Clinical importance of screening differential gene set of monocytes based on single-cell sequencing and digital polymerase chain reaction technology for early diagnosis of sepsis / 中华危重病急救医学

Objective:To verify the specific differentiated subsets of monocytes in sepsis, and to screen and construct the differential gene set of monocytes used for early diagnosis of sepsis.Methods:Patients with sepsis admitted to Guangdong Provincial People's Hospital from June 2020 to March 2021 were enrolled, and peripheral blood mononuclear cells (PBMC) were extracted. Single-cell sequencing technology and pseudo-time analysis were used to verify the differential subsets of monocytes. Bioinformatics methods were used to analyze the expression of genes in differential subsets of monocytes and screen out differential genes for the preliminary construction of a candidate differential gene set. The digital polymerase chain reaction (PCR) technology was used to verify the candidate differential genes in PBMC of sepsis patients and sepsis human myeloid leukemia mononuclear cells (THP-1) models, and the Venn diagram was used to construct the final differential gene set of monocytes. Gene Expression Omnibus (GEO) database was used to validate the differential gene set of monocytes.Results:① The results of cell annotation and pseudo-time analysis showed that the differentiation of NEAT1 +CD163 + monocyte occurred in the early stage of sepsis was significantly different from other subsets, which validated that NEAT1 +CD163 + monocyte was the characteristic subset in the pathological process of sepsis. ② Twenty-two differential genes related to sepsis were screened out from the gene expression of NEAT1 +CD163 + monocyte. After further verification by digital PCR, basic leucine zipper ATF-like transcription factor (BATF), JUNB proto-oncogene, carcinoembryonic antigen-related cell adhesion molecule 4 (CEACAM4), chromosome 9 open reading frame 95 (C9orf95), G protein subunit alpha 15 (GNA15), complement C3a receptor 1 (C3AR1), transforming growth factor beta 1 (TGFB1) and mitochondrial carrier homolog 1 (MTCH1) were screened out to construct the final differential gene set of monocytes. ③ The external validation results showed that C9orf95 gene had no data in GSE154918 and GSE133822 from GEO, it was excluded during validation. In GSE154918, the expressions of BATF, JUNB, CEACAM4, GNA15, C3AR1, TGFB1, and MTCH1 in the sepsis group were significantly higher than those in the healthy control group (log 2expression level: BATF was 12.78±0.08 vs. 11.39±0.35, JUNB was 16.88±0.07 vs. 16.04±0.03, CEACAM4 was 14.73±0.08 vs. 13.77±0.05, GNA15 was 13.16±0.06 vs. 12.30±0.04, C3AR1 was 14.62±0.13 vs. 12.87±0.05, TGFB1 was 16.95±0.05 vs. 16.57±0.36, MTCH1 was 14.80±0.02 vs. 14.61±0.15, all P < 0.05). In GSE133822, the expressions of BATF, CEACAM4, GNA15, and C3AR1 in the sepsis group were significantly higher than those in the health control group (log 2expression level: BATF was 8.66±0.16 vs. 7.92±0.14, CEACAM4 was 9.20±0.16 vs. 8.36±0.20, GNA15 was 10.66±0.18 vs. 10.13±0.16, C3AR1 was 11.49±0.27 vs. 10.48±0.16, all P < 0.05), while the expressions of JUNB, TGFB1, and MTCH1 were not statistically different between two groups. The results of gene set variation analysis (GSVA) showed that the enrichment scores of monocytes differential gene set of sepsis group were significantly higher than those of the healthy control group in both GSE154918 (0.38±0.04 vs. -0.44±0.02) and GSE133822 (0.56±0.02 vs. 0.20±0.05, both P < 0.01). Receiver operator characteristic curve (ROC curve) analysis showed that the differential gene set of monocytes had a reliable diagnostic value for early sepsis with the area under ROC curve (AUC) of 0.993 [95% confidence interval (95% CI) was 0.980-1.000] in GSE154918 and 0.944 (95% CI was 0.873-1.000) in GSE133822. Conclusion:A differential gene set of monocytes (BATF, JUNB, CEACAM4, GNA15, C3AR1, TGFB1, and MTCH1) screened out by single-cell sequencing and digital PCR technology has a reliable diagnostic value for the early sepsis, and may provide a new idea for the early diagnosis of sepsis.

Analysis of clinical features and risk factors for mortality in patients with culture-negative sepsis: a single-center retrospective cohort study based on MIMIC-Ⅳ / 中华危重病急救医学

Objective:To compare the characteristics and outcomes of culture-positive sepsis (CPS) with culture-negative sepsis (CNS) patients in order to understand the impact of CNS on prognosis and explore the possible risk factors for mortality.Methods:A retrospective cohort study was conducted. Patients with sepsis were identified from the Medical Information Mart for Intensive Care database-Ⅳ v0.4 (MIMIC-Ⅳ v0.4). Patients were divided into CPS and CNS groups according to the culture results within 24 hours before and after the diagnosis of sepsis. General information, baseline characteristics, and medical operation data between CNS and CPS groups were compared. Logistic regression analysis was used to calculate the relationship between CNS and in-hospital mortality under three regression models. Chi-square analysis and mediation analysis were used to analyze the effect of initial antibiotic and prior antibiotic use within 90 days on the in-hospital mortality of CNS. Results:A total of 8 587 patients with sepsis were enrolled in the final analysis, including 5 483 patients in the CPS group and 3 104 patients in the CNS group. Compared with the CPS group, the patients in the CNS group were younger [years old: 68 (56, 79) vs. 70 (58, 81)], had higher sequential organ failure assessment (SOFA) score and higher proportion of using mechanical ventilation, renal replacement therapy and vasopressin within 24 hours after intensive care unit (ICU) admission [SOFA score: 3 (2, 5) vs. 3 (2, 4), mechanical ventilation: 48.61% (1 509/3 104) vs. 39.25% (2 152/5 483), renal replacement therapy: 13.69% (425/3 104) vs. 9.68% (531/5 483), vasopressin: 15.79% (490/3 104) vs. 13.44% (737/5 483)], longer length of ICU stay [days: 5 (3, 10) vs. 3 (2, 6)] and higher in-hospital mortality [25.00% (776/3 104) vs. 18.53% (1 016/5 483)], with significant differences (all P < 0.01). However, there was no significant difference in gender, ICU type, simplified acute physiology score Ⅱ (SAPS Ⅱ), and Charlson comorbidity index (CCI) score between the two groups. After adjustment for multiple confounding factors, CNS was still a risk factor for in-hospital mortality [odds ratio ( OR) = 1.441, 95% confidence interval (95% CI) was 1.273-1.630, P < 0.001]. The results of Chi-square analysis and mediation analysis showed that the initial antibiotic had no significant effect on the higher in-hospital mortality of CNS, while the prior use of antibiotics within 90 days was related to higher in-hospital mortality of CNS ( OR = 1.683, 95% CI was 1.328-2.134, P < 0.05). The mediating effect of CNS in prior antibiotic use within 90 days and in-hospital death was significant ( Z = 5.302, P < 0.001), accounting for 7.58%. Conclusions:Compared with CPS, CNS was more severe and had a worse prognosis. Prior use of antibiotics within 90 days may be related to the higher in-hospital mortality of CNS patients, but it could not fully explain the high mortality of CNS.

Mechanism of resveratrol on ameliorating the cognitive dysfunction induced by sepsis associated encephalopathy in rats / 中华危重病急救医学

Objective:To explore the mechanism of resveratrol on ameliorating the cognitive dysfunction induced by sepsis associated encephalopathy (SAE) in rats.Methods:The 12 weeks old male Sprague-dawley (SD) male rats were randomly divided into sham group, sepsis group and resveratrol group, with 30 rats in each group. The rat model of sepsis was made by injecting LPS (10 mg/kg) into tail vein. The rats in sham group was given the same amount of normal saline (NS). After LPS injection, resveratrol (8 mg·kg -1·d -1) was intraperitoneally injected once daily for 2 days in the resveratrol group; the same amount of NS was given to the sepsis group and sham group. At 24 hours after model establishment, the cognitive function of the experimental rats was assessed by the Morris water maze test. The blood-brain barrier (BBB) permeability was evaluated by the brain water content (BWC) and Evans blue (EB) test. The protein expressions of matrix metalloproteinase 9 (MMP-9), Occludin and Claudin-5 in cortical tissue were detected by Western Blot. Double immunofluorescence was used to verify the co-localization of MMP-9 protein and the marker protein of astrocyte GFAP in the cortical tissue of rats. Results:Compared with the sham group, the escape latency in the sepsis group was significantly longer [48-hour escape latency (s): 56.56±6.43 vs. 36.62±3.32, 72-hour escape latency (s): 57.72±7.23 vs. 26.46±4.24, both P < 0.01], the BWC and extravasation of EB were increased [BWC: (84.56±2.03)% vs. (76.82±2.22)%, EB (μg/g): 17.56±2.28 vs. 6.25±1.36, both P < 0.01], the expression of MMP-9 protein was increased (MMP-9/β-actin: 0.73±0.01 vs. 0.24±0.01, P < 0.01), the protein expressions of Occludin and Claudin-5 were decreased (Occludin/β-actin: 0.45±0.02 vs. 0.86±0.04, Claudin-5/β-actin: 0.62±0.03 vs. 0.96±0.05, both P < 0.01). At the same time, the co-localization expression of MMP-9 protein and the astrocytes of the cortical were increased [MMP-9 fluorescence intensity (AU): 38.66±4.26 vs. 17.23±3.04, MMP-9 positive cells: (26.92±1.77)% vs. (12.82±1.46)%, both P < 0.01]. Compared with the sepsis group, the escape latency in resveratrol group was significantly shorter [48-hour escape latency (s): 41.42±6.27 vs. 56.56±6.43, 72-hour escape latency (s): 33.46±7.17 vs. 57.72±7.23, both P < 0.01], the BWC and extravasation of EB were decreased [BWC: (77.15±2.27)% vs. (84.56±2.03)%, EB (μg/g): 7.74±1.88 vs. 17.56±2.28, both P < 0.01], the expression of MMP-9 protein was decreased (MMP-9/β-actin: 0.25±0.01 vs. 0.73±0.01, P < 0.01), the protein expressions of Occludin and Claudin-5 were increased (Occludin/β-actin: 0.82±0.03 vs. 0.45±0.02, Claudin-5/β-actin: 0.92±0.04 vs. 0.62±0.03, both P < 0.01). At the same time, the co-localization expression of MMP-9 protein and the astrocytes of the cortical were decreased [MMP-9 fluorescence intensity (AU): 19.44±4.37 vs. 38.66±4.26, MMP-9 positive cells: (13.11±1.29)% vs. (26.92±1.77)%, both P < 0.01]. Conclusion:Resveratrol can inhibit the expression of MMP-9 protein in the astrocytes of the cortical cortex of rats, and then reduce the degradation of tight junction proteins of Occludin and Claudin-5, thereby reducing BBB permeability and eventually ameliorate the cognitive dysfunction induced by SAE.

Effect of hypercapnia on the clinical prognosis and severity of infection in patients with severe community-acquired pneumonia / 中华危重病急救医学

Objective:To investigate the effect of hypercapnia at admission on the clinical prognosis and the severity of infection in patients with severe community-acquired pneumonia (SCAP).Methods:The clinical data of 219 SCAP patients admitted to the department of emergency & critical care medicine of Guangdong Provincial People's Hospital from December 2017 to November 2019 were retrospectively analyzed. Based on the partial pressure of arterial carbon dioxide (PaCO 2) within 1 day after admission, the patients were divided into hypocapnia group [HO group, PaCO 2 < 35 mmHg (1 mmHg = 0.133 kPa)], normal carbonation group (NC group, PaCO 2 35-45 mmHg) and hypercapnia group (HC group, PaCO 2 > 45 mmHg). The clinical parameters of patients, such as gender, age, underlying diseases, white blood cell (WBC), procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6), pH value and lactate (Lac) within 1 day after admission were reviewed. The oxygenation index (PaO 2/FiO 2), pneumonia severity index (PSI) score and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score were evaluated. The change tendencies of each index on day 1, day 3, and day 5 after admission were observed subsequently. Meanwhile, the rate of invasive mechanical ventilation (IMV), length of hospital stays and 28-day mortality among three groups were compared. Kaplan-Meier survival analysis was performed to assess the 28-day cumulative survival rate of patients with SCAP among three groups. Multivariate Logistic regression analysis was used to screen the risk factors of IMV and 28-day death in patients with SCAP. Results:Compared with the HO group ( n = 68) and NC group ( n = 72), the HC group ( n = 79) had higher proportion of preexisting comorbid chronic obstructive pulmonary disease (COPD) and PSI score, lower PCT, CRP, IL-6, and pH values. Compared with the HO group and NC group, there were smaller improvement trends on the levels of WBC, PCT, CRP, IL-6, PaO 2/FiO 2 and Lac at day 3 and day 5 as compared with day 1 in the HC group. On the 5th day after admission, the levels of WBC, PCT, CRP, IL-6, and Lac in the HC group were significantly higher than those in the HO group and NC group [WBC (×10 9/L): 18.33±1.44 vs. 10.89±2.37, 11.15±1.74; PCT (μg/L): 5.04±1.18 vs. 3.46±0.87, 3.58±0.83; CRP (mg/L): 78.43±7.17 vs. 54.24±4.97, 57.93±5.39; IL-6 (ng/L): 75.35±11.92 vs. 60.11±10.27, 57.88±12.34; Lac (mmol/L): 4.36±1.24 vs. 0.78±0.39, 0.86±0.64; all P < 0.01], and the lowest in PaO 2/FiO 2 was found in the HC group as compared with the HO and NC groups (mmHg: 171.31±6.73 vs. 226.68±7.36, 225.93±6.92, both P < 0.01). Compared with the HO group and NC group, the HC group had highest proportion of IMV (29.1% vs. 22.1%, 22.2%, both P < 0.01) and 28-day mortality (26.6% vs. 13.2%, 13.9%, both P < 0.01). Even when the patients with COPD were excluded from the analysis, the differences persisted among the groups. Kaplan-Meier survival analysis suggested that HC group had a higher 28-day cumulative survival rate as compared with the HO and NC groups (Log-Rank test: χ 12 = 4.976, P1 = 0.026; χ 22 = 4.629, P2 = 0.031). Multivariate Logistic regression analysis showed that IL-6, PSI score and hypercapnia within 1 day and PCT on the 5th day after admission were the independent risk factors of requiring IMV and 28-day death in patients with SCAP [odds ratio ( OR) were 0.325, 1.229, 1.396, 1.313, respectively, all P < 0.01]. Even when patients with COPD were excluded from the analysis, the above results had not been changed. Conclusion:Hypercapnia at admission was associated with higher proportion of IMV and 28-day mortality in patients with SCAP, which may be related to its early suppression of inflammation and then increment of infection.

β1 receptor blocker decreases the myocardial inflammation in the sepsis adult rats through inhibition of TLR4/NF-κB signaling pathway / 中华危重病急救医学

Objective? To?explore?whether?β1?receptor?blocker?could?decrease?the?myocardial?inflammation??through?the?Toll-like?receptor?4/nuclear?factor-κB?(TLR4/NF-κB)?signaling?pathway?in?the?sepsis?adult?rats.? Methods? ?Sixty?male?Wistar?rats?(250-300?g)?aged?3?months?old?were?allocated?to?four?groups?by?random?number?table?(n?=?15):?sham?operation?group?(S?group),?sepsis?model?group?(CLP?group),?β1?receptor?blocker?esmolol?intervention?group??(ES?group),?and?inhibitor?of?the?TLR4?E5564?intervention?group?(E5564?group).?The?rat?sepsis?model?was?established?by?cecal?ligation?and?puncture?(CLP);?S?group?of?rats?underwent?only?an?incision.?Rats?in?S?group,?CLP?group?and?E5564?group?were?subcutaneous?injected?with?0.9%?sodium?chloride?(NaCl)?2.0?mL/kg.?Besides,?the?rats?in?ES?group?were?injected?with?esmolol?(15?mg·kg-1·h-1)?by?micro?pump?through?the?caudal?vein.?The?rats?in?E5564?group?were?injected?with?E5564?(0.3?mg·kg-1·h-1)?by?micro?pump?through?the?caudal?vein?1?hour?before?the?CLP?surgery.?Samples?were?collected?6?hours?after?the?modelling?in?each?group.?The?average?arterial?pressure?(MAP)?and?cardiac?output?index?(CI)?were?monitored?by?PU?electrical?conduction?ECG?monitor.?The?levels?of?serum?cardiac?troponin?I?(cTnI),?interleukin-1β?? (IL-1β)?and?tumor?necrosis?factor-α(TNF-α)?were?detected?by?enzyme?linked?immunosorbent?assay?(ELISA).?The?expressions?of?TLR4,?NF-κB?p65,?IL-1β,?TNF-α?in?myocardial?tissue?was?detected?by?Western?Blot.? Results? There?was?no?significant?difference?in?MAP?in?each?group.?Compared?with?the?S?group,?the?CI?in?the?CLP?group?was?significantly?decreased,?the?levels?of?serum?cTnI,?IL-1β,?TNF-α?were?significantly?increased,?the?protein?expressions?of?myocardial?tissue?TLR4,?NF-κB?p65,?IL-1β?and?TNF-α?were?significantly?increased.?Compared?with?the?CLP?group,?the?CI?in?the?ES?group?and?E5564?group?were?significantly?increased?(mL·s-1·m-2:?58.6±4.3,?58.9±4.4?vs.?41.2±3.9,?both?P?<?0.01),?the?levels?of?serum?cTnI,?IL-1β?and?TNF-α?were?significantly?decreased?[cTnI?(μg/L):?1?113.81±26.64,?1?115.74±25.90?vs.?1?975.96±42.74;?IL-1β(ng/L):?39.6±4.3,?38.9±4.4?vs.?61.2±3.9;?TNF-α?(ng/L):?43.1±2.8,?48.7±2.6?vs.?81.3±4.4,?all?P?<?0.01],?the?protein?expressions?of?myocardial?tissue?NF-κB?p65,?IL-1β,??TNF-αwere?significantly?decreased?(NF-κB?p65/β-actin:?0.31±0.03,?0.43±0.04?vs.?0.85±0.08;?IL-1β/β-actin:?0.28±0.05,?0.32±0.03?vs.?0.71±0.06;?TNF-α/β-actin:?0.18±0.04,?0.28±0.03?vs.?0.78±0.07,?all?P?<?0.01),?but?there?was?no?significant?difference?in?protein?expression?of?TLR4?(TLR4/β-actin:?0.89±0.07,?0.87±0.09?vs.?0.95±0.09,?both?P?>?0.05).?There?was?no?significant?difference?in?CI,?the?levels?of?serum?cTnI,?IL-1β,?TNF-α,?and?the?protein?expressions?of?myocardial?tissue?TLR4,?NF-κB?p65,?IL-1β,?TNF-αbetween?ES?group?and?E5564?group?(all?P?>??0.05).? Conclusion? β1?receptor?blocker?esmolol?may?inhibit?myocardial?inflammatory?response?in?sepsis?adult?rats?through?TLR4/NF-κB?signaling?pathway,?thereby?alleviating?sepsis-induced?myocardial?injury.

The value of serum presepsin in differentiating Gram-negative bacteria from Gram-positive bacteria and fungal infection in sepsis patients / 中华急诊医学杂志

Objective@#To examine whether presepsin level can serve as a distinguishing marker between G- bacteria and G+ bacteria, fungal infection in sepsis patients.@*Methods@#A prospective observation study was conducted on the consecutive patients with positive bacterial cultures in intensive care unit (ICU) from June 2017 to November 2018. The patients were divided into the G- group, G+ group and fungal group. Blood samples were collected upon admission to measure the levels of presepsin and procalcitonin (PCT).@*Results@#(1) Of the 156 patients met the inclusion criteria. 96 (62% G- rods, 25 (16%) G+ microbes, and 35 (22%) fungi were detected. (2) Presepsin concentrations were significantly higher in the G- group compared with the G+ and fungal groups (P = 0.000). (3) Presepsin level has a higher accuracy in differentiating G- sepsis from Gram+ and fungal sepsis than PCT level [area under the curve (AUC): 0.809 vs 0.712]. The AUC value of a combination of presepsin and PCT level was significantly larger than that of presepsin level alone in differentiating G- sepsis from Gram+ and fungal sepsis (AUC: 0.866 vs 0.809).@*Conclusions@#In contrast to PCT, presepsin is a good discriminative biomarker in different infections.

The value of serum presepsin in differentiating Gram-negative bacteria from Gram-positive bacteria and fungal infection in sepsis patients / 中华急诊医学杂志

Objective To examine whether presepsin level can serve as a distinguishing marker between G-bacteria and G+ bacteria,fungal infection in sepsis patients.Methods A prospective observation study was conducted on the consecutive patients with positive bacterial cultures in intensive care unit (ICU) from June 2017 to November 2018.The patients were divided into the G-group,G+ group and fungal group.Blood samples were collected upon admission to measure the levels of presepsin and procalcitonin (PCT).Results (1) Of the 156 patients met the inclusion criteria.96 (62％ G-rods,25 (16％) G+ microbes,and 35 (22％) fungi were detected.(2) Presepsin concentrations were significantly higher in the G-group compared with the G+ and fungal groups (P =0.000).(3) Presepsin level has a higher accuracy in differentiating G-sepsis from Gram+ and fungal sepsis than PCT level [area under the curve (AUC):0.809 vs 0.712].The AUC value of a combination of presepsin and PCT level was significantly larger than that of presepsin level alone in differentiating G-sepsis from Gram+ and fungal sepsis (AUC:0.866 vs 0.809).Conclusions In contrast to PCT,presepsin is a good discriminative biomarker in different infections.

β1 receptor blocker decreases the myocardial inflammation in the sepsis adult rats through inhibition of TLR4/NF-ΚB signaling pathway / 中华危重病急救医学

OBJECTIVE@#To explore whether β1 receptor blocker could decrease the myocardial inflammation through the Toll-like receptor 4/nuclear factor-ΚB (TLR4/NF-ΚB) signaling pathway in the sepsis adult rats.@*METHODS@#Sixty male Wistar rats (250-300 g) aged 3 months old were allocated to four groups by random number table (n = 15): sham operation group (S group), sepsis model group (CLP group), β1 receptor blocker esmolol intervention group (ES group), and inhibitor of the TLR4 E5564 intervention group (E5564 group). The rat sepsis model was established by cecal ligation and puncture (CLP); S group of rats underwent only an incision. Rats in S group, CLP group and E5564 group were subcutaneous injected with 0.9% sodium chloride (NaCl) 2.0 mL/kg. Besides, the rats in ES group were injected with esmolol (15 mg×kg-1×h-1) by micro pump through the caudal vein. The rats in E5564 group were injected with E5564 (0.3 mg×kg-1×h-1) by micro pump through the caudal vein 1 hour before the CLP surgery. Samples were collected 6 hours after the modelling in each group. The average arterial pressure (MAP) and cardiac output index (CI) were monitored by PU electrical conduction ECG monitor. The levels of serum cardiac troponin I (cTnI), interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) were detected by enzyme linked immunosorbent assay (ELISA). The expressions of TLR4, NF-ΚB p65, IL-1β, TNF-α in myocardial tissue was detected by Western Blot.@*RESULTS@#There was no significant difference in MAP in each group. Compared with the S group, the CI in the CLP group was significantly decreased, the levels of serum cTnI, IL-1β, TNF-α were significantly increased, the protein expressions of myocardial tissue TLR4, NF-ΚB p65, IL-1β and TNF-α were significantly increased. Compared with the CLP group, the CI in the ES group and E5564 group were significantly increased (mL×s-1×m-2: 58.6±4.3, 58.9±4.4 vs. 41.2±3.9, both P < 0.01), the levels of serum cTnI, IL-1β and TNF-α were significantly decreased [cTnI (μg/L): 1 113.81±26.64, 1 115.74±25.90 vs. 1 975.96±42.74; IL-1β (ng/L): 39.6±4.3, 38.9±4.4 vs. 61.2±3.9; TNF-α (ng/L): 43.1±2.8, 48.7±2.6 vs. 81.3±4.4, all P < 0.01], the protein expressions of myocardial tissue NF-ΚB p65, IL-1β, TNF-α were significantly decreased (NF-ΚB p65/β-actin: 0.31±0.03, 0.43±0.04 vs. 0.85±0.08; IL-1β/β-actin: 0.28±0.05, 0.32±0.03 vs. 0.71±0.06; TNF-α/β-actin: 0.18±0.04, 0.28±0.03 vs. 0.78±0.07, all P < 0.01), but there was no significant difference in protein expression of TLR4 (TLR4/β-actin: 0.89±0.07, 0.87±0.09 vs. 0.95±0.09, both P > 0.05). There was no significant difference in CI, the levels of serum cTnI, IL-1β, TNF-α, and the protein expressions of myocardial tissue TLR4, NF-ΚB p65, IL-1β, TNF-α between ES group and E5564 group (all P > 0.05).@*CONCLUSIONS@#β1 receptor blocker esmolol may inhibit myocardial inflammatory response in sepsis adult rats through TLR4/NF-ΚB signaling pathway, thereby alleviating sepsis-induced myocardial injury.

Relationship between sepsis-induced immunosuppression and multi-drugs resistant bacteria / 中华危重病急救医学

Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection. Immunosuppression is an important factor of secondary infection in the late state of sepsis, including multi-drugs resistant bacteria, which ultimately leads to the death of patients. The aim of this article was to help clinical staffs better manage patients with sepsis, improve long-term survival rate of the patients, and reduce their re-hospitalization rate by reviewing the relationship between sepsis-induced immunosuppression and multi-drugs resistant bacteria through three aspects: the mechanism of sepsis-induced immunosuppression, the mechanism of antibiotic resistance and the relationship between sepsis-induced immunosuppression and secondary infections.

Clinical evaluation of the (1, 3)-β-D-glucan assay as an aid to diagnosis of fungal infections in severe pneumonia patients / 中华急诊医学杂志

Objective To evaluate (1,3)-β-D-glucan (BG) assay as an aid for invasive fungal infection (IFI) diagnosis in severe pneumonia patients (diagnosis followed 2007 American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) severe pneumonia standard).Methods BG antigenemia was measured by BG Assay Box.IFIs was classified according to the blood fungal laboratory reports.Results 558 patients (185 females,373 males,mean age 64.7) were included.41 patients were proven to be fungal infected to be classified in exposure group.BG assay mean value in exposure group and unexposure group were (568.53 ±796.57) pg/mL,(51.4 ±63.27) pg/mL,respectively.Patients in the exposure group had significantly higher BG assay value than patients in the unexposure group (P ＜0.05).For the cutoff 100 pg/mL recommended by manufacturer,the sensitivity,specificity,positive predict value and negative predict value of the BG assay were 92.7％,92.5％,49.4％ and 0.6％,respectively.Conclusion BG assay has positive clinical value in invasive fungal infection diagnosis in severe pneumonia patients.

Analysis of the clinical effect of noninvasive positive pressure ventilation in the treatment of acute respiratory ;distress syndrome / 中华危重病急救医学

Objective To evaluate the clinical efficacy of noninvasive positive pressure ventilation (NPPV) in the treatment of patients with acute respiratory distress syndrome (ARDS), and to look for the predictors of failure of NPPV. Methods A retrospective observation was conducted. ARDS patients underwent NPPV admitted to emergency intensive care unit (EICU) of Guangdong General Hospital from January 2013 to December 2015 were enrolled. The patients were divided into success group and failure group according to the clinical efficacy. The condition of the patients in the two groups was evaluated, and ARDS classification and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score before treatment were recorded. Etiological composition of ARDS was analyzed. The parameters, including heart rate (HR), respiratory rate (RR), oxygenation index (PaO2/FiO2), arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2) and arterial oxygen saturation (SaO2), were recorded before and 2 hours after the treatment of NPPV. Multivariate logistic regression analysis was conducted for predicting the independent factors inducing the failure of NPPV treatment of patients with ARDS. Results The date of 137 patients with ARDS were collected, excluding the followed patients, 6 with coma, 18 with hemodynamic instability, 5 with severe hypoxia, and 5 with incomplete date. Finally, a total of 103 patients entered the statistics. There were 69 patients in NPPV success group, and 34 in failure group. Compared with success group, APACHE Ⅱ score in the failure group was higher (21.4±6.2 vs. 19.7±8.9), the ratios of patients with severe ARDS and those induced by pulmonary infection were higher [82.4% (28/34) vs. 5.8% (4/69), 32.4% (11/34) vs. 8.7% (6/69), respectively, both P < 0.05]. HR and RR before NPPV in the failure group were significantly higher than those of success group [HR (bpm): 124±13 vs. 117±12, RR (bpm): 39±5 vs. 33±4], and PaO2/FiO2, PaO2, PaCO2, and SaO2 were significantly lower than those of the success group [PaO2/FiO2 (mmHg, 1 mmHg = 0.133 kPa): 104±10 vs. 156±12, PaO2 (mmHg): 53±8 vs. 68±7, PaCO2 (mmHg): 31±5 vs. 37±7, SaO2: 0.83±0.07 vs. 0.91±0.05, all P < 0.05]. It was shown by logistic regression analysis that severe ARDS [odds ratio (OR) = 10.533, 95% confidence interval (95%CI) = 5.847-89.852, P = 0.000], pulmonary infection resulted ARDS (OR = 4.831, 95%CI = 1.688-13.825, P = 0.003) and PaO2/FiO2 < 140 mmHg 2 hours after treatment (OR = 7.049, 95%CI = 1.266-39.236, P = 0.026) were the independent risk factors of NPPV failure for the treatment of patients with ARDS. Conclusions Patients with severe ARDS and pulmonary infection derived ARDS were the risk factors of failure to NPPV in ARDS. Lack of improvement in oxygenation 2 hours after NPPV is the predictor of NPPV failure and change to invasive ventilation.

The effect of hypertonic saline on notch signaling pathway in experimentally induced cerebral ischemic rats / 中华急诊医学杂志

Objective To explore whether hypertonic saline would partake in regulating Notch signaling in microglia in experimentally induced cerebral ischemic rats.Methods Male SD rats were randomly divided into sham group, cerebral ischemia group, normal saline group ( NS group ) , 10%hypertonic saline group (10%HS group) , the model of cerebral ischemia were established in all rats except the sham group by using middle cerebral artery occlusion ( MCAO) .After 2 hours of MCAO, the rats were through reperfusion for 24 h.In addition, rats in the normal saline group and 10% HS group were respectively treated with a continuous intravenous injection of normal saline (0.3 mL/h) and 10%HS (0.3 mL/h) by tail vein for 24 h.Immunofluorescence methods, RT-PCR and Western blot were used to detect the expression of Notch1 and intracellular Notch receptor domain ( NICD) .All data was analyzed by one-way analysis of variance ( ANOVA) , The intergroup comparisons were analyzed by the least-significant-difference (LSD) tests.Differences were considered statistically significant if P<0.05.Results Immunofluorescence showed that the expression of Notch1 and NICD were significantly increased in the microglia around peri-ischemia area in cerebral ischemia group and normal saline group compared to sham group;the expression of Notch1 and NICD in the microglia around peri-ischemia area were significantly reduced in 10% HS group compared to ischemia group and NS group.RT-PCR showed that the mRNA expression of Notch1 was significantly increased in ischemia group and NS group compared to sham group ( sham group: 1.000 ± 0.076; ischemia group: 2.203 ±0.283; NS group: 1.616 ±0.185; P <0.01 ); however, it was significantly reduced in 10% HS group compared to ischemia group and NS group ( ischemia group:2.203 ±0.283; NS group: 1.616 ±0.185; 10%HS group: 1.202 ±0.177; P <0.05 ) .Western blot showed that the protein expression of Notch1 was significantly increased in ischemia group and NS group compared to sham group ( sham group: 0.290 ±0.079; ischemia group: 0.750 ±0.029; NS group:0.765 ±0.182;P<0.01);but was significantly reduced in 10%HS group compared to ischemia group and NS group ( ischemia group:0.750 ±0.029; NS group:0.765 ±0.182;10%HS group:0.390 ±0.195;P<0.05 ) .The protein expression of NICD was significantly increased in ischemia group and NS group compared to sham group ( sham group: 0.401 ±0.196; ischemia group: 0.906 ±0.359; NS group:0.847 ±0.153;P<0.01);but was significantly reduced in 10%HS group compared to ischemia group and NS group ( ischemia group:0.906 ±0.359; NS group:0.847 ±0.153;10%HS group:0.561 ±0.165;P<0.05 ) .Conclusion Our results suggest that HS markedly suppresses Notch signaling in microglia around the ischemia tissue area in experimental induced cerebral ischemic rats.

Esmolol improves clinical outcome and tissue oxygen metabolism in patients with septic shock through controlling heart rate / 中华危重病急救医学

ObjectiveTo investigate whether esmolol could improve clinical outcome and tissue oxygen metabolism by controlling heart rate (HR) in patients with septic shock.Methods A single-center double-blinded randomized controlled trial was conducted. The patients suffering from septic shock received 6-hour early goal directed therapy (EGDT) with pulmonary artery wedge pressure≥ 12 mmHg (1 mmHg = 0.133 kPa) or central venous pressure (CVP)≥ 12 mmHg requiring norepinephrine to maintain mean arterial pressure (MAP)≥ 65 mmHg and HR≥95 bpm admitted to intensive care unit (ICU) of Guangdong General Hospital from September 2013 to September 2014 were enrolled. They were randomly divided into esmolol group and control group by computer-based random number generator. All patients received conventional basic treatment, while those in the esmolol group received in addition persistent esmolol infusion by micro pump with dosage of 0.05 mg·kg-1·min-1 with the dosage adjusted to maintain HR lower than 100 bpm within 24 hours. The patients in control group did not receive drug intervention for HR. The primary end-points consisted of length of stay in ICU and 28-day mortality. The secondary end-points included hemodynamic parameters [HR, MAP, CVP, cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI)] and tissue oxygen metabolism parameters [central venous oxygen saturation (ScvO2), lactate level (Lac)]before and 24, 48, 72 hours after the treatment.Results A total of 48 patients with septic shock were enrolled with 24 patients in esmolol group and 24 in control group.① The primary end-points: compared with control group, the length of stay in the ICU in the esmolol group was significantly shortened (days: 13.75±8.68 vs. 21.70±6.06,t = 3.680, P = 0.001), and 28-day mortality was significantly lowered [25.0% (6/24) vs. 62.5% (15/24),χ2 = 6.857,P = 0.009].② The secondary end-points: there were no significant difference in the hemodynamic and tissue metabolism parameters before treatment between two groups. No significant difference was found between before and after treatment of all above parameters in control group. HR and Lac in the esmolol group were obviously declined, SVI, SVRI, ScvO2 were gradually increased, but no significant difference in MAP, CVP, and CI was found. Compared with the control group, HR in the esomolol group was significantly lowered (bpm: 84.4±3.5 vs. 111.2±7.2,P< 0.01), SVRI and ScvO2 were significantly increased from 24 hours [SVRI (kPa·s·L-1·m-2): 137.9±1.6 vs. 126.9±1.3, ScvO2: 0.652±0.017 vs. 0.620±0.017, bothP< 0.01]; SVI was significantly increased (mL/m2: 39.9±2.2 vs. 36.8±1.7,P< 0.01) and Lac level significantly declined from 48 hours (mmol/L: 2.8±0.3 vs. 3.4±0.3,P< 0.01).Conclusion The results demonstrate that HR controlled by a titrated esmolol infusion given to septic shock patients was associated with an improvement in tissue metabolism, reduction in the length of ICU stay and lowering of 28-day mortality.

The clinical significance of procalcitonin to identifying microorganism strains in ICU patients with bloodstream infection / 中华急诊医学杂志

Objective To investigate the level of serum procalcitonin (PCT) for exploring the clinical value in identifying microorganism strains in the intensive care unit (ICU) patients with blood stream infections.Methods A retrospective analysis of patients with positive blood culture of a single strain and with serum PCT levels detected simultaneously was carried out from January 2010 through December 2012.The comparisons of PCT levels were done among Gram-negative (G-) bacteria,Gram-positive (G +) bacteria and fungi in patients with bloodstream infections.The diagnostic performance of PCT was determined by the receiver operating characteristic curve (ROC).Results A total of 524 patients with blood stream infection were enrolled and categorized into three different groups,namely G-bacteria infection group (n =206),G + bacteria infection group (n =276),and fungi infection group (n =42).The median value of PCT level of G-bacteria group was 14.9 ng/ml,which was significantly higher than that of the other two groups with 0.14 ng/ml and 1.76 ng/ml,respectively (P ＜ 0.01).Further,the PCT level of fungi group also obviously higher than that of G + bacteria group (P ＜ 0.001).According to ROC,PCT level at 2.11 ng/ml could distinguish G-bacteria infection from G + bacteria infection with sensitivity 82.8％ and specificity 80.1％,while PCT at 5.09 ng/ml was used to distinguish G-bacteria infection from fungi infection with sensitivity 68％ and specificity 73.8％.The area under the ROC of G + bacteria and fungi was 33.0％ (P ＜ O.01).Conclusions Serum PCT level is valid for distinguishing ICU patients with blood stream infection caused by G-bacteria from G+ bacteria or from fungi,but the validity of PCT for distinguishing G + bacteria from fungi infection needs to be set up by further studies.