVID-19 septic patients yielded similar results in cell populations and outcome.

CONCLUSIONS

Gene expression reveals two endotypes in patients with acute endocarditis, with different underlying pathogenetic mechanisms, responses to surgery, and outcomes.

The effect of anesthesia methods on the neutrophil-lymphocyte ratio in patients undergoing forearm surgery: A monocentric and retrospective study

Surgical trauma can induce systemic inflammation. The selected anesthesia method may modulate the inflammatory response and surgical results in the inflammatory process that occurs during surgical trauma. In this retrospective study, we aimed to compare the anti-inflammatory effects of general anesthesia and peripheral nerve block (infraclavicular block). Demographic, clinical, and laboratory records (hemogram, total leukocyte count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and mean platelet volume) were obtained from the archival data. The patients were divided into 2 groups: Group G, who received general anesthesia, and Group P, who received a peripheral nerve block (infraclavicular block) for forearm surgery. The amount of opioid consumed postoperatively was significantly lower in Group P. Infraclavicular block as an alternative to general anesthesia was found to be associated with a significant decrease in the neutrophil-to-lymphocyte ratio, total leukocyte count, and platelet-to-lymphocyte ratio levels compared to those observed after general anesthesia. Peripheral nerve blocks may play a role in reducing inflammation and alleviating stress.

The Crucial Triad: Endothelial Glycocalyx, Oxidative Stress, and Inflammation in Cardiac Surgery-Exploring the Molecular Connections

Since its introduction, the number of heart surgeries has risen continuously. It is a high-risk procedure, usually involving cardiopulmonary bypass, which is associated with an inflammatory reaction that can lead to perioperative and postoperative organ dysfunction. The extent of complications following cardiac surgery has been the focus of interest for several years because of their impact on patient outcomes. Recently, numerous scientific efforts have been made to uncover the complex mechanisms of interaction between inflammation, oxidative stress, and endothelial dysfunction that occur after cardiac surgery. Numerous factors, such as surgical and anesthetic techniques, hypervolemia and hypovolemia, hypothermia, and various drugs used during cardiac surgery trigger the development of systemic inflammatory response and the release of oxidative species. They affect the endothelium, especially endothelial glycocalyx (EG), a thin surface endothelial layer responsible for vascular hemostasis, its permeability and the interaction between leukocytes and endothelium. This review highlights the current knowledge of the molecular mechanisms involved in endothelial dysfunction, particularly in the degradation of EG. In addition, the major inflammatory events and oxidative stress responses that occur in cardiac surgery, their interaction with EG, and the clinical implications of these events have been summarized and discussed in detail. A better understanding of the complex molecular mechanisms underlying cardiac surgery, leading to endothelial dysfunction, is needed to improve patient management during and after surgery and to develop effective strategies to prevent adverse outcomes that complicate recovery.

Comprehensive review of perioperative factors influencing ferroptosis

The perioperative period encompasses all phases of patient care from the decision to perform surgery until full recovery. Ferroptosis, a newly identified type of regulated cell death, influences a wide array of diseases, including those affecting the prognosis and regression of surgical patients, such as ischemia-reperfusion injury and perioperative cognitive dysfunction. This review systematically examines perioperative factors impacting ferroptosis such as surgical trauma-induced stress, tissue hypoxia, anesthetics, hypothermia, and blood transfusion. By analyzing their intrinsic relationships, we aim to improve intraoperative management, enhance perioperative safety, prevent complications, and support high-quality postoperative recovery, ultimately improving patient outcomes.

The new pattern for dual NOTCH pathway involving nuclear transcription and mitochondrial regulation supports therapeutic mechanism of 4-butyl benzophenone derivatives against SIRS

The systemic inflammatory response syndrome (SIRS) represents a self-amplifying cascade of inflammatory reactions and pathophysiological states triggered by infectious or non-infectious factors. The identification of disease targets and differential proteins in the liver (the unique and important immune organ) of SIRS mice treated with the lead compound D1 was conducted using the Genecards database and proteomic analysis, respectively. Subsequently, NOTCH1 was identified as the potential hub target via an intersection analysis between the aforementioned differentially expressed proteins and disease targets. Based on our previous research on the structure-activity relationship, we designed and synthesized a series of SIRS-related derivatives, wherein butyl, halogen, and ester groups were incorporated into benzophenone, aiming at exploring the anti-inflammatory protective action from the perspective of macrophage polarization. Notably, these derivatives exhibited a direct binding capability to the O-glucosylation site (SER496) or its vicinities (such as SER492, VAL485) of NOTCH1 using docking, SPR, DARTS, and CETSA techniques. Mechanistically, derivative D6 exerted anti-inflammatory effects via the dual NOTCH pathway. Firstly, it could inhibit NOTCH1 nuclear transcriptional activity, attenuate the interaction between NICD and RBPJK, concurrently suppress NF-κB and NLRP3 inflammasome (NLRP3, ASC, and cleaved CASP1) activation, and promote NICD (NOTCH1 active fragments) ubiquitination metabolism (the nuclear transcriptional pathway). Secondly, it might possess the ability to increase PGC1α level, subsequently, enhance ATP and MMP levels, mitigate ROS production, increase mitochondrial numbers, and ameliorate mitochondrial inflammatory damage (the mitochondrial pathway). Importantly, the activator Jagged1 could effectively reverse the aforementioned effects, while the inhibitor DAPT exhibited a synergistic effect, suggesting that the nuclear transcriptional regulation and mitochondrial regulation were both in a NOTCH1-dependent manner. Subsequently, it effectively alleviated the inflammatory response and preserved organ function as evidenced by up-regulating M2-type macrophage-related anti-inflammatory cytokines (IL10, TGFβ, CD206, and ARG1) and down-regulating M1-type macrophage-related pro-inflammatory cytokines (NO, IL6, IL18, iNOS, TNFα, CD86, and IL1β). In a word, derivative D6 modulated macrophage polarization and effectively mitigated SIRS by targeting inhibition of the dual NOTCH pathway.

Assessing the predictive value of pre- and post-operative inflammatory markers in patients undergoing total knee arthroplasty

BACKGROUND AND OBJECTIVE

Total Knee Arthroplasty (TKA) has proven highly effective in improving quality of life for patients with severe knee conditions. Despite advancements, surgical complications such as periprosthetic joint infections (PJIs) pose risks. The potential predictive value of pre- and post-operative inflammatory markers like neutrophil-to-lymphocyte ratio (NLR), D-dimer, and albumin levels on surgical outcomes is garnering attention. There is a growing interest in leveraging these markers to enhance patient selection and outcome prediction in the context of TKA.Focusing on the natural course of these markers, and the incidence of PJIs and to refine perioperative care strategies, improve patient outcomes, and identify high-risk patients for targeted intervention.

METHODS

The study included 94 patients who underwent total knee arthroplasty (TKA) between 2019 and 2023. Blood tests were conducted before surgery and at 1, 3, 7, and 15 days after surgery to assess various parameters including white blood cell count, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein, D-dimers, total protein, albumin, and total cholesterol values and ratios.

RESULTS

Following total knee arthroplasty (TKA), key observations in blood markers included a sharp rise in white blood cell (WBC) counts from 5.81 to 10.22 (*10^9/L) on the first day post-surgery, with levels returning close to preoperative values by day-15. Neutrophil counts similarly increased from 3.46 to 8.50 (*10^9/L) on day-1, decreasing to 4.01 by day-15. Hemoglobin levels significantly decreased from 115.70 g/L to 90.62 by day-3 before improving to 100.30 by day-15. C-reactive protein (CRP) levels also saw a significant rise from 6.15 mg/L to a peak of 47.07 on day-3, then reducing to 10.55 by day-15, indicating a response to inflammation.

CONCLUSION

Following total knee arthroplasty (TKA), a significant initial postoperative increase in white blood cell count, neutrophils, and C-reactive protein levels, indicative of an acute inflammatory response, before returning towards baseline values by day 15. Hemoglobin levels displayed a notable dip post-surgery, gradually improving by the study's end. These patterns emphasize the dynamic nature of inflammatory and hematological responses after TKA, highlighting their potential role in predicting surgical outcomes and guiding postoperative care.

Perioperative care of the patient with a periodic fever syndrome

Periodic fever syndromes are autoinflammatory disorders associated with recurrent fevers unrelated to infection. Little is known about the perioperative management of patients with these syndromes, and existing literature consists primarily of case reports and occasional case series. This narrative review discusses background information and diagnostic criteria for the three most common periodic fever syndromes: periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA), familial Mediterranean fever (FMF), and TNF receptor-associated periodic syndrome (TRAPS), and describes perioperative considerations for anesthesia providers when caring for the patient with a periodic fever syndrome. We include a systems-based framework in which to organize these considerations.

Exploring the Analgesic Efficacy and mechanisms of low-dose esketamine in pregnant women undergoing cesarean section: A randomized controlled trial

Background

Postoperative pain is a prevalent concern following a cesarean section. This study aimed to investigate the effect and mechanism of low-dose (0.1 mg/kg) esketamine on postoperative pain management in pregnant women undergoing cesarean sections, specifically in cases where both patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) were employed.

Methods

Pregnant women intending to undergo elective cesarean section were divided into four subgroups based on the intravenous administration of esketamine and the specific analgesia methods employed: E1 (0.1 mg/kg esketamine + PCEA), E2 (0.1 mg/kg esketamine + PCIA), C1 (saline + PCEA), and C2 (saline + PCIA). The primary outcome was the maximum pain score within 24 h postoperatively. Secondary outcomes included the pressure pain threshold and tolerance at 30 min and 24 h postoperatively, along with the inflammation and adverse event index scores.

Results

A total of 118 pregnant women were assigned to the four groups: E1 (n = 29), E2 (n = 29), C1 (n = 30), and C2 (n = 30). Compared with those in the control groups (C1 + C2), the maximum postoperative pain scores within 24 h in the esketamine groups (E1 + E2) were significantly lower (4 [2-5] vs. 4 [4-6], P = 0.002), and the E1 group exhibited superior analgesic effects compared with other groups. No significant differences were observed in postoperative hyperalgesia or inflammation across the four groups. Notably, esketamine combined with PCIA increased the incidence of postoperative nausea and vomiting (7 [25 %] vs. 0 [0 %]; P = 0.005).

Conclusion

The administration of low-dose (0.1 mg/kg) esketamine effectively alleviates pain following cesarean section, and the analgesic effect is notably enhanced in combination with PCEA. Importantly, these effects do not appear to be mediated through anti-inflammatory mechanisms or the inhibition of hyperalgesia.

Clinical trial registration number

NCT05414006.

Neuroinflammatory Approach to Surgical Trauma: Biomarkers and Mechanisms of Immune and Neuroendocrine Responses

The severity and invasiveness of clinical outcomes from organic responses to trauma are influenced by individual, surgical, and anesthetic factors. A stress response elicits neuroendocrine and immune reactions that may lead to multi-organ dysfunction. The degree of neuroinflammatory reflex activation from trauma can increase pro-inflammatory cytokine production, leading to endothelial dysfunction, glycocalyx damage, neutrophil activation, and multisystem tissue destruction. A shift in patient treatment towards a neuroinflammatory perspective has prompted a new evaluation protocol for surgical patients, required to understand surgical pathogenesis and its link to chosen anesthetic-surgical methods. The goal of this study is to summarize and disseminate the present knowledge about the mechanisms involved in immune and neuroendocrine responses, focusing on video laparoscopic surgeries. This article outlines various measures cited in the literature aimed at reducing the burden of surgical trauma. It reviews anesthetic drugs, anesthetic techniques, and intensive care procedures that are known to have immunomodulatory effects. The results show a preference for more sensitive inflammatory mediators to tissue trauma serving as care tools, indicators for prognosis, and therapeutic outcomes.

Additive antinociceptive action of intrathecal anandamide reuptake inhibitor and morphine in the management of post-incisional pain in rats

Spinal opioids have mixed efficacy and their adverse effects force treatment cessation of postoperative pain. Consequently, there is an ongoing search for new therapeutic strategies. Here, we evaluated the analgesic efficacy of intrathecal UCM707, an anandamide reuptake inhibitor, and morphine combination. Firstly, we assessed the effects of morphine (1, 5 and 10 μg), UCM707 (75 μg) and its combination in the hot plate. Then, morphine + UCM707 at sub-effective doses was evaluated in a rat post-incisional pain model. In addition, μ-, CB1r-, CB2r- and TRPV1-antagonists were pre-administered before the combination. Activation of μ-opioid and CB1r, and Cnr1, Cnr2, Oprm1 and TRPV1 expressions were evaluated in the lumbar sacra and periaqueductal grey by [35 S]-GTPγS binding autoradiography and qPCR studies. In the hot plate, morphine (1 μg) and UCM707 (75 μg) induced a more robust analgesic effect than each drug alone. Morphine plus UCM707 did not modify μ-opioid nor CB1 receptor function in the PAG or LS. Cnr1 and TRPV1 expression increased in the lumbar sacra (LS). Morphine plus UCM707 significantly reduced post-incisional pain at 1 and 4 days after surgery. Cnr1, Cnr2 and TRPV1 expressions increased in the LS. Blockade of μ-opioid receptor reduced combination effects on days 1 and 4. CB1r- and CB2r-antagonism reduced morphine + UCM707 effects on days 1 and 4, respectively. CB1r and TRPV1-antagonism improved their antinociceptive effects on day 4. These results revealed a synergistic/additive analgesic effect of UCM707 and morphine combination controlling postincisional pain. CB1r, CB2r and TRPV1 contribute differently as central sensitization occurs.

β-Caryophyllene promotes the survival of random skin flaps by upregulating the PI3K/AKT signaling pathway

BACKGROUND

Flap transplantation is a widely used plastic repair technique in surgical procedures, aimed at addressing skin defects resulting from diverse wounds and diseases. However, due to the insufficient blood supply after flap surgery, the occurrence of ischemia-reperfusion injury, and an excessive sterile inflammatory response, flaps frequently develop complications (e.g., partial or complete ischemic necrosis). These complications have adverse effects on wound healing and repair. β-Caryophyllene (BCP) is a bicyclic sesquiterpene that is widely present in plants. It mitigates oxidative stress and inflammatory responses, demonstrates neuroprotective and analgesic properties, and serves a protective function in organs or tissues subjected to ischemia-reperfusion injury. However, no study has confirmed whether BCP can be used in the field of flap transplantation to improve the flap survival rate.

METHODS

To assess the impact of BCP on random flap survival, we constructed a modified McFarlane random flap model on the rat. After 7 consecutive days of gavage with different doses of BCP, we measured the survival area ratio, angiogenesis, blood perfusion, tissue inflammation level, apoptosis-related protein levels, and the PI3K/AKT signaling pathway expression of the random flap.

RESULTS

BCP treatment increased the survival area of the flap in a dose-dependent manner after random flap transplantation in rats. BCP mainly promoted the formation of tissue blood vessels, improved flap blood perfusion, limited the local inflammatory response, and reduced apoptosis. In addition, we demonstrated that BCP works primarily by promoting the PI3K/AKT signaling expression while enhancing the phosphorylation of AKT. Administration of wortmannin, a selective inhibitor of PI3K, eliminated the effects of BCP.

CONCLUSION

BCP can promote the survival of random flaps by upregulating the PI3K/AKT signaling pathway, increasing tissue blood perfusion, and limiting the inflammatory response and apoptosis.

Cannabinoid Analgesia in Postoperative Pain Management: From Molecular Mechanisms to Clinical Reality

Postoperative pain (POP) is a challenging clinical phenomenon that affects the majority of surgical patients and demands effective management to mitigate adverse outcomes such as persistent pain. The primary goal of POP management is to alleviate suffering and facilitate a seamless return to normal function for the patient. Despite compelling evidence of its drawbacks, opioid analgesia remains the basis of POP treatment. Novel therapeutic approaches rely on multimodal analgesia, integrating different pharmacological strategies to optimize efficacy while minimizing adverse effects. The recognition of the imperative role of the endocannabinoid system in pain regulation has prompted the investigation of cannabinoid compounds as a new therapeutic avenue. Cannabinoids may serve as adjuvants, enhancing the analgesic effects of other drugs and potentially replacing or at least reducing the dependence on other long-term analgesics in pain management. This narrative review succinctly summarizes pertinent information on the molecular mechanisms, clinical therapeutic benefits, and considerations associated with the plausible use of various cannabinoid compounds in treating POP. According to the available evidence, cannabinoid compounds modulate specific molecular mechanisms intimately involved in POP. However, only two of the eleven clinical trials that evaluated the efficacy of different cannabinoid interventions showed positive results.

Postoperative bioactive adrenomedullin is associated with the onset of ARDS and adverse outcomes in patients undergoing open thoracoabdominal aortic surgery

Cytokine-mediated systemic inflammation after open thoracoabdominal aortic aneurysm (TAAA) repairs plays a pivotal role in disrupting circulatory homeostasis, potentially leading to organ dysfunction. The bioactive form of adrenomedullin (bio-ADM) is a peptide hormone with immunomodulatory and vasomotor effects, making it a potential diagnostic agent in these cases. This retrospective, bicentric study, conducted between January 2019 and December 2022, recruited 36 elective open TAAA repair patients in two German centres. Serum and plasma samples were collected at multiple time points to measure bio-ADM levels. The primary objective was to evaluate the association of bio-ADM levels with the onset of acute respiratory distress syndrome (ARDS), with secondary endpoints focusing on mortality and SIRS-related morbidity. Results showed a significant association between postoperative bio-ADM levels (12-48 h after surgery) and the onset of ARDS (p < .001), prolonged ventilation (p = .015 at 12h after surgery), atrial fibrillation (p < .001), and mortality (p = .05 at 24h). The biomarker was also strongly associated with sepsis (p = .01 at 12 h) and multi-organ dysfunction syndrome (MODS) (p = .02 at 24 h after surgery). The study underscores the potential utility of bio-ADM as a diagnostic tool for identifying patients at risk of postoperative complications following open TAAA repairs.

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Efficacy of preoperative single-dose dexamethasone in preventing postoperative pulmonary complications following minimally invasive esophagectomy: a retrospective propensity score-matched study

BACKGROUND

The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE).

METHODS

Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery.

RESULTS

In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019).

CONCLUSIONS

Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023).

Preoperative Albumin and Postoperative CRP/Albumin Ratio (CARS) are Independent Predictive Factors in Estimating 1-Year Mortality in Patients Operated for Proximal Femoral Metastasis with Endoprosthesis

Background

Proximal femur resection and prosthetic reconstruction are preferred in patients with extensive bone destruction, pathological fractures, tumours resistant to radiation therapy, and patients with more proximal metastatic lesions. There is increasing evidence that the CRP/albumin ratio (CAR) is an independent marker of inflammation in various primary organ cancers and maybe a more accurate prognostic factor. We aimed to evaluate whether preoperative and postoperative CAR values could be a factor in predicting mortality in these patients. We hypothesized that CAR could predict these patients' postoperative 90-day and 1-year mortality.

Methods

The patient's age and gender, primary tumour, number of bone metastases, and presence of visceral metastases were recorded using imaging techniques such as computed tomography and bone scan or positron emission tomography. The following laboratory data were analyzed before and after surgery.

Results

The mean age of the patients was 62.67 ± 14.8; 56.9% were female (n:29), and 43.1% were male (n:22). When the results of the ROC analysis of the parameters in predicting 1-year mortality were examined, and the cut-off value for preoperative albumin was taken as ≤ 3.75, the AUC value was found to be statistically significant as 0.745 (p:0.003). When the cut-off value for postoperative CAR was taken as ≥ 87.32, the AUC value was found to be 0.7 statistically significant (p:0.015).

Conclusion

Length of stay, preoperative albumin and postoperative CAR values can be used as independent predictive values in predicting 1-year mortality in patients undergoing endoprosthesis due to proximal femur metastasis.

Thrombopoietin levels in sepsis and septic shock - a systematic review and meta-analysis

OBJECTIVES

Sepsis is a life-threatening condition implicating an inadequate activation of the immune system. Platelets act as modulators and contributors to immune processes. Indeed, altered platelet turnover, thrombotic events, and changes in thrombopoietin levels in systemic inflammation have been reported, but thrombopoietin-levels in sepsis and septic-shock have not yet been systematically evaluated. We therefore performed a meta-analysis of thrombopoietin (TPO)-levels in patients with sepsis.

METHODS

Two independent reviewers screened records and full-text articles for inclusion. Scientific databases were searched for studies examining thrombopoietin levels in adult sepsis and septic-shock patients until August 1st 2022.

RESULTS

Of 95 items screened, six studies met the inclusion criteria, including 598 subjects. Both sepsis and severe sepsis were associated with increased levels of thrombopoietin (sepsis vs. control: standardized mean difference 3.06, 95 % CI 1.35-4.77; Z=3.50, p=0.0005) (sepsis vs. severe sepsis: standardized mean difference -1.67, 95 % CI -2.46 to -0.88; Z=4.14, p<0.0001). TPO-levels did not show significant differences between severe sepsis and septic shock patients but differed between sepsis and inflammation-associated non-septic controls. Overall, high heterogeneity and low sample size could be noted.

CONCLUSIONS

Concluding, increased levels of thrombopoietin appear to be present both in sepsis and severe sepsis with high heterogeneity but thrombopoietin does not allow to differentiate between severe sepsis and septic-shock. TPO may potentially serve to differentiate sepsis from non-septic trauma and/or tissue damage related (systemic) inflammation. Usage of different assays and high heterogeneity demand standardization of methods and further large multicenter trials.

Inhaled NO at a crossroads in cardiac surgery: current need to improve mechanistic understanding, clinical trial design and scientific evidence

Inhaled nitric oxide (NO) has been used in pediatric and adult perioperative cardiac intensive care for over three decades. NO is a cellular signaling molecule that induces smooth muscle relaxation in the mammalian vasculature. Inhaled NO has the unique ability to exert its vasodilatory effects in the pulmonary vasculature without any hypotensive side-effects in the systemic circulation. In patients undergoing cardiac surgery, NO has been reported in numerous studies to exert beneficial effects on acutely lowering pulmonary artery pressure and reversing right ventricular dysfunction and/or failure. Yet, various investigations failed to demonstrate significant differences in long-term clinical outcomes. The authors, serving as an advisory board of international experts in the field of inhaled NO within pediatric and adult cardiac surgery, will discuss how the existing scientific evidence can be further improved. We will summarize the basic mechanisms underlying the clinical applications of inhaled NO and how this translates into the mandate for inhaled NO in cardiac surgery. We will move on to the popular use of inhaled NO and will talk about the evidence base of the use of this selective pulmonary vasodilator. This review will elucidate what kind of clinical and biological barriers and gaps in knowledge need to be solved and how this has impacted in the development of clinical trials. The authors will elaborate on how the optimization of inhaled NO therapy, the development of biomarkers to identify the target population and the definition of response can improve the design of future large clinical trials. We will explain why it is mandatory to gain an international consensus for the state of the art of NO therapy far beyond this expert advisory board by including the different major players in the field, such as the different medical societies and the pharma industry to improve our understanding of the real-life effects of inhaled NO in large scale observational studies. The design for future innovative randomized controlled trials on inhaled NO therapy in cardiac surgery, adequately powered and based on enhanced biological phenotyping, will be crucial to eventually provide scientific evidence of its clinical efficacy beyond its beneficial hemodynamic properties.

Pulmonary Hypertension and the Risk of 30-Day Postoperative Pulmonary Complications after Gastrointestinal Surgical or Endoscopic Procedures: A Retrospective Propensity Score-Weighted Cohort Analysis

Background: Pulmonary hypertension (PH) patients are at higher risk of postoperative complications. We analyzed the association of PH with 30-day postoperative pulmonary complications (PPCs). Methods: A single-center propensity score overlap weighting (OW) retrospective cohort study was conducted on 164 patients with a mean pulmonary artery pressure (mPAP) of >20 mmHg within 24 months of undergoing elective inpatient abdominal surgery or endoscopic procedures under general anesthesia and a control cohort (N = 1981). The primary outcome was PPCs, and the secondary outcomes were PPC sub-composites, namely respiratory failure (RF), pneumonia (PNA), aspiration pneumonia/pneumonitis (ASP), pulmonary embolism (PE), length of stay (LOS), and 30-day mortality. Results: PPCs were higher in the PH cohort (29.9% vs. 11.2%, p < 0.001). When sub-composites were analyzed, higher rates of RF (19.3% vs. 6.6%, p < 0.001) and PNA (11.2% vs. 5.7%, p = 0.01) were observed. After OW, PH was still associated with greater PPCs (RR 1.66, 95% CI (1.05-2.71), p = 0.036) and increased LOS (median 8.0 days vs. 4.9 days) but not 30-day mortality. Sub-cohort analysis showed no difference in PPCs between pre- and post-capillary PH patients. Conclusions: After covariate balancing, PH was associated with a higher risk for PPCs and prolonged LOS. This elevated PPC risk should be considered during preoperative risk assessment.

When Our Best Friend Becomes Our Worst Enemy: The Mitochondrion in Trauma, Surgery, and Critical Illness

Common for major surgery, multitrauma, sepsis, and critical illness, is a whole-body inflammation. Tissue injury is able to trigger a generalized inflammatory reaction. Cell death causes release of endogenous structures termed damage associated molecular patterns (DAMPs) that initiate a sterile inflammation. Mitochondria are evolutionary endosymbionts originating from bacteria, containing molecular patterns similar to bacteria. These molecular patterns are termed mitochondrial DAMPs (mDAMPs). Mitochondrial debris released into the extracellular space or into the circulation is immunogenic and damaging secondary to activation of the innate immune system. In the circulation, released mDAMPS are either free or exist in extracellular vesicles, being able to act on every organ and cell in the body. However, the role of mDAMPs in trauma and critical care is not fully clarified. There is a complete lack of knowledge how they may be counteracted in patients. Among mDAMPs are mitochondrial DNA, cardiolipin, N-formyl peptides, cytochrome C, adenosine triphosphate, reactive oxygen species, succinate, and mitochondrial transcription factor A. In this overview, we present the different mDAMPs, their function, release, targets, and inflammatory potential. In light of present knowledge, the role of mDAMPs in the pathophysiology of major surgery and trauma as well as sepsis, and critical care is discussed.

Early predictors of bacterial pneumonia infection in children with congenital heart disease after cardiopulmonary bypass: a single-centre retrospective study

OBJECTIVES

The objective of this study was to evaluate the early predictors of bacterial pneumonia infection in children with congenital heart disease (CHD) after cardiopulmonary bypass (CPB).

DESIGN

Retrospective study.

SETTING

A freestanding tertiary paediatric hospital in China.

PARTICIPANTS

Patients admitted to the hospital due to CHD who underwent open-heart surgery.

OUTCOME MEASURES

We retrospectively reviewed and analysed data from 1622 patients with CHD after CPB from June 2018 to December 2020 at the Children's Hospital of Nanjing Medical University. Enrolled patients were assigned to an infection group or a non-infection group according to the presence of postoperative bacterial pneumonia infection, and the differences in clinical indicators were compared. Potential predictors were analysed by multivariate logistic regression analysis and area under the curve (AUC) analysis.

RESULTS

Among the 376 patients (23.2%) in the infection group, the three most common bacteria were Streptococcus pneumoniae in 67 patients (17.8%), Escherichia coli in 63 patients (16.8%) and Haemophilus influenzae in 53 patients (14.1%). The infection group exhibited a lower weight (8.0 (6.0-11.5) kg vs 11.0 (7.5-14.5) kg, p<0.001). In the infection group, procalcitonin (PCT) (ng/mL: 4.72 (1.38-9.52) vs 1.28 (0.47-3.74), p<0.001) and C reactive protein (CRP) (mg/L: 21.0 (12.1-32.0) vs 17.0 (10.0-27.0), p<0.001) levels were significantly greater than those in the non-infection group. Binary logistic regression analysis revealed that weight, PCT and CRP were independent risk factors for pulmonary bacterial infection after CPB. The AUCs of weight, PCT, CRP and PCT+CRP for predicting pulmonary bacterial infection after CPB were 0.632 (95% CI 0.600 to 0.664), 0.697 (95% CI 0.667 to 0.727), 0.586 (95% CI 0.554 to 0.618) and 0.694 (95% CI 0.664 to 0.724), respectively, and the cut-off values were ≤10.25 kg, ≥4.25 ng/mL, ≥6.50 mg/L and ≥0.20, respectively. The sensitivities were 69.7%, 54.0%, 93.9% and 70.2%, and the specificities were 53.5%, 77.7%, 19.4% and 59.1%, respectively.

CONCLUSIONS

In our study, weight, PCT and CRP were found to be independent predictors of pulmonary bacterial infection after CPB. Moreover, PCT was the most specific predictor, and CRP was the most sensitive independent predictor that might be beneficial for the early diagnosis of pulmonary bacterial infection after CPB in patients with CHD.