Outcomes of combined mitochondria and mesenchymal stem cellsderived exosome therapy in rat acute respiratory distress syndrome and sepsis

BACKGROUND The treatment of acute respiratory distress syndrome(ARDS)complicated by sepsis syndrome(SS)remains challenging.AIM To investigate whether combined adipose-derived mesenchymal-stem-cells(ADMSCs)-derived exosome(EXAD)and exogenous mitochondria(mitoEx)protect the lung from ARDS complicated by SS.METHODS In vitro study,including L2 cells treated with lipopolysaccharide(LPS)and in vivo study including male-adult-SD rats categorized into groups 1(sham-operated-control),2(ARDS-SS),3(ARDS-SS+EXAD),4(ARDS-SS+mitoEx),and 5(ARDS-SS+EXAD+mitoEx),were included in the present study.RESULTS In vitro study showed an abundance of mitoEx found in recipient-L2 cells,resulting in significantly higher mitochondrial-cytochrome-C,adenosine triphosphate and relative mitochondrial DNA levels(P<0.001).The protein levels of inflammation[interleukin(IL)-1β/tumor necrosis factor(TNF)-α/nuclear factor-κB/toll-like receptor(TLR)-4/matrix-metalloproteinase(MMP)-9/oxidative-stress(NOX-1/NOX-2)/apoptosis(cleaved-caspase3/cleaved-poly(ADP-ribose)polymerase)]were significantly attenuated in lipopolysaccharide(LPS)-treated L2 cells with EXAD treatment than without EXAD treatment,whereas the protein expressions of cellular junctions[occluding/β-catenin/zonula occludens(ZO)-1/E-cadherin]exhibited an opposite pattern of inflam-mation(all P<0.001).Animals were euthanized by 72 h post-48 h-ARDS induction,and lung tissues were harvested.By 72 h,flow cytometric analysis of bronchoalveolar lavage fluid demonstrated that the levels of inflam-matory cells(Ly6G+/CD14+/CD68+/CD11b/c+/myeloperoxidase+)and albumin were lowest in group 1,highest in group 2,and significantly higher in groups 3 and 4 than in group 5(all P<0.0001),whereas arterial oxygen-saturation(SaO2%)displayed an opposite pattern of albumin among the groups.Histopathological findings of lung injury/fibrosis area and inflammatory/DNA-damaged markers(CD68+/γ-H2AX)displayed an identical pattern of SaO2%among the groups(all P<0.0001).The protein expressions of inflammatory(TLR-4/MMP-9/IL-1β/TNF-α)/oxidative stress(NOX-1/NOX-2/p22phox/oxidized protein)/mitochondrial-damaged(cytosolic-cytochrome-C/dynamin-related protein 1)/autophagic(beclin-1/Atg-5/ratio of LC3B-II/LC3B-I)biomarkers exhibited a similar manner,whereas antioxidants[nuclear respiratory factor(Nrf)-1/Nrf-2]/cellular junctions(ZO-1/E-cadherin)/mitochondrial electron transport chain(complex I-V)exhibited an opposite manner of albumin among the groups(all P<0.0001).CONCLUSION Combined EXAD-mitoEx therapy was better than merely one for protecting the lung against ARDS-SS induced injury.

The Slippery Slope of Sepsis

Mortality, morbidity, early recognition, and treatment of sepsis remain a diagnostic dilemma for clinicians, in addition, the timely diagnosis of sepsis represents an ongoing clinical challenge. This review looks at the challenges of early recognition, the scope of the problem, the immunologic basis of the sepsis cascade, new frontiers related to interventions, and the role of antibiotics in an era of antimicrobial resistance. In Figure 1, once a patient is on the slippery slope of sepsis, the ability to reverse the momentum is challenging;hoping antibiotics, fluid resuscitation, vasopressors may buy time for the immunologic cascade to equilibrate to its homeostatic balance. While the development of septic shock is much more complex than pathogen proliferation, our understanding of the pathogenesis and ability to therapeutically intervene is in its infancy. Patients with sepsis frequently present for urgent medical care with undifferentiated infection and nonspecific symptoms. As 80% of patients with sepsis are initially treated in an Emergency Department, the burden of early recognition and intervention falls squarely on the shoulders of Emergency Department Clinicians. [1] This is an entity that occurs in all age groups, without regard to race, geography, or health status. Survival and mortality related to this clinical entity are poorly understood. Our understanding of sepsis needs to expand beyond the downstream effects and collateral damage of multiorgan dysfunction and failure. Immunologically, the antigenic triggers, be it invasive infection, severe injury, and systemic inflammation without concomitant infection, elicit similar pattern recognition receptors and innate host responses. If you are lucky enough to have survived an acute episode of sepsis, patients with sepsis often develop new adverse sequelae after treatment, a concept called persistent critical illness or post sepsis syndrome, characterized by long-term disability, and worsening chronic health conditions requiring re-hospitalization. [2]

Diagnostic and prognostic roles of soluble CD22 in patients with Gram-negative bacterial sepsis

BACKGROUND： Soluble CD22（sCD22） is a fragment of CD22, a B cell-specific membrane protein that negatively regulates B-cell receptor signaling. To date, sCD22 has only been regarded as a tumor marker of B-cell malignancies. Its expression in infectious diseases has not yet been assessed.METHODS： Serum concentrations of sCD22, procalcitonin（PCT） and interleukin-6（IL-6） were measured by enzymelinked immunosorbent assays in patients with intra-abdominal Gram-negative bacterial infection. Receiver operating characteristic curve analysis was performed to evaluate the diagnostic accuracy of these biomarkers in this type of infection. The correlations between biomarkers and the Acute Physiology and Chronic Health Evaluation（APACHE） II scores were also analyzed.RESULTS： Concentrations of sCD22 were significantly elevated in patients with sepsis and the elevation is correlated with the severity of sepsis. sCD22 was also slightly elevated in patients with non-infected systemic inflammatory response syndrome or local infection. The diagnostic accuracy of sCD22 for sepsis was equivalent to that of PCT or IL-6. In addition, the correlation of sCD22 with APACHE II scores was stronger than that of PCT or IL-6.CONCLUSIONS： Serum sCD22 is a novel inflammatory mediator released during infection. This soluble biomarker plays a potential role in the diagnosis of Gram-negative bacterial sepsis, with a diagnostic accuracy as efficient as that of PCT or IL-6. Furthermore, sCD22 is more valuable to predict the outcomes in patients with sepsis than PCT or IL-6. The present study suggested that sCD22 might be potentially useful in supplementing current criteria for sepsis.

Based on the Four Segments and Treatment by Syndrome Differentiation to Lower the Mortality of Sepsis

Lowering the mortality of sepsis has become an important issue in the international critical care medicine because of its unacceptably high incidence. In 2004 and 2008,there were no essential breakthroughs in international guidelines for the management of severe sepsis

Euthyroid sick syndrome in trauma patients with severe inflammatory response syndrome

Objective： To investigate the alternations of thyroid hormone in traumatic patients with severe inflammatory response syndrome （SIRS）. Methods： Fifty traumatic patients with severe SIRS were enrolled and divided into two groups according to whether they presented multiorgan dysfunction syndrome （MODS）. Thyroid hormone measurements were taken, including total triiodothyronine （ TT3 ）, total thyroxine （TT4）, free triiodothyronine （FT3）, free thyroxine （ FT4 ） and thyroid stimulating hormone （TSH）. The acute physiology and chronic health evaluation II （ APACHE II ） score was calculated according to clinical data. The outcomes of recovery or deterioration were recorded, as well as the length of time from the onset of SIRS to the time thyroid hormones were measured. Results： Euthyroid sick syndrome （ESS） was presented in 45 cases. TT3 level was negatively correlated with APACHE II score （r = -0.330, P 〈0. 05）, and TT3/TI＇4 value was negatively correlated with the duration of SIRS（ r = -0.316, P〈0.05）. TT3, TT4 and levels in MODS patients were significantly lower than those without MODS （ P 〈 0.05 ）. MODS patients got low TT4 or FT4 level more frequently than those without MODS （ P 〈 0.05 ）. Compared with the patients in normal TSH group, the patients with decreased TSH had lower T3, T4, recovery rate and higher APACHE II scores, MODS incidence, but there was no difference between two groups （P〉0.05）. Conclusions： Trauma patients with severe SIRS have high possibility to get ESS, which occurs more frequently and severely in MODS patients. It shows the influences of SIRS on the thyroid axes. With the persistence and aggravation of SIRS, there is a progressive reduction of thyroid hormone.

Clinical significance of scoring system for systemic inflammatory response syndrome

The concepts of systemic inflammatory response syndrome （SIRS） and scoring system were defined by the journal of Bone in 1992. SIRS was described as occurrence of two or more clinical criteria in four ones （fever or hypothermia, tachypnea, tachycardia, and leukocytosis）. An early diagnosis and estimation of systemic inflammation in patients is helpful for treatment selection. This paper reviews the application of SIRS scoring system, which has been extensively validated for large groups of critical carepatients with severe injury and critical surgical diseases. Recent studies have documented SIRS score as a significant predictive parameter of adverse outcome in critical care patients. Furthermore, some studies also give us a suggestion on how to reduce the overload systemic response.

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis （SAP）. In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP. Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution （hematocrit （HCT） 〈35%, n=56） or slow hemodilution （HCT 〉35%, n=-59） within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined. Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution （P 〈0.05） on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution （（7.4±1.9） days） compared with the slow hemodilution group （（10.2±2.3） days）, and the incidence of sepsis （78.6%） was higher in the rapid group compared to the slow （57.6%） in the first 28 days. The survival rate of the slow hemodilution group （84.7%） was better than the rapid hemodilution （66.1%. P 〈0.05）. Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.

Anti-Inflammatory Effect of Qingwen Baidu Decoction (清瘟败毒饮) in Sepsis Rats

Objective：To explore the pharmacological anti-inflammatory mechanism of Chinese formula Qingwen Baidu Decoction（清瘟败毒饮,QBD） from the view of holistic biology.Methods：The rats were randomly divided into a normal conrol group,a lipopolysaccharide（LPS） group,the low- and high-dose QBD groups,and a dexamethasone（DXM） group.NR8383 cells were treated with culture fluid containing 6%serum from rats of each group respectively.Inflammatory mediators were detected by reverse transcription polymerase chain reaction（RT-PCR）,Western blotting hybridization,enzyme linked immunosorbent assay（ELISA）,polymerase chain reaction（PCR） gene array and antibody array.Results：It is showed that the levels of interleukin（IL）-1 α,IL-4 and IL-12 were enhanced in the low-dose QBD group;levels of IL-1 α,IL-12 and IL-18 were augmented in the high-dose QBD group,compared with the LPS group after ELISA detection.Western blot showed that IL-1β and tumor necrosis factor（TNF）-α expression of the control group were lower than other groups.IL-1 βlevel of the low-dose and high-dose QBD groups detected by RT-PCR was higher in early stage but lower after24 h than that of the control group（P〈0.01）.Expression of 84 main inflammatory cytokines and receptors was detected by rat inflammatory cytokines and receptors PCR array.Up-regulation genes were 22 in both the LPS group and the low-dose QBD group,among which 16 up-regulating genes were the same.In these 16 genes,the up-regulating amplitude of 9 genes in the low-dose QBD group was less than that in the LPS group,4 were similar to and 3 were more.Twenty-nine main cytokines were inspected by rat cytokine antibody array.Intergroup gray value differences were found in 7 expressed cytokines.The levels of these 7 cytokines in the lowdose QBD group were all lower than those in the the LPS group.Conclusions：QBD has anti-inflammatory effect on sepsis by changing the level of inflammatory mediators.