Biomarkers of sepsis

Evaluation of the modified quick sequential organ failure assessment scoring system for triage and prognostic assessment in canine emergency and critically ill patients: a retrospective study

BACKGROUND

In veterinary medicine, the qSOFA model has been studied in patients with conditions such as peritonitis or pyometra, and among the modified qSOFA models, only the qSOFA-lactate model has been researched. Thus, this study aimed to evaluate the effectiveness of q-SOFA-C-reactive protein (CRP), qSOFA-lactate, and quick systemic inflammatory response syndrome (qSIRS) models for triaging emergency and critically ill patients. These models were juxtaposed with conventional systems (SIRS, qSOFA, and acute patient physiology and laboratory evaluation [APPLE] fast) to ascertain their efficacy in patient triage and prognostication. In this retrospective cohort study, data from 166 dogs admitted to the Department of Emergency and Critical care at Konkuk Veterinary Medical Teaching Hospital between February 2021 and May 2023 were analyzed. Scoring systems were computed based on initial admission physical examinations (respiratory rate, heart rate, temperature, mentation, and systolic blood pressure) and laboratory results (white blood cell and platelet count and albumin, glucose, lactate, and CRP levels). Because no prior veterinary studies on the qSOFA-CRP model were available, optimal cutoff values were established using receiver operating characteristic (ROC) curves and the Youden index. Conventional scoring systems were compared with the modified qSOFA within the survivor and non-survivor groups. The most effective system was determined through ROC curve analysis.

RESULTS

For the qSOFA-CRP model, we identified an optimal cutoff value for CRP at > 1.55 mg/dL. All modified qSOFA scoring systems showed significant differences between survivors and non-survivors, in contrast to the conventional scoring systems. Notably, the qSOFA-CRP model demonstrated the highest area under the ROC curve value (0.761, 95% CI 0.68-0.83) and odds ratio (13.373, p < 0.001) when evaluating mortality at 28 days.

CONCLUSIONS

The qSOFA-CRP model, when employing a CRP threshold of 1.55 mg/dL, demonstrated promising potential as a novel criterion for triaging emergency and critically ill patients. However, further assessment is required in a larger population of patients at the precise early stage of sepsis.

Optical Bionanosensors for Sepsis Diagnostics

Sepsis is a global health challenge, characterized by a dysregulated immune response, leading to organ dysfunction and death. Despite advances in medical care, sepsis continues to claim a significant toll on human lives, with mortality rates from 10-25% for sepsis and 30-50% for septic shock, making it a leading cause of death worldwide. Current diagnostic methods rely on clinical signs, laboratory parameters, or microbial cultures and suffer from delays and inaccuracies. Therefore, there is a pressing need for novel diagnostic tools that can rapidly and accurately identify sepsis. This review highlights advances in biosensor development that could ultimately lead to faster and more accurate sepsis diagnostics. The focus is on nanomaterial-based optical approaches that promise rapid diagnostics without the need for large equipment or trained personnel. An overview of sepsis is provided, highlighting potential molecular targets and the challenges they present for assay development. The requirements for an ideal point-of-care test (POC) are discussed, including speed, simplicity, and cost-effectiveness. Different nanomaterials suitable for various optical detection methods are reviewed and innovative nanosensors are discussed for sepsis diagnostics, focusing on chemical design and approaches to increase selectivity by multiplexing.

Retrospective analysis of 300 microbial cell-free DNA sequencing results in routine blood stream infection diagnostics

Introduction

Bloodstream infections are a critical challenge worldwide due to the slow turnaround time of conventional microbiological tests for detecting bacteremia in septic patients. Noscendo GmbH (Duisburg, Germany) has developed the CE/IVD pipeline DISQVER for clinical metagenomics testing based on cell-free DNA (cfDNA) from blood samples to address this issue.

Methods

We conducted a retrospective study to evaluate the diagnostic utility of this methodological setup in improving treatment decisions since it was introduced into our clinical setting. Between January 2021 and June 2022, the first 300 cases in which DISQVER was applied at our university hospital were collected and analyzed. The results were compared with routine microbiology test results, clinical picture, associated treatment decisions, and clinical course.

Results

Our findings demonstrate that DISQVER results where no pathogen was reported effectively ruled out bacterial bloodstream infections, whereas positive results varied in their usefulness. While the metagenomic approach proved highly valuable for detecting non-culturable and rare pathogens, its utility was limited in cases where detected microorganisms were commonly associated with the microbiota.

Discussion

Performing on-site analysis might mitigate delays resulting from logistical challenges and might help optimizing antibiotic stewardship. Once prompt results can be obtained, the relevance of incorporating molecular resistograms will become more pronounced. Further, the specific patient subgroups that most benefit from this analysis must be worked out. Guiding clinicians in identifying the infection focus based on the detected bacteria would significantly improve patient care. Lastly, evidence of filamentous fungi must be diligently followed up.

Association between cytokines, nitric oxide, hemodynamic and microcirculation in a porcine model of sepsis

Systemic inflammation and hemodynamic or microvascular alterations are a hallmark of sepsis and play a role in organs hypoperfusion and dysfunction. Pimobendan, an inodilator agent, could be an interesting option for inotropic support and microcirculation preservation during shock. The objectives of this study were to evaluate effect of pimobendan on cytokine and nitric oxide (NO) release and investigate whether changes of macro and microcirculation parameters are associated with the release of cytokines and NO in pigs sepsis model. After circulatory failure, induced by intravenous inoculation of live Pseudomonas aeruginosa, eight animals were treated with pimobendan and eight with placebo. Pimobendan did not affect cytokines secretion (TNF-α, IL-6 and IL-10), but decreased time-dependently NO release. Data of macro and microcirculation parameters, NO and TNF- α recorded at the time of circulatory failure (Thypotension) and the time maximum of production cytokines was used for analyses. A positive correlation was observed between TNF-α and cardiac index (r = 0.55, p = 0.03) and a negative with systemic vascular resistance (r = -0.52, p = 0.04). Positive correlations were seen both between IL-10, 30 min after resuscitation (T30min), and systolic arterial pressure (r = 0.57, p = 0.03) and cardiac index (r = 0.67, p = 0.01), and also between IL-6, taken 2 h after resuscitation and systolic arterial pressure (r = 0.53, p = 0.04). Negative correlations were found between IL-10 and lactate, measured resuscitation time (r = -0.58, p = 0.03). Regarding microcirculation parameters, we observed a positive correlation between IL-6 and IL-10 with the microvascular flow index (r = 0.52, p = 0.05; r = 0.84, p = 0.0003) and a negative correlation with the heterogeneity index with TNF-α and IL-10 (r = -0.51, p = 0.05; r = -0.74, p = 0.003) respectively. NO derivatives showed a positive correlation with temperature gradient (r = 0.54, p = 0.04). Pimobendan did not show anti-inflammatory effects in cytokines release. Our results also, suggest changes of macro- and microcirculation are associated mainly with low levels of IL-10 in sepsis.

The Prospective Analysis of Biomarkers in Sepsis: Correlation With Clinical Outcomes

Background Sepsis is a medical emergency and necessitates immediate diagnosis and treatment to prevent the progression to severe sepsis, septic shock, and potentially mortality. Aim This study aims to study the diagnostic significance of conventional and new markers, interleukin-10 (IL-10), in predicting the severity of sepsis. Methodology A prospective observational study was conducted in the department of surgery in a tertiary care hospital in Pune, India. The study included 100 patients diagnosed with a quick Sequential Organ Failure Assessment (qSOFA) score of ≥2. Serum C-reactive protein (CRP), procalcitonin (PCT), and interleukin-10 (IL-10) levels were measured. Receiver operating characteristic (ROC) curves were plotted to assess the diagnostic performance of these biomarkers. Results The mean serum CRP level on day 7 was significantly higher than the baseline, day 1, and day 3 groups (p=0.0001). On analysis by repeated measure, the ANOVA test revealed that the mean CRP levels on day 7 were significantly higher. The mean PCT levels on day 7, day 3, and day 1 groups were significantly lower than those on day 1, day 2, and day 2, respectively (p=0.0001). The mean p-value of 3.3 g/L CRP was significantly lower on day 1 than that on day 3. IL-10 levels showed a significant upward trend, rising from 5.21 pg/mL at baseline to 7.57 pg/mL by day 7, with a p-value of <0.0001. Our cohort population showed elevated IL-10 values on the day of admission in a total of 15 patients. In our study, we observed that 11 patients with elevated IL-10 levels progressed toward multiple organ dysfunction syndrome (MODS) and four mortalities. IL-10 is a crucial marker for identifying patients with worsening surgical sepsis. Conclusion IL-10, CRP, and PCT have potential as prognostic markers in assessing and predicting disease severity. The dynamic changes in these biomarkers correlate strongly with clinical outcomes, suggesting their role in guiding treatment decisions.

Early prediction of sepsis in intensive care patients using the machine learning algorithm NAVOY® Sepsis, a prospective randomized clinical validation study

PURPOSE

To prospectively validate, in an ICU setting, the prognostic accuracy of the sepsis prediction algorithm NAVOY® Sepsis which uses 4 h of input for routinely collected vital parameters, blood gas values, and lab values.

MATERIALS AND METHODS

Patients 18 years or older admitted to the ICU at Skåne University Hospital Malmö from December 2020 to September 2021 were recruited in the study. A total of 304 patients were randomized into one of two groups: Algorithm group with active sepsis alerts, or Standard of care. NAVOY® Sepsis made silent predictions in the Standard of care group, in order to evaluate its performance without disturbing the outcome. The study was blinded, i.e., study personnel did not know to which group patients were randomized. The healthcare provider followed standard practices in assessing possible development of sepsis and intervening accordingly. The patients were followed-up in the study until ICU discharge.

RESULTS

NAVOY® Sepsis could predict the development of sepsis, according to the Sepsis-3 criteria, three hours before sepsis onset with high performance: accuracy 0.79; sensitivity 0.80; and specificity 0.78.

CONCLUSIONS

The accuracy, sensitivity, and specificity were all high, validating the prognostic accuracy of NAVOY® Sepsis in an ICU setting, including Covid-19 patients.

Navigating the Cytokine Storm: A Comprehensive Review of Chemokines and Cytokines in Sepsis

This comprehensive review thoroughly explores the intricate relationship between chemokines, cytokines, and the cytokine storm in sepsis, offering a nuanced understanding of the molecular mechanisms underpinning this life-threatening syndrome. Beginning with examining sepsis stages and immune response dynamics, the review emphasizes the dysregulation leading to the cytokine storm, where pro- and anti-inflammatory cytokines disrupt the delicate immune equilibrium. Delving into chemokines, the discussion encompasses subfamilies, receptors, and functions, highlighting their critical roles in immune cell migration and activation during sepsis. The implications for clinical practice are substantial, suggesting avenues for targeted diagnostics and therapeutic interventions. The review identifies areas for future research, including the search for novel biomarkers, deeper insights into cytokine regulation, and the pursuit of personalized medicine approaches. This comprehensive exploration aims to guide clinicians, researchers, and policymakers in navigating the complexities of sepsis, fostering a foundation for transformative advancements in understanding and managing this formidable clinical challenge.

A two-minute assay for electronic quantification of antibodies in saliva enabled through a reusable microfluidic multi-frequency impedance cytometer and machine learning analysis

The use of saliva as a diagnostic fluid has always been appealing due to the ability for rapid and non-invasive sampling for monitoring health status and the onset and progression of disease and treatment progress. Saliva is rich in protein biomarkers and provides a wealth of information for diagnosis and prognosis of various disease conditions. Portable electronic tools which rapidly monitor protein biomarkers would facilitate point-of-care diagnosis and monitoring of various health conditions. For example, the detection of antibodies in saliva can enable rapid diagnosis and tracking disease pathogenesis of various auto-immune diseases like sepsis. Here, we present a novel method involving immuno-capture of proteins on antibody coated beads and electrical detection of dielectric properties of the beads. The changes in electrical properties of a bead when capturing proteins are extremely complex and difficult to model physically in an accurate manner. The ability to measure impedance of thousands of beads at multiple frequencies, however, allows for a data-driven approach for protein quantification. By moving from a physics driven approach to a data driven approach, we have developed, for the first time ever to the best of our knowledge, an electronic assay using a reusable microfluidic impedance cytometer chip in conjunction with supervised machine learning to quantifying immunoglobulins G (IgG) and immunoglobulins A (IgA) in saliva within two minutes.

Monocyte distribution width (MDW) as a useful indicator for early screening of sepsis and discriminating false positive blood cultures

BACKGROUND

Severe sepsis and septic shock are the leading cause of in-hospital death. As sepsis progresses, expression and activity of endogenous mediators of inflammation change. Early detection of biomarkers can play a role in sepsis screening and in improvement of patient outcomes. Recent studies suggest that increase in monocyte volume may be helpful in early detection of sepsis. Therefore, we evaluated the utility of monocyte distribution width (MDW) for the early assessment of sepsis compared with the blood culture and other inflammatory biomarkers.

METHODS

Medical records of 1,404 patients (aged ≥19 years) who were admitted to the emergency department owing to clinically suspected infectious disease and requested blood cultures from Oct 2019 to Jan 2021 were reviewed. The patients were grouped based on Sepsis-3 criteria. They had undergone other laboratory tests to evaluate their clinical status. MDW was analyzed using DxH900 hematology analyzer (Beckman Coulter, Brea, California, USA). To determine the diagnostic performance of MDW, C-reactive protein (CRP), and procalcitonin (PCT) for sepsis, the area under the curve (AUC) of receiver operating characteristics curves and their sensitivity and specificity were measured.

RESULTS

Among 1,404 patients, 520 patients were designated the sepsis group based on Sepsis-3 criteria. In the sepsis group, MDW value was 24.1 (median, IQR 21.6-28.1); AUC values for MDW, CRP, and PCT were 0.67 (95% CI, 0.64-0.69), 0.66 (95% CI, 0.63-0.68), and 0.75 (95% CI, 0.72-0.77), respectively. For diagnosis of the sepsis, the cut-off value of MDW was 21.7 (sensitivity 74% and specificity 54%). Measured values of MDW were higher for the blood culture positive group than that of the blood culture contamination group (P<0.001, 95% CI, -5.9 to -3.0) or blood culture negative group (P<0.001, 95% CI = -5.8 to -4.2).

CONCLUSIONS

MDW is a new hematological parameter that is simultaneously calculated during complete blood cell counting by Beckman Coulter hematology analyzer. MDW is expected to serve as a useful indicator for early screening of sepsis in conjunction with CRP and PCT. MDW is especially useful for sepsis assessment in patients with a suspected infection. MDW can also assist in discriminating false positive blood cultures.

Optimal Predictors of Postoperative Complications After Gastrectomy: Results from the Procalcitonin and C-reactive Protein for the Early Diagnosis of Anastomotic Leakage in Esophagogastric Surgery (PEDALES) Study

BACKGROUND

The aim of this study was to define whether procalcitonin (PCT) is an earlier and more accurate predictor than C-reactive protein (CRP) for anastomotic leakage (AL) and major infective complications (MICs).

METHODS

This was a prospective multicentric observational study conducted in three Italian centers, including all patients undergoing gastrectomy from May 2016 to April 2021. The endpoint was the assessment of the discrimination and accuracy achieved by the PCT and CRP values measured from POD1 to POD7 for predicting the occurrence of AL and MICs. Accuracy was assessed by calculating the area under the receiver operating curve (AUROC) values and Youden's statistics. Two charts were created for risk stratification during the postoperative course.

RESULTS

The rate of AL was 4.6%, with a median day of occurrence on POD5 (range 3-26). The overall rate of major infective complications was 19.9%, with a median day of occurrence on POD6 (range 2-30). PCT showed a significant association with AL on POD6 and POD7 and a significant association with MICs on POD2, while CRP values showed a significant association with AL on POD4 and a significant association with MICs on POD1. No difference in the prediction of AL was observed between PCT and CRP, while CRP was found to be a superior predictor of major infective complications on POD5 (p = 0.024) and POD7 (p = 0.035).

CONCLUSIONS

PCT was not superior to CRP as an early predictor of AL and major infective complications after gastrectomy. CRP should be used as the reference screening postoperative marker.

mSep: investigating physiological and immune-metabolic biomarkers in septic and healthy pregnant women to predict feto-maternal immune health - a prospective observational cohort study protocol

INTRODUCTION

Maternal sepsis remains a leading cause of death in pregnancy. Physiological adaptations to pregnancy obscure early signs of sepsis and can result in delays in recognition and treatment. Identifying biomarkers that can reliably diagnose sepsis will reduce morbidity and mortality and antibiotic overuse. We have previously identified an immune-metabolic biomarker network comprising three pathways with a >99% accuracy for detecting bacterial neonatal sepsis. In this prospective study, we will describe physiological parameters and novel biomarkers in two cohorts-healthy pregnant women and pregnant women with suspected sepsis-with the aim of mapping pathophysiological drivers and evaluating predictive biomarkers for diagnosing maternal sepsis.

METHODS AND ANALYSIS

Women aged over 18 with an ultrasound-confirmed pregnancy will be recruited to a pilot and two main study cohorts. The pilot will involve blood sample collection from 30 pregnant women undergoing an elective caesarean section. Cohort A will follow 100 healthy pregnant women throughout their pregnancy journey, with collection of blood samples from participants at routine time points in their pregnancy: week 12 'booking', week 28 and during labour. Cohort B will follow 100 pregnant women who present with suspected sepsis in pregnancy or labour and will have at least two blood samples taken during their care pathway. Study blood samples will be collected during routine clinical blood sampling. Detailed medical history and physiological parameters at the time of blood sampling will be recorded, along with the results of routine biochemical tests, including C reactive protein, lactate and white blood cell count. In addition, study blood samples will be processed and analysed for transcriptomic, lipidomic and metabolomic analyses and both qualitative and functional immunophenotyping.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Wales Research Ethics Committee 2 (SPON1752-19, 30 October 2019).

TRIAL REGISTRATION NUMBER

NCT05023954.

Performance of presepsin and procalcitonin predicting culture-proven bacterial infection and 28-day mortality: A cross sectional study

Presepsin is a highly specific biomarker for diagnosing bacterial infections, but its clinical usefulness is not well validated. A retrospective cross-sectional study was conducted. Among the patients suspected bacterial infection or fulfilled the criteria of systemic inflammatory response syndrome (SIRS) and patients who underwent blood culture, presepsin, procalcitonin (PCT), and C-reactive protein (CRP) at the same time were included. Receiver operating characteristic (ROC) curve analysis and logistic regression were used to compare performance of three biomarkers. A total of 757 patients were enrolled, including 256 patients (33.8%) with culture-proven bacterial infection and 109 patients (14.4%) with bacteremia. The 28-day mortality rate was 8.6%. ROC curve analysis revealed that the area under the curve (AUC) of PCT was higher than that of presepsin for both culture-proven bacterial infection (0.665 and 0.596, respectively; p = 0.003) and bacteremia (0.791 and 0.685; p < 0.001). In contrast, AUC of PCT for 28-day mortality was slower than presepsin (0.593 and 0.720; p = 0.002). In multivariable logistic regression analysis, PCT showed the highest ORs for culture-proven bacterial infection (OR 2.23, 95% CI 1.55–3.19; p < 0.001) and for bacteremia (OR 5.18, 95% CI 3.13–8.56; p < 0.001), while presepsin showed the highest OR for 28-day mortality (OR 3.31, 95% CI 1.67–6.54; p < 0.001). CRP did not show better performance than PCT or presepsin in any of the analyses. PCT showed the best performance predicting culture-proven bacterial infection and bacteremia, while presepsin would rather be useful as a prognostic marker.

Involvement of blood lncRNA UCA1 in sepsis development and prognosis, and its correlation with multiple inflammatory cytokines

BACKGROUND

Sepsis is a highly life-threatening disease. Long non-coding RNA urothelial carcinoma associated 1 (lncRNA UCA1) participates in the processes of inflammation and organ injury in several diseases, whereas its role in sepsis patients is still unclear. The aim was to explore the clinical value of lncRNA UCA1 in sepsis patients.

METHODS

One hundred seventy-four sepsis patients and 100 age and gender-matched controls were enrolled. LncRNA UCA1 in peripheral blood mononuclear cell samples was examined, and the level of inflammatory cytokines in serum samples was assessed.

RESULTS

LncRNA UCA1 was highly expressed in sepsis patients compared with controls. LncRNA UCA1 was positively correlated with tumor necrosis factor-α, interleukin (IL)-6, IL-17, intercellular adhesion molecule 1, and vascular cell adhesion molecule 1 in sepsis patients, while it was not correlated with these inflammatory cytokines in controls. lncRNA UCA1 upregulation was related to raised APACHE II score and SOFA score in sepsis patients. Moreover, lncRNA UCA1 was increased in sepsis deaths compared with sepsis survivors and was independently correlated with increased 28-day sepsis mortality risk. Further receiver operating characteristic curves presented that lncRNA UCA1 had a good value to predict 28-motality risk, while its combination with other independent factors (including age, history of chronic kidney disease, G+ bacterial infection, Fungus infection, C-reactive protein, and APACHE II score) exerted a great predictive value for 28-day mortality risk.

CONCLUSION

LncRNA UCA1 is upregulated and correlates with multiple pro-inflammatory cytokines, terrible disease severity, and poor prognosis in sepsis patients.

The Potential Cost and Cost-Effectiveness Impact of Using a Machine Learning Algorithm for Early Detection of Sepsis in Intensive Care Units in Sweden

Background: Early diagnosis of sepsis has been shown to reduce treatment delays, increase appropriate care, and reduce mortality. The sepsis machine learning algorithm NAVOY® Sepsis, based on variables routinely collected at intensive care units (ICUs), has shown excellent predictive properties. However, the economic consequences of forecasting the onset of sepsis are unknown. Objectives: The potential cost and cost-effectiveness impact of a machine learning algorithm forecasting the onset of sepsis was estimated in an ICU setting. Methods: A health economic model has been developed to capture short-term and long-term consequences of sepsis. The model is based on findings from a randomized, prospective clinical evaluation of NAVOY® Sepsis and from literature sources. Modeling the relationship between time from sepsis onset to treatment and prevalence of septic shock and in-hospital mortality were of particular interest. The model base case assumes that the time to treatment coincides with the time to detection and that the algorithm predicts sepsis 3 hours prior to onset. Total costs include the costs of the prediction algorithm, days spent at the ICU and hospital ward, and long-term consequences. Costs are estimated for an average patient admitted to the ICU and for the healthcare system. The reference method is sepsis diagnosis in accordance with clinical practice. Results: In Sweden, the total cost per patient amounts to €16 436 and €16 512 for the algorithm and current practice arms, respectively, implying a potential cost saving per patient of €76. The largest cost saving is for the ICU stay, which is reduced by 0.16 days per patient (5860 ICU days for the healthcare sector) resulting in a cost saving of €1009 per ICU patient. Stochastic scenario analysis showed that NAVOY® Sepsis was a dominant treatment option in most scenarios and well below an established threshold of €20 000 per quality-adjusted life-year. A 3-hour faster detection implies a reduction in in-hospital mortality, resulting in 356 lives saved per year. Conclusions: A sepsis prediction algorithm such as NAVOY® Sepsis reduces the cost per ICU patient and will potentially have a substantial cost-saving and life-saving impact for ICU departments and the healthcare system.

Diagnostic and prognostic value of new bioscore in critically ill septic patients

OBJECTIVE

To evaluate the diagnostic and prognostic value of biomarkers and new bioscore in septic patients in intensive care unit (ICU).

MATERIALS AND METHODS

A study was conducted on septic and non-septic patients in ICU. Diagnostic and prognostic values of C-reactive protein (CRP), procalcitonin (PCT), Sequential Organ Failure Assessments (SOFA) score and new bioscore were analysed statistically.

RESULTS

A total of 226 patients were enrolled in the study. In septic patients, PCT, SOFA and bioscore were found significantly increased (p = .007, p = .001 and p = .001, respectively). The AUC value of bioscore was higher than PCT and SOFA in septic patients. SOFA was found to be more significant prognostic marker than bioscore in predicting 28-day mortality. The prognostic value of bioscore and SOFA was similar for predicting 90-day mortality.

CONCLUSIONS

The new bioscore formed by combination of CRP, PCT and SOFA score may be useful in early diagnosis of sepsis.

Biochemical but not imaging parameters are predictive of outcome in septic shock: a pilot study

Background

Septic shock is a severe form of sepsis marked by hypotension with an ominous outcome despite the introduction of modern intensive care. The aim of the present study is to obtain a panel with biomarkers, echocardiographic and vascular parameters to better risk stratify patients and identify those at higher risk of ominous outcome.

Methods

Between May 2013 and April 2016, 35 consecutive patients admitted at the Intensive Care Unit (ICU) of ASST Great Metropolitan Hospital Niguarda with the diagnosis of severe sepsis or septic shock were enrolled. All patients underwent rest echocardiography and several circulating biomarkers of myocardial damage or oxidative stress.

Results

The multivariate Cox’s proportional hazard model showed that the only independent prognostic predictor for 30-day mortality was the angiopoietin-2, (HR 1.017, 95% CI 1.000–1.034; P = 0.049). An angiopoietin-2 concentrations ≥ of 33,418 pg/mL was identified as the optimal threshold for the discrimination between survivors and non survivors at the time of admission in ICU, with a sensitivity of 80% and a specificity of 68%.

Conclusions

Septic shock has a poor in-hospital outcome even when the best of care is implemented. Among the biochemical parameters angiopoietin was able to identify patients at risk of death. The lowest the value at admission, the highest the risk of in-hospital death. No echocardiographic nor vascular parameter was able to predict outcome in this setting.

Plasma fibronectin can affect the cytokine profile and monocytes/macrophages function in addition to predicting the prognosis of advanced sepsis

The value of plasma fibronectin (pFN) in the diagnosis and prognosis of sepsis has not been fully established. Previous studies finding that pFN is significantly reduced in sepsis, however, whether reduced pFn affects the prognosis of sepsis has not been clarified. Here, we detected and analyzed pFN and other conventional inflammatory markers in advanced sepsis patients and performed correlation analysis with SOFA score. We also used Fn gene conditional knockout mice which were performed by cecum ligation and puncture (CLP) to investigate the effect of FN deficiency on sepsis prognosis. We found, compared with procalcitonin, c-reactive protein, and interleukin-6, pFN was more correlated with SOFA score in advanced sepsis patients (r -.720, p < .001). In animal experiments, Fn gene knockout mice showed significantly greater mortality after CLP compared with the control group because of inhibited phagocytosis and bacterial clearance ability of macrophages, with double cytokine storm. Furthermore, FN can regulate macrophages through the integrin α5β1/Fak/Src signaling pathway. Overall, we found pFN can more accurately reflect the severity and prognosis of advanced sepsis. The absence of FN altered the cytokine storm and phagocytic function of macrophages, suggesting that FN could be a potential therapeutic target in sepsis.

The inflammatory response is related to circulatory failure after out-of-hospital cardiac arrest: A prospective cohort study

BACKGROUND

Whole body ischemia and reperfusion injury after cardiac arrest leads to the massive inflammation clinically manifested in the post-cardiac arrest syndrome. Previous studies on the inflammatory effect on circulatory failure after cardiac arrest have either investigated a selected patient group or a limited part of the inflammatory mechanisms. We examined the association between cardiac arrest characteristics and inflammatory biomarkers, and between inflammatory biomarkers and circulatory failure after cardiac arrest, in an unselected patient cohort.

METHODS

This was a prospective study of 50 consecutive patients with out-of-hospital cardiac arrest. Circulation was invasively monitored from admission until day five, whereas inflammatory biomarkers, i.e. complement activation, cytokines and endothelial injury, were measured daily. We identified predictors for an increased inflammatory response, and associations between the inflammatory response and circulatory failure.

RESULTS

We found a marked and broad inflammatory response in patients after cardiac arrest, which was associated with clinical outcome. Long time to return of spontaneous circulation and high lactate level at admission were associated with increased complement activation (TCC and C3bc), pro-inflammatory cytokines (IL-6, IL-8) and endothelial injury (syndecan-1) at admission. These biomarkers were in turn significantly associated with lower mean arterial blood pressure, lower cardiac output and lower systemic vascular resistance, and increased need of circulatory support in the initial phase. High levels of TCC and IL-6 at admission were significantly associated with increased 30-days mortality.

CONCLUSION

Inflammatory biomarkers, including complement activation, cytokines and endothelial injury, were associated with increased circulatory failure in the initial period after cardiac arrest.

Efficiency of Monocyte/High-Density Lipoprotein Cholesterol Ratio Combined With Neutrophil/Lymphocyte Ratio in Predicting 28-Day Mortality in Patients With Sepsis

Background: Sepsis can cause unpredictable harm, and early identification of risk for mortality may be conducive to clinical diagnosis. The present study proposes to assess the efficacy of the monocyte/high-density lipoprotein cholesterol ratio (MHR) combined with the neutrophil/lymphocyte ratio (NLR) on the day of admission in predictive efficacy in the 28-day mortality risk in critical patients with sepsis.

Material and Methods: We administered observational and retrospective cohort research from a single center. The correlation of the clinical variables, together with the system severity scores of APACHE II and SOFA, are displayed by correlation analysis, and a Cox regression model could be performed to screen the independent risk factors and estimate the capacity of multiple markers in predicting 28-day mortality. The receiver operating characteristic (ROC) curve served as an applied method to output cutoff values for the diagnosis and prognostic risk, and the area under the ROC curve and net reclassification improvement index (NRI), as well as integrated discrimination improvement index (IDI) were employed to assess the feasibility of multiple parameters for predictive value in 28-day mortality of septic patients.

Results: The study enrolled 274 eligible patients with sepsis. The correlation analysis indicated NLR and MHR were related to the sepsis severity. A multivariate Cox regression analysis indicated that NLR together with MHR displayed a close relation to death rate after adjusting for other potential confounders (NLR, HR = 1.404 [95% CI 1.170–1.684], P < 0.001; MHR, HR = 1.217 [95% CI 1.112–1.331], P < 0.001). The AUC of NLR, MHR, NLR_MHR was 0.827, 0.876, and 0.934, respectively. The addition on the biomarker NLR_MHR to the prediction model improved IDI by 18.5% and NRI by 37.8%.

Conclusions: Our findings suggest that NLR and MHR trend to an elevated level in non-surviving patients with sepsis. Evaluation of NLR_MHR, an independent risk factor for increased mortality, might improve the predictive efficacy for 28-day mortality risk in septic patients.

Machine learning identification of specific changes in myeloid cell phenotype during bloodstream infections

The early identification of bacteremia is critical for ensuring appropriate treatment of nosocomial infections in intensive care unit (ICU) patients. The aim of this study was to use flow cytometric data of myeloid cells as a biomarker of bloodstream infection (BSI). An eight-color antibody panel was used to identify seven monocyte and two dendritic cell subsets. In the learning cohort, immunophenotyping was applied to (1) control subjects, (2) postoperative heart surgery patients, as a model of noninfectious inflammatory responses, and (3) blood culture-positive patients. Of the complex changes in the myeloid cell phenotype, a decrease in myeloid and plasmacytoid dendritic cell numbers, increase in CD14⁺CD16⁺ inflammatory monocyte numbers, and upregulation of neutrophils CD64 and CD123 expression were prominent in BSI patients. An extreme gradient boosting (XGBoost) algorithm called the “infection detection and ranging score” (iDAR), ranging from 0 to 100, was developed to identify infection-specific changes in 101 phenotypic variables related to neutrophils, monocytes and dendritic cells. The tenfold cross-validation achieved an area under the receiver operating characteristic (AUROC) of 0.988 (95% CI 0.985–1) for the detection of bacteremic patients. In an out-of-sample, in-house validation, iDAR achieved an AUROC of 0.85 (95% CI 0.71–0.98) in differentiating localized from bloodstream infection and 0.95 (95% CI 0.89–1) in discriminating infected from noninfected ICU patients. In conclusion, a machine learning approach was used to translate the changes in myeloid cell phenotype in response to infection into a score that could identify bacteremia with high specificity in ICU patients.

Step-by-Step Construction of Gene Co-Expression Network Analysis for Identifying Novel Biomarkers of Sepsis Occurrence and Progression

Background

Sepsis is the leading cause of death in critically ill patients. Although it is well known that the immune system plays a key role in sepsis, exactly how it works remains unknown.

Methods

In our study, we used weighted gene co-expression network analysis (WGCNA) to screen out the immune-related genes that may play a critical role in the process of sepsis.

Results

A total of three sepsis-related hub genes were screened for further verification. Subsequent analysis of immune subtypes suggested their potential predictive effect in the clinic.

Conclusion

Our study shows that three immune-related genes CHMP1A, MED15 and MGAT1 are important biomarkers of sepsis. The screened genes may help to distinguish normal individuals from patients with different degrees of sepsis.

A Machine Learning Sepsis Prediction Algorithm for Intended Intensive Care Unit Use (NAVOY Sepsis): Proof-of-Concept Study

Background

Despite decades of research, sepsis remains a leading cause of mortality and morbidity in intensive care units worldwide. The key to effective management and patient outcome is early detection, for which no prospectively validated machine learning prediction algorithm is currently available for clinical use in Europe.

Objective

We aimed to develop a high-performance machine learning sepsis prediction algorithm based on routinely collected intensive care unit data, designed to be implemented in European intensive care units.

Methods

The machine learning algorithm was developed using convolutional neural networks, based on Massachusetts Institute of Technology Lab for Computational Physiology MIMIC-III clinical data from intensive care unit patients aged 18 years or older. The model uses 20 variables to produce hourly predictions of onset of sepsis, defined by international Sepsis-3 criteria. Predictive performance was externally validated using hold-out test data.

Results

The algorithm—NAVOY Sepsis—uses 4 hours of input and can identify patients with high risk of developing sepsis, with high performance (area under the receiver operating characteristics curve 0.90; area under the precision-recall curve 0.62) for predictions up to 3 hours before sepsis onset.

Conclusions

The prediction performance of NAVOY Sepsis was superior to that of existing sepsis early warning scoring systems and comparable with those of other prediction algorithms designed to predict sepsis onset. The algorithm has excellent predictive properties and uses variables that are routinely collected in intensive care units.

Reactive hyperemia correlates with the presence of sepsis and glycocalyx degradation in the intensive care unit: a prospective cohort study

Objective

To investigate whether reactive hyperemia measured by peripheral arterial tonometry correlates with markers of endothelial dysfunction and may be used to identify sepsis in critical illness.

Methods

A prospective study was performed using a cohort of critically ill patients. Endothelial dysfunction was assessed on admission by quantifying reactive hyperemia-peripheral arterial tonometry and plasma levels of endothelin-1, soluble E-selectin, endocan and syndecan-1. Septic patients were compared to patients without evidence of infection.

Results

Fifty-eight septic patients were compared to 28 controls. The natural logarithm of reactive hyperemia-peripheral arterial tonometry was negatively correlated with cardiovascular comorbidities, disease severity and plasma levels of soluble E-selectin (p = 0.024) and syndecan-1 (p < 0.001). The natural logarithm of reactive hyperemia-peripheral arterial tonometry was lower in septic patients than in controls (0.53 ± 0.48 versus 0.69 ± 0.42, respectively). When adjusted for age, the multivariable model predicted that each 0.1-unit decrease in natural logarithm of reactive hyperemia-peripheral arterial tonometry increased the odds for infection by 14.6%. m.

Conclusion

Reactive hyperemia-peripheral arterial tonometry is closely related to soluble E-selectin and syndecan-1, suggesting an association between endothelial activation, glycocalyx degradation and vascular reactivity. Reactive hyperemia-peripheral arterial tonometry appears to be compromised in critically ill patients, especially those with sepsis.

Chronic Kidney Disease as a Systemic Inflammatory Syndrome: Update on Mechanisms Involved and Potential Treatment

Chronic kidney disease (CKD) is characterized by manifestations and symptoms involving systemic organs and apparatus, associated with elevated cardiovascular morbidity and mortality, bone disease, and other tissue involvement. Arterial hypertension (AH), diabetes mellitus (DM), and dyslipidemia, with glomerular or congenital diseases, are the traditional risk factors recognized as the main causes of progressive kidney dysfunction evolving into uremia. Acute kidney injury (AKI) has recently been considered an additional risk factor for the worsening of CKD or the development of CKD de novo. Evidence underlies the role of systemic inflammation as a linking factor between AKI and CKD, recognizing the role of inflammation in AKI evolution to CKD. Moreover, abnormal increases in oxidative stress (OS) and inflammatory status in CKD seem to exert an important pathogenetic role, with significant involvement in the clinical management of this condition. With our revision, we want to focus on and update the inflammatory mechanisms responsible for the pathologic conditions associated with CKD, with particular attention on the development of AKI and AKI-CKD de novo, the alteration of calcium-phosphorus metabolism with bone disease and CKD-MBD syndrome, the status of malnutrition and malnutrition-inflammation complex syndrome (MICS) and protein-energy wasting (PEW), uremic sarcopenia, the status of OS, and the different inflammatory pathways, highlighting a new approach to CKD. The depth comprehension of the mechanisms underlying the development of inflammation in CKD may present new possible therapeutic approaches in CKD and hopefully improve the management of correlated morbidities and provide a reduction in associated mortality.

Prognostic Value of Procalcitonin and C-Reactive Protein in 1608 Critically Ill Patients with Severe Influenza Pneumonia

Background: Procalcitonin (PCT) and C-Reactive protein (CRP) are well-established sepsis biomarkers. The association of baseline PCT levels and mortality in pneumonia remains unclear, and we still do not know whether biomarkers levels could be related to the causative microorganism (GPC, GNB). The objective of this study is to address these issues. Methods: a retrospective observational cohort study was conducted in 184 Spanish ICUs (2009–2018). Results: 1608 patients with severe influenza pneumonia with PCT and CRP available levels on admission were included, 1186 with primary viral pneumonia (PVP) and 422 with bacterial Co-infection (BC). Those with BC presented higher PCT levels (4.25 [0.6–19.5] versus 0.6 [0.2–2.3]ng/mL) and CRP (36.7 [20.23–118] versus 28.05 [13.3–109]mg/dL) as compared to PVP (p < 0.001). Deceased patients had higher PCT (ng/mL) when compared with survivors, in PVP (0.82 [0.3–2.8]) versus 0.53 [0.19–2.1], p = 0.001) and BC (6.9 [0.93–28.5] versus 3.8 [0.5–17.37], p = 0.039). However, no significant association with mortality was observed in the multivariate analysis. The PCT levels (ng/mL) were significantly higher in polymicrobial infection (8.4) and GPC (6.9) when compared with GNB (1.2) and Aspergillus (1.7). The AUC-ROC of PCT for GPC was 0.67 and 0.32 for GNB. The AUROC of CRP was 0.56 for GPC and 0.39 for GNB. Conclusions: a single PCT/CRP value at ICU admission was not associated with mortality in severe influenza pneumonia. None of the biomarkers have enough discriminatory power to be used for predicting the causative microorganism of the co-infection.

Effects of Neutrophil-to-Lymphocyte Ratio Combined With Interleukin-6 in Predicting 28-Day Mortality in Patients With Sepsis

Background

The current study aimed to evaluate the relationship between the neutrophil-to-lymphocyte ratio (NLR) combined with interleukin (IL)-6 on admission day and the 28-day mortality of septic patients.

Material and Methods

We conducted an observational retrospective study. Patients with presumed sepsis were included. We observed the correlation of studied biomarkers (NLR, IL-6, PCT, and CRP) and the severity scores (APACHE II and SOFA scores) by plotting scatter plots. The relationships of the studied biomarkers and 28-day mortality were evaluated by using Cox regression model, receiver-operating characteristic (ROC) curve, and reclassification analysis.

Results

A total of 264 patients diagnosed with sepsis were enrolled. It was revealed that IL-6 had the strongest correlation with both APACHE II and SOFA scores, followed by the NLR and PCT, and there was no obvious correlation between CRP and the illness severity. NLR and IL-6 were independent predictors of the 28-day mortality in septic patients in the Cox regression model [NLR, odds ratio 1.281 (95% CI 1.159-1.414), P < 0.001; IL-6, odds ratio 1.017 (95% CI 1.005-1.028), P=0.004]. The area under the ROC curve (AUC) of NLR, IL-6 and NLR plus IL-6 (NLR_IL-6) was 0.776, 0.849, and 0.904, respectively.

Conclusion

Our study showed that the levels of NLR and IL-6 were significantly higher in the deceased patients with sepsis. NLR and IL-6 appeared to be independent predictors of 28-day mortality in septic patients. Moreover, NLR combined with IL-6 could dramatically enhance the prediction value of 28-day mortality.

Inhibition of complement C5a receptor protects lung cells and tissues against lipopolysaccharide-induced injury via blocking pyroptosis

Acute lung injury (ALI) is the injury of alveolar epithelial cells and capillary endothelial cells caused by various factors. Complement system and pyroptosis have been proved to be involved in ALI, and inhibition of C5a/C5a receptor (C5aR) could alleviate ALI. This study aimed to investigate whether C5a/C5aR inhibition could protect against LPS-induced ALI via mediating pyroptosis. Rats were assigned into four groups: Control, LPS, LPS+W-54011 1mg/kg, and LPS+W-54011 5mg/kg. Beas-2B cells pretreated with or without C5a and W-54011, alone and in combination, were challenged with LPS+ATP. Results unveiled that LPS caused lung tissue injury and inflammatory response, increased pyroptotic and apoptotic factors, along with elevated C5a concentration and C5aR expressions. However, W-54011 pretreatment alleviated lung damage and pulmonary edema, reduced inflammation and prevented cell pyroptosis. In vitro studies confirmed that LPS+ATP reduced cell viability, promoted cell death, generated inflammatory factors and promoted expressions of pyroptosis-related proteins, which could be prevented by W-54011 pretreatment while intensified by C5a pretreatment. The co-treatment of C5a and W-54011 could blunt the effects of C5a on LPS+ATP-induced cytotoxicity. In conclusion, inhibition of C5a/C5aR developed protective effects against LPS-induced ALI and the cytotoxicity of Beas-2B cells, and these effects may depend on blocking pyroptosis.

Synthetic immunomodulation with a CRISPR super-repressor in vivo

Transient modulation of the genes involved in immunity, without exerting a permanent change in the DNA code, can be an effective strategy to modulate the course of many inflammatory conditions. CRISPR-Cas9 technology represents a promising platform for achieving this goal. Truncation of guide RNA (gRNA) from the 5' end enables the application of a nuclease competent Cas9 protein for transcriptional modulation of genes, allowing multifunctionality of CRISPR. Here, we introduce an enhanced CRISPR-based transcriptional repressor to reprogram immune homeostasis in vivo. In this repressor system, two transcriptional repressors-heterochromatin protein 1 (HP1a) and Krüppel-associated box (KRAB)-are fused to the MS2 coat protein and subsequently recruited by gRNA aptamer binding to a nuclease competent CRISPR complex containing truncated gRNAs. With the enhanced repressor, we demonstrate transcriptional repression of the Myeloid differentiation primary response 88 (Myd88) gene in vitro and in vivo. We demonstrate that this strategy can efficiently downregulate Myd88 expression in lung, blood and bone marrow of Cas9 transgenic mice that receive systemic injection of adeno-associated virus (AAV)2/1-carrying truncated gRNAs targeting Myd88 and the MS2-HP1a-KRAB cassette. This downregulation is accompanied by changes in downstream signalling elements such as TNF-α and ICAM-1. Myd88 repression leads to a decrease in immunoglobulin G (IgG) production against AAV2/1 and AAV2/9 and this strategy modulates the IgG response against AAV cargos. It improves the efficiency of a subsequent AAV9/CRISPR treatment for repression of proprotein convertase subtilisin/kexin type 9 (PCSK9), a gene that, when repressed, can lower blood cholesterol levels. We also demonstrate that CRISPR-mediated Myd88 repression can act as a prophylactic measure against septicaemia in both Cas9 transgenic and C57BL/6J mice. When delivered by nanoparticles, this repressor can serve as a therapeutic modality to influence the course of septicaemia. Collectively, we report that CRISPR-mediated repression of endogenous Myd88 can effectively modulate the host immune response against AAV-mediated gene therapy and influence the course of septicaemia. The ability to control Myd88 transcript levels using a CRISPR-based synthetic repressor can be an effective strategy for AAV-based CRISPR therapies, as this pathway serves as a key node in the induction of humoral immunity against AAV serotypes.

Toll-Like Receptor 4 Signaling in the Ileum and Colon of Gnotobiotic Piglets Infected with Salmonella Typhimurium or Its Isogenic ∆rfa Mutants

Salmonella Typhimurium is a Gram-negative bacterium that causes enterocolitis in humans and pigs. Lipopolysaccharide (LPS) is a component of the outer leaflet of Gram-negative bacteria that provokes endotoxin shock. LPS can be synthesized completely or incompletely and creates S (smooth) or R (rough) chemotypes. Toll-like receptors (TLR) 2, 4, and 9 initiate an inflammatory reaction to combat bacterial infections. We associated/challenged one-week-old gnotobiotic piglets with wild-type S. Typhimurium with S chemotype or its isogenic ∆rfa mutants with R chemotype LPS. The wild-type S. Typhimurium induced TLR2 and TLR4 mRNA expression but not TLR9 mRNA expression in the ileum and colon of one-week-old gnotobiotic piglets 24 h after challenge. The TLR2 and TLR4 stimulatory effects of the S. Typhimurium ∆rfa mutants were related to the completeness of their LPS chain. The transcription of IL-12/23 p40, IFN-γ, and IL-6 in the intestine and the intestinal and plasmatic levels of IL-12/23 p40 and IL-6 but not IFN-γ were related to the activation of TLR2 and TLR4 signaling pathways. The avirulent S. Typhimurium ∆rfa mutants are potentially useful for modulation of the TLR2 and TLR4 signaling pathways to protect the immunocompromised gnotobiotic piglets against subsequent infection with the virulent S. Typhimurium.

Circular RNAs in Sepsis: Biogenesis, Function, and Clinical Significance

Sepsis is a life-threatening condition that occurs when the body responds to an infection that damages it is own tissues. The major problem in sepsis is rapid, vital status deterioration in patients, which can progress to septic shock with multiple organ failure if not properly treated. As there are no specific treatments, early diagnosis is mandatory to reduce high mortality. Despite more than 170 different biomarkers being postulated, early sepsis diagnosis and prognosis remain a challenge for clinicians. Recent findings propose that circular RNAs (circRNAs) may play a prominent role in regulating the patients’ immune system against different pathogens, including bacteria and viruses. Mounting evidence also suggests that the misregulation of circRNAs is an early event in a wide range of diseases, including sepsis. Despite circRNA levels being altered in sepsis, the specific mechanisms controlling the dysregulation of these noncoding RNAs are not completely elucidated, although many factors are known to affect circRNA biogenesis. Therefore, there is a need to explore the molecular pathways that lead to this disorder. This review describes the role of this new class of regulatory RNAs in sepsis and the feasibility of using circRNAs as diagnostic biomarkers for sepsis, opening up new avenues for circRNA-based medicine.

Biomarkers and Associated Immune Mechanisms for Early Detection and Therapeutic Management of Sepsis

Sepsis is conceptually defined as life-threatening organ dysfunction that is caused by a dysregulated host response to infection. Although there has been significant advancement in recent decades in defining and understanding sepsis pathology, clinical management of sepsis is challenging due to difficulties in diagnosis, a lack of reliable prognostic biomarkers, and treatment options that are largely limited to antibiotic therapy and fundamental supportive measures. The lack of reliable diagnostic and prognostic tests makes it difficult to triage patients who are in need of more urgent care. Furthermore, while the acute inpatient treatment of sepsis warrants ongoing attention and investigation, efforts must also be directed toward longer term survival and outcomes. Sepsis survivors experience incomplete recovery, with long-term health impairments that may require both cognitive and physical treatment and rehabilitation. This review summarizes recent advances in sepsis prognosis research and discusses progress made in elucidating the underlying causes of prolonged health deficits experienced by patients surviving the early phases of sepsis.

A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes

BACKGROUND

Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis.

METHODS

A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others.

RESULTS

The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting.

CONCLUSION

There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.

An Update on Sepsis Biomarkers

Sepsis is a dysregulated systemic reaction to a common infection, that can cause life-threatening organ dysfunction. Over the last decade, the mortality rate of patients with sepsis has decreased as long as patients are treated according to the recommendations of the Surviving Sepsis Campaign, but is still unacceptably high. Patients at risk of sepsis should therefore be identified prior to the onset of organ dysfunction and this requires a rapid diagnosis and a prompt initiation of treatment. Unfortunately, there is no gold standard for the diagnosis of sepsis and traditional standard culture methods are time-consuming. Recently, in order to overcome these limitations, biomarkers which could help in predicting the diagnosis and prognosis of sepsis, as well as being useful for monitoring the response to treatments, have been identified. In addition, recent advances have led to the development of newly identified classes of biomarkers such as microRNAs, long-non-coding RNAs, and the human microbiome. This review focuses on the latest information on biomarkers that can be used to predict the diagnosis and prognosis of sepsis.

A proposal for a comprehensive approach to infections across the surgical pathway

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Considering the Effect of Rosa damascena Mill. Essential Oil on Oxidative Stress and COX-2 Gene Expression in the Liver of Septic Rats

OBJECTIVES

Sepsis is a clinical illness with a high rate of mortality all over the world. Oxidative stress is considered the main phenomenon that occurs in sepsis. Rosa damascena Mill. is an ancient herbal plant with high pharmacological activities.

MATERIALS AND METHODS

Cecal ligation and puncture (CLP) as a standard model was used to induce sepsis in rats. Male adult rats were randomly divided into 5 groups. Different doses of R. damascena essential oil (50 and 100 mg/kg.bw) were gavaged orally for 14 days and on day 15 CLP was performed. After 24 h, blood samples and liver tissues were removed in order to measure oxidative stress [myeloperoxidase (MPO), malondialdehyde (MDA), glutathione (GSH), glutathione-S-transferase, and ferric reducing ability of plasma (FRAP)] and biochemical parameters [alkaline phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT), and bilirubin] together with plasma prostaglandin E2 (PGE2) and COX-2 expression.

RESULTS

The essential oil was capable of modulating all of the oxidative stress, antioxidant, and anti-inflammatory parameters induced by CLP as characterized by elevations in MPO and MDA levels as well as increases in AST and ALT concentrations concomitant with PGE2 and COX-2 increments. The antioxidant defense system such as GSH and FRAP was also increased in the essential oil treated groups.

CONCLUSION

Our results showed that the essential oil has antioxidative and hepatoprotective activities through reducing the oxidative injury in sepsis caused by CLP.

C Reactive Protein and Procalcitonine as Diagnostic Markers in Critically Ill Patients with Suspected Sepsis

The primary aim of this retrospective study was to estimate significance of determining C-reactive protein and procalcitonine for a diagnosis of sepsis in adult patients in early triage. Also, the aim of this study was to measure the sensitivity of the SIRS criteria, PCT and CRP levels and sepsis definitions to identify the most serious sepsis cases in the prehospital setting and at the Emergency Department (ED) triage. All patients were divided into two groups according to specific criteria for defining sepsis. First group (SIRS+ group) of patients were patients with clinically and/or laboratory confirmed sepsis (or systemic inflammatory response syndrome (SIRS) to bacterial infection with different localization). For confirmation of the SIRS we consider positive two or more clinical criteria (≥2 clinical criteria). The SIRS criteria use the clinical criteria of the Surviving Sepsis Campaign (SSC) for the SIRS, comprising at least two of the following criteria: HR > 90/min, RR > 20/min and temperature < 36° or ≥ 38.3°C and the next laboratory parameters such as leucocytosis > 15x109/L, leucopenia < 4x109/L, > 10% immature leucocytes. Second group of patients were patients with the SIRS negative criteria as a diagnostic tool (SIRS- group). We have founded that the CRP showed high sensitivity but no specificity in patients with sepsis, but on the other side, the PCT as a diagnostic marker showed a high sensitivity and high specificity in these patients. Also, the PCT is in positive correlation with the SIRS criteria, which could be of a clinical significance in early diagnosis of septic infections.

Biomarkers of Infection and Sepsis

The role of biomarkers for detection of sepsis has come a long way. Molecular biomarkers are taking front stage at present, but machine learning and other computational measures using bigdata sets are promising. Clinical research in sepsis is hampered by lack of specificity of the diagnosis; sepsis is a syndrome with no uniformly agreed definition. This lack of diagnostic precision means there is no gold standard for this diagnosis. The final conclusion is expert opinion, which is not bad but not perfect. Perhaps machine learning will displace expert opinion as the final and most accurate definition for sepsis.

Circulating extracellular vesicle content reveals de novo DNA methyltransferase expression as a molecular method to predict septic shock

Extracellular vesicles (EVs) are mRNA-containing cell fragments shed into circulation during pathophysiological events. DNA methyltransferases (DNMT1, DNMT3A, and DNMT3B) regulate gene expression by modifying DNA methylation and altering transcription. Sepsis is a systemic insult resulting in vascular dysfunction, which can lead to shock and death. We analysed plasma from ICU patients for circulating EV numbers, defined as particles isolated from 1 mL plasma at 21,000xg, and DNMTs mRNA content as prognostic markers of septic shock. Compared to plasma from critically ill patients with or without sepsis, plasma from septic shock patients contained more EVs per mL, expressed as total DNMTs mRNAs over 5 days, and more individual DNMT mRNAs at each day. A comparison of EV-DNMT1 (maintenance methylation) with EV-DNMT3A+DNMT3B (de novo methylation) expression correlated highly with severity, and EVs from septic shock patients carried more total DNMT mRNAs and more DNMT3A+DNMT3B mRNAs than control or sepsis EVs. Total plasma EVs also correlated with sepsis severity. EV-DNMT mRNAs load, when coupled with total plasma EV number, may be a novel method to diagnose septic shock upon ICU admittance and offer opportunities to more precisely intervene with standard therapy or other targeted interventions to regulate EV release and/or specific DNMT activity.

Early Blood Biomarkers to Improve Sepsis/Bacteremia Diagnostics in Pediatric Emergency Settings

Background: Sepsis is the leading cause of death in children worldwide. Early recognition and treatment are essential for preventing progression to lethal outcomes. CRP and Complete Blood Count (CBC) are the initial preferred tests to distinguish between bacterial and viral infections. Specific early diagnostic markers are still missing. Aim: To investigate diagnostic value of Neutrophil-Lymphocyte Ratio (NLR), Mean Platelet Volume (MPV) and Platelet-MPV ratio (PLT/MPV) to distinguish sepsis/bacteremia and viral infection. Methods: We conducted a retrospective data analysis of case records of 115 children from 1 month to 5 years of age. All cases were divided into two groups-sepsis/bacteremia (n = 68) and viral (n = 47) patients, and further subdivided according to the time of arrival into early or late (≤12 or 12-48 h post the onset of fever, respectively). Analysis of CBC and CRP results was performed. NLR and PLT/MPV were calculated. Results: Sepsis/bacteremia group demonstrated higher absolute platelets count (370.15 ± 134.65 × 10⁸/L versus 288.91 ± 107.14 × 10⁸/L; p = 0.001), NLR (2.69 ± 2.03 versus 1.83 ± 1.70; p = 0.006), and PLT/MPV (41.42 ± 15.86 versus 33.45 ± 17.97; p = 0.001). PLT/MPV was increased in early arrival sepsis/bacteremia infants (42.70 ± 8.57 versus 31.01 ± 8.21; p = 0.008). NLR and MPV were significantly lower in infants (≤12 months) with viral infection on late arrival (1.16 ± 1.06 versus 1.90 ± 1.25, p = 0.025 for NLR and 8.94 ± 0.95fl versus 9.44 ± 0.85fl, p = 0.046 for MPV). Conclusion: Together with standard blood biomarkers, such as CRP, neutrophils, or platelets count, PLT/MPV is a promising biomarker for clinical practice to help discriminate between viral disease or sepsis/bacteremia in all children, especially in early onset of symptoms. NLR and MPV could support exclusion of sepsis/bacteremia in late arrival cases.

A Novel Combination of Biomarkers to Herald the Onset of Sepsis Prior to the Manifestation of Symptoms

Sepsis, which kills over 200,000 patients and costs over $20 billion in the United States alone, presents a constant but preventable challenge in the healthcare system. Among the more challenging problems that it presents is misdiagnosis due to conflation with other inflammatory processes, as its mechanisms are identical to those of other inflammatory states. Unfortunately, current biomarker tests can only assess the severity and mortality risk of each case, whereas no single test exists that can predict sepsis prior to the onset of symptoms for the purpose of pre-emptive care and monitoring. We propose that a single test utilizing three, rather than two, biomarkers that appear most quickly in the blood and are the most specific for sepsis rather than trauma, may improve diagnostic accuracy and lead to lessened patient morbidity and mortality. Such a test would vastly improve patient outcomes and quality of life, prevent complications for sepsis survivors, and prevent hospital readmissions, saving the American healthcare system money. This review summarizes the current use of sepsis biomarkers to prognosticate morbidity and mortality, and rejects the current single-biomarker and even combination biomarker tests as non-specific and inaccurate for current patient needs/pro-inflammatory cytokines, general markers of inflammation, and proteins specific to myeloid cells (and therefore to infection) are discussed. Ultimately, the review suggests a three-biomarker test of procalcitonin (PCT), interleukin-6 (IL-6), and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) to diagnose sepsis before the onset of symptoms.

Dietary Supplementation With High Fiber Alleviates Oxidative Stress and Inflammatory Responses Caused by Severe Sepsis in Mice Without Altering Microbiome Diversity

In this study, we demonstrated the effects of a high-fiber diet on intestinal lesions, oxidative stress and systemic inflammation in a murine model of endotoxemia. C57BL/6 mice were randomly assigned to four groups: the control group (CONTROL), which received a commercial normal-fiber rodent diet comprising normal fiber; a CLP group, which received a commercial normal-fiber rodent diet and underwent caecal ligation puncture (CLP); a high-fiber group (HFG), which received a commercial high-fiber rodent diet; and a high fiber + CLP group (HFCLP) which received a commercial high-fiber rodent diet and underwent CLP (30%). The sepsis model was created via CLP after 2 weeks of dietary intervention. Notably, dietary high-fiber supplementation in HFCLP group improved survival rates and reduced bacterial loads, compared with CLP alone. In the HFCLP group, dietary fiber supplementation decreased the serum concentrations of pro-inflammatory cytokines such as tumor necrosis factor-α (TNF-α), interleukin 6 (IL-6) and high-mobility group protein 1 (HMG-1) but raised the concentration of interleukin 10 (IL-10), compared with the levels in CLP mice. Meanwhile, high-fiber supplementation increased the relative proportions of Akkermansia and Lachnospiraceae. These data show that dietary high-fiber supplementation may be therapeutic for sepsis-induced lesions.

APRIL and sTACI could be predictors of multiorgan dysfunction syndrome in sepsis

Although the role of B cells in sepsis immunoregulation has become an interesting topic, there is lack of data on the role of B cell function regulators in prediction of multiorgan dysfunction syndrome (MODS). The aim of this study was to evaluate the prognostic value of A Proliferation Inducing Ligand (APRIL) and soluble Transmembrane Activator and CAML Interactor Protein (sTACI), the main B cell function regulators, in prediction of MODS development within the first 48 h after admission to intensive care unit, among septic patients. We included 112 patients with sepsis, treated at Clinic for Infectious Diseases and Emergency Center, Clinical Center of Vojvodina, Novi Sad, Serbia. Plasma concentrations of APRIL and sTACI were determined at the admission and potential development of MODS was confirmed in the first 48 h. Concentrations of APRIL (p = 0.003) and sTACI (p<0.001) were higher in patients who developed MODS (n = 30). ROC curve analysis showed that AUC for sTACI (AUC = 0.764) was greater than that for procalcitonin (AUC = 0.719) and APRIL (AUC = 0.673) in MODS development prediction. Multivariate regression analysis showed that sTACI, as an anti-inflammatory biomarker stimulating the apoptosis of B cells, was the only independent predictor of MODS, beside SOFA score. Elevated level of sTACI could be the alarm for the increased B cell apoptosis and development of immune paralysis. Including these biomarkers into predictive scores specific for septic patients may potentially improve their sensitivity and specificity. Measurement of their concentrations dynamics could contribute to better assessment of sepsis evolution and timely introduction of immunomodulatory therapy.

Approach of minimal invasive monitoring and initial treatment of the septic patient in emergency medicine

Sepsis and septic shock constitute a complex disease condition that requires the engagement of several medical specialties. A great number of patients with this disease are constantly admitted to the emergency department, which warrants the need for emergency physicians to lead in the recognition and early management of septic patients. Timely and appropriate interventions may help reduce mortality in a disease with an unacceptably high mortality rate. Poor control of cellular hypoperfusion is one of the most influential mechanisms contributing to the high mortality rate in these patients. This article aims to make an evidence-based approach and an algorithm for the active identification of hypoperfusion in patients with suspicion of severe infection, based on both clinical variables (capillary refill, mottling index, left ventricular function by ultrasound, temperature gradient, etc.) and laboratory-measured variables (lactate, central venous oxygen saturation [ScvO₂], and venous-to-arterial carbon dioxide tension difference [P (v-a) CO₂]). Such variables are feasible to use in the emergency department and would help to explain the cause behind the inadequate oxygen use by cells, thereby guiding treatment at the macrovascular, microvascular, or cellular level.

[Inflammatory markers in diagnosis and prognosis of abdominal sepsis]

For today, it is necessary to recognize, that treatment of patients with abdominal sepsis remains the basic problem in urgent surgery due to the invariably high mortality. Early diagnostics and targeted therapy are the key points for improving of sepsis outcome. At present, researchers around the world have proposed a large number of biological markers for diagnosing sepsis and predicting mortality. Ideally, doctors can use biomarkers for risk stratification, diagnosing, monitoring of treatment effectiveness and outcome prediction. The biomarker is a laboratory parameter that can be objectively measured and characterized as an indicator of normal and pathological biological processes. The article presents the modern concept of the sepsis pathogenesis for understanding the role of various biomarkers and inflammatory indicators in its development. We have analyzed literature data and summarized information on the possible use of biological markers and their combinations in the early detection of sepsis, for monitoring sepsis and predicting its outcome.

Comparison of accuracy of presepsin and procalcitonin concentrations in diagnosing sepsis in patients with and without acute kidney injury

BACKGROUND

Levels of the biomarkers presepsin and procalcitonin are affected by renal function. We evaluated the accuracies of presepsin and procalcitonin levels for diagnosing sepsis in patients with and without acute kidney injury (AKI).

METHODS

We evaluated patients with presepsin and procalcitonin data, and classified them into AKI and non-AKI groups based on the Kidney Disease Improving Global Outcomes criteria. Each group was then subdivided according to sepsis status for each stage of AKI. Receiver operating characteristic curve analyses were used to investigate the accuracies of biomarker levels for diagnosing sepsis.

RESULTS

In the non-AKI group, the area under the curves (AUCs) for procalcitonin and presepsin levels were 0.897 and 0.880, respectively (p = .525) and optimal cut-off values were 0.10 ng/ml (sensitivity: 85.1%, specificity: 79.1%) and 240 pg/ml (sensitivity: 80.9%, specificity: 83.2%), respectively. In the stage 3 subgroup, the AUC for procalcitonin (0.946) was significantly higher than that for presepsin (0.768, p < .001). The optimal cut-off values for diagnosing sepsis were 4.07 ng/ml (sensitivity: 87.2%, specificity: 93.5%) for procalcitonin and 500 pg/ml (sensitivity: 89.7%, specificity: 59.7%) for presepsin.

CONCLUSIONS

In patients with severe AKI, the accuracy of the diagnosis of sepsis with procalcitonin was significantly higher than with presepsin.

Lipidomic analysis of plasma lipids composition changes in septic mice

A lipidomic study on extensive plasma lipids in bacterial peritonitis (cecal ligation and puncture, CLP)-induced sepsis in mice was done at 24 h post-CLP. The effects of administration of lysophosphatidylcholine (LPC) and lysophosphatidic acid (LPA), compounds known to have beneficial effects in CLP, on the sepsis-induced plasma lipid changes were also examined. Among the 147 plasma lipid species from 13 lipid subgroups (fatty acid [FA], LPA, LPC, lysophosphatidylethanolamine [LPE], phosphatidic acid [PA], phosphatidylcholine [PC], phosphatidylethanolamine [PE], phosphatidylinositol [PI], monoacylglyceride [MG], diacylglyceride [DG], triacylglyceride [TG], sphingomyelin [SM], and ceramide [Cer]) analyzed in this study, 40 and 70 species were increased, and decreased, respectively, in the CLP mice. Treatments with LPC and LPA affected 14 species from 7 subgroups, and 25 species from 9 subgroups, respectively. These results could contribute to finding the much needed reliable biomarkers of sepsis.

Role of complement C5a and histones in septic cardiomyopathy

Polymicrobial sepsis (after cecal ligation and puncture, CLP) causes robust complement activation with release of C5a. Many adverse events develop thereafter and will be discussed in this review article. Activation of complement system results in generation of C5a which interacts with its receptors (C5aR1, C5aR2). This leads to a series of harmful events, some of which are connected to the cardiomyopathy of sepsis, resulting in defective action potentials in cardiomyocytes (CMs), activation of the NLRP3 inflammasome in CMs and the appearance of extracellular histones, likely arising from activated neutrophils which form neutrophil extracellular traps (NETs). These events are associated with activation of mitogen-activated protein kinases (MAPKs) in CMs. The ensuing release of histones results in defective action potentials in CMs and reduced levels of [Ca²⁺]i-regulatory enzymes including sarco/endoplasmic reticulum Ca²⁺-ATPase (SERCA2) and Na⁺/Ca²⁺ exchanger (NCX) as well as Na⁺/K⁺-ATPase in CMs. There is also evidence that CLP causes release of IL-1β via activation of the NLRP3 inflammasome in CMs of septic hearts or in CMs incubated in vitro with C5a. Many of these events occur after in vivo or in vitro contact of CMs with histones. Together, these data emphasize the role of complement (C5a) and C5a receptors (C5aR1, C5aR2), as well as extracellular histones in events that lead to cardiac dysfunction of sepsis (septic cardiomyopathy).