联合肝素结合蛋白和降钙素原诊断脓毒症及分级的临床应用价值

目的探讨肝素结合蛋白（HBP）、降钙素原（PCT）、C 反应蛋白（CRP）、WBC 在脓毒症诊断及分级中的临床应用价值.方法选取脓毒症患者22 例、重症脓毒症患者25 例、脓毒症休克患者20例、局部感染患者21例以及健康体检者29例,测定各组患者血清HBP、PCT、CRP 及全血WBC 水平,并对部分病例进行HBP 与PCT 的跟综监测.结果（1）脓毒症组HBP、PCT、CRP水平明显高于局部感染和健康对照组,差异均有统计学意义（均P〈0.05）;脓毒症、重症脓毒症、脓毒性休克组中PCT 水平分别为2.3（0.6～5.1）、6.2（2.8～16.1）、15.3（4.4～49.0）ng/ml,各组间差异有统计学意义（P〈0.05）;脓毒症组HBP 为283.1（168.9～397.6）ng/ml,高于脓毒性休克组的111.6（62.6～250.5）ng/ml（P〈0.05）.CRP 在脓毒症分级中无统计学意义（P〉0.05）.（2）跟综监测显示,在脓毒症的进展过程中,PCT 水平进行性升高,而HBP 水平却下降.（3）HBP 与PCT 联合诊断脓毒症的效能高于单一指标的应用.结论在HBP、PCT 是脓毒症诊断的有效标志物,HBP 和PCT 联合检测有助于脓毒症的诊断,PCT进行性升高而HBP 下降提示疾病预后不良.

Maresin 1 alleviates neuroinflammation and cognitive decline in a mouse model of cecal ligation and puncture

Objective:Inflammation in the central nervous system plays a crucial role in the occurrence and development of sepsis-associated encephalopathy.This study aims to explore the effects of maresin 1(MaR1),an anti-inflammatory and pro-resolving lipid mediator,on sepsis-induced neuroinflammation and cognitive impairment.Methods:Mice were randomly assigned to 4 groups:A sham group(sham operation+vehicle),a cecal ligation and puncture(CLP)group(CLP operation+vehicle),a MaR1-LD group(CLP operation+1 ng MaR1),and a MaR1-HD group(CLP operation+10 ng MaR1).MaR1 or vehicle was intraperitoneally administered starting 1 h before CLP operation,then every other day for 7 days.Survival rates were monitored,and serum inflammatory cytokines[tumor necrosis factor alpha(TNF-α),interleukin(IL)-1β,and IL-6]were measured 24 h after operation using enzyme-linked immunosorbent assay(ELISA).Cognitive function was assessed 7 days after operation using the Morris water maze(MWM)test and novel object recognition(NOR)task.The mRNA expression of TNF-α,IL-1β,IL-6,inducible nitric oxide synthase(iNOS),IL-4,IL-10,and arginase 1(Arg1)in cortical and hippocampal tissues was determined by real-time reverse transcription PCR(RT-PCR).Western blotting was used to determine the protein expression of iNOS,Arg1,signal transducer and activator of transcription 6(STAT6),peroxisome proliferator-activated receptor gamma(PPARγ),and phosphorylated STAT6(p-STAT6)in hippocampal tissue.Microglia activation was visualized via immunofluorescence.Mice were also treated with the PPARγantagonist GW9662 to confirm the involvement of this pathway in MaR1’s effects.Results:CLP increased serum levels of TNF-α,IL-1β,and IL-6,and reduced body weight and survival rates(all P<0.05).Both 1 ng and 10 ng doses of MaR1 significantly reduced serum TNF-α,IL-1β,and IL-6 levels,improved body weight,and increased survival rates(all P<0.05).No significant difference in efficacy was observed between the 2 doses(all P>0.05).MWM test and NOR task indicated that CLP impaired spatial learning,which MaR1 mitigated.However,GW9662 partially reversed MaR1’s protective effects.Real-time RTPCR results demonstrated that,compared to the sham group,mRNA expression of TNF-α,IL-1β,and iNOS significantly increased in hippocampal tissues following CLP(all P<0.05),while IL-4,IL-10,and Arg1 showed a slight decrease,though the differences were not statistically significant(all P>0.05).Compared to the CLP group,both 1 ng and 10 ng MaR1 decreased TNF-α,IL-1β,and iNOS mRNA expression in hippocampal tissues and increased IL-4,IL-10,and Arg1 mRNA expression(all P<0.05).Immunofluorescence results indicated a significant increase in Iba1-positive microglia in the hippocampus after CLP compared to the sham group(P<0.05).Administration of 1 ng and 10 ng MaR1 reduced the percentage area of Iba1-positive cells in the hippocampus compared to the CLP group(both P<0.05).Western blotting results showed that,compared to the CLP group,both 1 ng and 10 ng MaR1 down-regulated the iNOS expression,while up-regulated the expression of Arg1,PPARγ,and p-STAT6(all P<0.05).However,the inclusion of GW9662 counteracted the MaR1-induced upregulation of Arg1 and PPARγcompared to the MaR1-LD group(all P<0.05).Conclusion:MaR1 inhibits the classical activation of hippocampal microglia,promotes alternative activation,reduces sepsis-induced neuroinflammation,and improves cognitive decline.

Blood glucose control in patients with severe sepsis and septic shock

The main pathophysiological feature of sepsis is the uncontrollable activation of both pro-and anti-inflammatory responses arising from the overwhelming pro-duction of mediators such as pro-and anti-inflammatory cytokines. Such an uncontrollable inflammatory response would cause many kinds of metabolic derangements. One such metabolic derangement is hyperglycemia. Accordingly, control of hyperglycemia in sepsis is considered to be a very effective therapeutic approach. However, despite the initial enthusiasm, recent studies reported that tight glycemic control with intensive insulin therapy failed to show a beneficial effect on mortality of patients with severe sepsis and septic shock. One of the main reasons for this disappointing result is the incidence of harmful hypoglycemia during intensive insulin therapy. Therefore, avoidance of hypoglycemia during intensive insulin therapy may be a key issue in effective tight glycemic control. It is generally accepted that glycemic control aimed at a blood glucose level of 80-100 mg/dL, as initially proposed by van den Berghe, seems to be too tight and that such a level of tight glycemic control puts septic patients at increased risk of hypoglycemia. Therefore, now many researchers suggest less strict glycemic control with a target blood glucose level of 140-180 mg/dL. Also specific targeting of glycemic control in diabetic patients should be considered. Since there is a significantcorrelation between success rate of glycemic control and the degree of hypercytokinemia in septic patients, some countermeasures to hypercytokinemia may be an important aspect of successful glycemic control. Thus, in future, use of an artificial pancreas to avoid hypoglycemia during insulin therapy, special consideration of septic diabetic patients, and control of hypercytokinemia should be considered for more effective glycemic control in patients with severe sepsis and septic shock.

Aquaporins:Their role in cholestatic liver disease

This review focuses on current knowledge on hepato-cyte aquaporins(AQPs)and their significance in bile formation and cholestasis.Canalicular bile secretion results from a combined interaction of several solute transporters and AQP water channels that facilitate water flow in response to the osmotic gradients created. During choleresis,hepatocytes rapidly increase their canalicular membrane water permeability by modulating the abundance of AQP8.The question was raised as to whether the opposite process,i.e.a decreased canalicular AQP8 expression would contribute to the development of cholestasis.Studies in several experimental models of cholestasis,such as extrahepatic obstructive cholestasis,estrogen-induced cholestasis, and sepsis-induced cholestasis demonstrated that the protein expression of hepatocyte AQP8 was impaired. In addition,biophysical studies in canalicular plasma membranes revealed decreased water permeability associated with AQP8 protein downregulation.The combined alteration in hepatocyte solute transporters and AQP8 would hamper the efficient coupling of osmotic gradients and canalicular water flow.Thus cholestasis may result from a mutual occurrence of impaired solute transport and decreased water permeability.

Exogenous carbon monoxide attenuates inflammatory responses in the small intestine of septic mice

AIM： To determine whether the carbon monoxide （CO）-releasing molecules （CORM）-Iiberated CO sup- press inflammatory responses in the small intestine of septic mice. METHODS： The C57BL/6 mice （male, n = 36; weight 20±2 g） were assigned to four groups in three re- spective experiments. Sepsis in mice was induced by cecal ligation and puncture （CLP） （24 h）. Tricarbonyl- dichlororuthenium （Ⅱ） dimer （CORM-2） （8 mg/kg, i. v.） was administrated immediately after induction of CLP. The levels of inflammatory cytokines [interleukin-1β （IL-1β） and tumor necrosis factor-α （TNF-α）] in tis- sue homogenates were measured with enzyme-linked immunosorbent assay. The levels of malondialdehyde （MDA） in the tissues were determined. The levels of nitric oxide （NO） in tissue homogenate were measured and the expression levels of intercellular adhesion mol- ecule 1 （ICAM-1） and inducible nitric oxide synthase （iNOS） in the small intestine were also assessed. NO and IL-8 levels in the supernatants were determined after the human adenocarcinoma cell line Caco-2 was stimulated by lipopolysaccharide （LPS） （10 g/mL） for 4 h in vitro. RESULTS： At 24 h after CLP, histological analysis showed that the ileum and jejunum from CLP mice in- duced severe edema and sloughing of the villous tips, as well as infiltration of inflammatory cells into the mu- cosa. Semi-quantitative analysis of histological samples of ileum and jejunum showed that granulocyte infil- tration in the septic mice was significantly increased compared to that in the sham group. Administration of CORM-2 significantly decreased granulocyte infiltration. At 24 h after CLP, the tissue MDA levels in the mid- ileum and mid-jejunum significantly increased com- pared to the sham animals （103.68 ± 23.88 nmol/ml vs 39.66 ± 8.23 nmol/mL, 89.66±9.98 nmol/mL vs 32.32 ± 7.43 nmol/mL, P 〈 0.01）. In vitro administra- tion of CORM-2, tissue MDA levels were significantly decreased （50.65±11.46 nmol/mL, 59.32 ± 6.62 nmol/mL, P 〈 0.05）. Meanwhile, the tissue IL-1β and TNF-α levels in the mid-ileum significantly increased compared to the sham animals （6.66±1.09 pg/mL vs 1.67±0.45 pg/mL, 19.34±3.99 pg/mL vs 3.98 ± 0.87 pg/mL, P 〈 0.01）. In vitro administration of CORM-2, tissue IL-1β and TNF-α levels were significantly de- creased （3.87 ± 1.08 pg/mL, 10.45±2.48 pg/mL, P 〈 0.05）. The levels of NO in mid-ileum and mid-jejunum tissue homogenate were also decreased （14.69 ± 2.45 nmol/mL vs 24.36 ± 2.97 nmol/mL, 18.47 ± 2.47 nmol/mL vs 27.33 ± 3.87 nmol/mL, P 〈 0.05）. The ex- pression of iNOS and ICAM-1 in the mid-ileum of septic mice at 24 h after CLP induction significantly increased compared to the sham animals. In vitro administration of CORM-2, expression of iNOS and ICAM-1 were sig- nificantly decreased. In parallel, the levels of NO and IL-8 in the supernatants of Caco-2 stimulated by LPS was markedly decreased in CORM-2-treated Caco-2 cells （2.22 ± 0.12 nmol/mL vs 6.25±1.69 nmol/mL, 24.97 ± 3.01 pg/mL vs 49.45± 5.11 pg/mL, P 〈 0.05）. CONCLUSION： CORM-released CO attenuates the inflammatory cytokine production （IL-1β and TNF-α）, and suppress the oxidative stress in the small intestine during sepsis by interfering with protein expression of ICAM-1 and iNOS.

Lipocalin-2 Test in Distinguishing Acute Lung Injury Cases from Septic Mice Without Acute Lung Injury

Objective To explore whether the amount of lipocalin-2 in the biofluid could reflect the onset of sepsis-induced acute lung injury(ALI) in mice. Methods Lipopolysaccharide(LPS, 10 mg/kg) injection or cecal ligation and puncture(CLP) was performed to induce severe sepsis and ALI in C57 BL/6 male mice randomly divided into 5 groups(n=10 in each group): group A(intraperitoneal LPS injection), group B(intravenous LPS injection via tail vein), group C(CLP with 25% of the cecum ligated), group D(CLP with 75% of the cecum ligated), and the control group(6 sham-operation controls plus 4 saline controls). All the mice received volume resuscitation. Measurements of pulmonary morphological and functional alterations were used to identify the presence of experimental ALI. The expressions of lipocalin-2 and interleukin(IL)-6 in serum, bronchoalveolar lavage fluid(BALF), and lung tissue were quantified at both protein and mRNA levels. The overall abilities of lipocalin-2 and IL-6 tests to diagnose sepsis-induced ALI were evaluated by generating receiver operator characteristic curves(ROC) and computing area under curve(AUC). Results In both group B and group D, most of the "main features" of experimental ALI were reproduced in mice, while group A and group C showed septic syndrome without definite evidence for the presence of ALI. Compared with septic mice without ALI(group A+group C), lipocalin-2 protein expression in septic mice with ALI(group B+group D) was significantly up-regulated in BALF(P<0.01) and in serum(P<0.01), and mRNA expression boosted in lung tissues(all P<0.05). Lipocalin-2 tests performed better than IL-6 tests in recognizing sepsis-induced ALI cases, evidenced by the larger AUC of the former(BALF tests, 0.8800 versus 0.6625; serum tests, 0.8500 versus 0.7000). Using a dual cutoff system to diagnose sepsis-induced ALI, BALF lipocalin-2 test exhibited the highest positive likelihood ratio(13.000) and the lowest negative likelihood ratio(0.077) among the tests of lipocalin-2 and IL-6 in blood and BALF. A statistically significant correlation was found between lipocalin-2 concentration in BALF and that in serum(Spearman r=0.8803,P<0.0001). Conclusions Lipocalin-2 expression is significantly up-regulated in septic ALI mice compared with those without ALI. Lipocalin-2 tests with a dual cutoff system could be an effective tool in distinguishing experimental ALI cases.

Diagnosis and treatment of peripherally inserted central catheters(PICC)-related sepsis in breast cancer patients carrying PICC catheter for chemotherapy

Objective:The aim of our research was to study the incidence,clinical diagnosis and treatment of peripherally inserted central catheters(PICC)-related sepsis in breast cancer patients carrying PICC catheter for chemotherapy.Methods:The data of the incidence,diagnosis and treatment of PICC-related sepsis in 215 cases of breast cancer patients carrying PICC catheter for chemotherapy in our hospital from August,2009 to September,2011 were analyzed retrospectively.Results:216 PICCs had been successfully applied in 215 cases of breast cancer patients and followed for a total of 19,109 catheter days,(median catheterization duration,88.9 days,range 1-212 days).Among those,3(1.39%) PICCs were removed respectively as a result of PICC-related sepsis in 29,73 and 108 catheter-days(median 70 d),with a rate of 0.16 per 1000 catheter-days.Conclusion:Chemotherapeutic treatment via PICC for breast cancer patients is one of the most secure and effective measures but there exists small number of cases in which PICC catheter related sepsis is possible.Careful observation of relevant symptoms and signs,early diagnosis and treatment,not relying completely on blood culture tests and timely removal of PICC catheter can be very effective in treating PICC-related sepsis in these patients.

Dysfunction of neuroendocrine system in sepsis and implication of hormone therapy

Sepsis and related syndromes are the major cause of multiple organ failure and death in patients with critical illnesses. Neuroendocrine dysfunction has long been thought to be an important event in sepsis. In clinic, optimal management of the hormones could alleviate severe complications in sepsis. In this article, we review the dysfunction ofneuroendocrine system as well as autonomic nervous system in sepsis, and summarize the respective therapy strategies.

Double balloon endoscopy associated pancreatitis:A description of six cases

AIM:To perform a single-center analysis of all double balloon endoscopy (DBE) related cases of pancreatitis identified prospectively from a recorded DBE-complication database. METHODS:From November 2003 until January 2007, 603 DBE procedures were performed on 412 patients, with data on complications recorded in a database. The setting was a tertiary care center offering DBE. DBE was performed from the antegrade or retrograde route. Out-come measurements included age, gender, medication, indication, DBE-endoscope type, insertion depth, proce-dure duration, findings, interventions, post-procedural abdominal pain, and post-procedural hospitalization. RESULTS:This is the largest single-center study report-ing on post-DBE pancreatitis prospectively. Six patients (1.0%) developed post-DBE pancreatitis, all after antegrade DBE. There was no association with gender, duration of the procedure or type of endoscope. The mean age was 51.9 years (range 25-78). Four patients had severe pancreatitis. Of these, two had inflammatory signs in the body-tail region, one had pancreatitis in the tail region, and the total pancreas was involved in one. CONCLUSION:The incidence of post-DBE pancreatitis in our series is higher than previously reported. We found no relation with DBE-endoscope type. The inflammatory changes occurred in the body-tail region of the pancreas, suggesting that post-DBE pancreatitis is caused by repetitive mechanical strain on the pancreas.

ROLE OF TUMOR NECROSIS FACTOR IN NEONATAL SEPSIS

In order to assess the role of tumor necrosis factor (TNF) in neonatal sepsis, plasma TNF levels were determined by a method using L929 cells at the time of septic work-up in 67 neonates. Thirty-three patients, with sepsis were found to have significantly higher TNF levels (533. 33 ±468. 74 U/ml ; 1 U corresponding to 1. 67 pg recombinant TNF) as compared with 34 non-sepsis patients (100. 0±188, 97 U/ml) and 30 healthy newborns (27. 33±1 6. 1 7 U/ml, P<0. 05. respectively) . The upper limit of normal plasma TNF levels was 60 U/ml and the best cutoff value for predicting neonatal sepsis was 160 U/ml. This had remarkable sensitivity (88%), specificity (82%). positive predictive value (83%). and negative predictive value (88%). Plasma TNF levels were significantly associated with the occurrence of shock,organ failure. sclerema and outcome. Thus, anti-TNF antibodies might be used in protecting newborns from septic death.

Comparison of Mortality Predictive Models of Sepsis Patients Based on Machine Learning

Objective To compare the performance of five machine learning models and SAPSⅡ score in predicting the 30-day mortality amongst patients with sepsis.Methods The sepsis patient-related data were extracted from the MIMIC-Ⅳ database.Clinical features were generated and selected by mutual information and grid search.Logistic regression,Random forest,LightGBM,XGBoost,and other machine learning models were constructed to predict the mortality probability.Five measurements including accuracy,precision,recall,F1 score,and area under curve(AUC) were acquired for model evaluation.An external validation was implemented to avoid conclusion bias.Results LightGBM outperformed other methods,achieving the highest AUC(0.900),accuracy(0.808),and precision(0.559).All machine learning models performed better than SAPSⅡ score(AUC=0.748).LightGBM achieved 0.883 in AUC in the external data validation.Conclusions The machine learning models are more effective in predicting the 30-day mortality of patients with sepsis than the traditional SAPS Ⅱ score.

Use of chorioamniotic membrane instead of bogota bag in open abdomen: How I Do It?

It is one of the most important problems for general surgeons to decide which operation should be undertaken on patients with intra-abdominal infection, especially those with concomitant abdominal hypertension. Recentlly, closure techniques using prosthetic meshes in order to retain abdominal tension and to control sepsis have become very popular for patients with abdominal sepsis and hypertension. We used chorioamniotic membrane instead of plastic material to cover the open abdomen. We conclude that human chorioamniotic membrane prepared under sterile conditions may be an alternative to conventional plastic bags in daily practice, for preventing serosal erosion and fistulas in patients undergoing open abdominal surgery.

Effect of Xuebijing injection on hematopoietic homeostasis of LPS induced sepsis in mice

Objective:To explore the effect and mechanism of Xuebijing injection (XBJ) on the hematopoietic homeostasis of bone marrow (BM) in septic mice. Methods:BM cells stimulated with XBJ were analyzed by inverted optical microscope and qPCR, to evaluate the effect of XBJ on differentiation function of BM cells in vitro. Lipopolysaccharide (LPS) 055:B5 at the dose of 20mg/kg was used to establish the sepsis model. To determine the hematopoietic stem cells homeostasis affected by LPS in mice, BM cells were isolated and analyzed by flow cytometry based on the immunophenotypic surface markers. 20ml/kg of XBJ was administered by tail vein once/day after peritoneal injection of LPS. All animals were sacrificed on the fifth day. The frequency of hematopoietic stem cells (HSC) and immune cells in mice were quantified by flow cytometry. The gene expression of transcription factors were detected by qPCR. Results:XBJ promoted myeloid differentiation of BM cells in vitro, which may be related to the mRNA expression of the transcription factors. The results in vivo showed the percentage of BM Lin-SCA-1+c-KIT+(LSK) cells, and Long-term HSCs (LT-HSC) were significantly increased in LPS group. But the percentage of multipotential progenitors (MPPs), granulocyte-monocyte progenitor (GMP) and megakaryocytic-erythroid precursor (MEP) were significantly decreased in LPS group. Whereas, XBJ improved the immune function in sepsis mice by suppression the LSK expansion in vivo. The result of qPCR showed that LSD1 and PU.1 mRNA expression in XBJ group were significantly higher than LPS group and control group respectively. Conclusion:Xuebijing injection can improve immune function in sepsis mice by regulating hematopoietic homeostasis. Its mechanism may be related to the up-regulation of LSD1 and PU.1 gene expressions.

Effect of electroacupuncture on hepatic blood flow and lipid peroxidation in rats with sepsis

Objective To investigate protective effects of electroacupuncture on injury of lipid peroxidation-induced by liver ischemia in rats with sepsis.Methods Forty-eight male SD rats were subjected to sepsis by cecal ligation and puncture （CLP）,and were randomly divided into a sham operation group （group A）,a CLP model group （group B）,a CLP model plus electroacupuncture （EA） at Zúsānlǐ （足三里 ST 36） group （group C）,a CLP model plus electroacupuncture at a sham acupoint group （group D）,a CLP model with vagotomy group （group E） and a CLP model plus electroacupuncture group after vagotomy （group F）,with 8 rats in each group.CLP was performed after abdominal vagotomy in group E and group F.EA （2 mA,2/100 Hz） was applied at bilateral ＂Zúsānlǐ＂ （足三里 ST 36） in group C and group F,and at sham acupoints in group D,respectively,for 1 hour.The hepatic blood flow （HBF） was detected by a laser-doppler flowmetry at 6 hours after CLP.The activity of plasma alanine transarninase （ALT） was determined;contents of hepatic malondialdehyde （MDA）,activity of xanthine oxidase （XOD） and the rate of water content in the hepati tissue were assessed,respectively.Results Hepatic blood flow was （56.97±11.95） U in group C,which was significantly lower than （80.12± 19.57） U shown in group A,but higher than （42.61±10.97） U in group B,（44.53±9.23） U in group D,（30.05 ±4.46） U in group E and （30.46±6.38） U in group F （all P0.05） at 6 hours after CLP.Meanwhile,the levels of MDA,XOD,ALT and hepatic water content in group C were all significantly higher than those in group A,but lower than those in the other four groups （all P0.05）.The levels of MDA,XOD,ALT and hepatic water content in group E and group F were all significantly higher than those in group D （all P0.05）,while their hepatic blood flow were lower than that in group D （both P0.05）,and no significant differences were found in all the indices mentioned above between group E and group F （all P0.05）.Conclusion Electroacupuncture at ＂Zúsānlǐ＂ （足三里 ST 36） can improve hepatic ischemia,inhibit lipid peroxidation and alleviate hepatic edema and dysfunction in septic rats,which might be related with the completeness of vagus nerves.

Protective effect of periplaneta americana extract on intestinal mucosal barrier function in patients with sepsis

OBJECTIVE： To investigate the effect of the periplaneta americana extract on the intestinal mucosal barrier and prognostic implications in patients with sepsis. METHODS： Sixty and six patients with sepsis were assigned randomly to treatment group （32 cases） and control group （32 cases）. The extractfrom periplaneta americana plus conventional medication for sepsis was administered to the treatment group, while the control group only received conventional treatment. The gastrointestinal function scores and acute physiology and chronic health evaluation II （APACHE 11 ） scores of all subjects were documented at baseline, at days 1, 3 and 7 after treatment respectively and their blood endotoxin was tested at the same time points as well. The incidence of death was recorded for both groups throughout the trial. RESULTS： At days 3 and 7 after treatment, gastrointestinal function score, APACHE II, and endotoxin level in treatment group wasbetter than that in con- trol group and the difference between them was significant （both P〈0~05）. Although the incidence of death in treatment group was less than that in control group, the difference between the two groups was not significant （P〉 0.05）. CONCLUSION： The extract of periplaneta ameri- cana had protective effect on intestinal mucosal barrier and could improve the condition and prog- nosis in patients with sepsis.

Immunotherapy improves immune homeostasis and increases survival rate of septic patients

Objective： To investigate the efficacy of immunotherapy on septic patients with Ulinastatin plus Thymosina α1; Methods： Seventy postoperative septic patients were divided into two groups at random： the immunotherapy group （n=36） and the conventional therapy group （n=34）. Patients in the immunotherapy group received intravenous Ulinastatin of 200 000 U, 3 times per day for 3 days, Ulinastatin of 100 000 U, 3 times per day for 4 days, and subcutaneous injection of Thymosin- α1 of 1.6 mg, twice per day for 3 days, then once per day for 4 days. While conventional therapies such as antibiotics and fluid resuscitation were undertaken in both groups. The expression levels of serum tumor necrosis factor- α（TNF- α）, intedeukin-10 （IL-10）, IgG, C3, T lymphocyte subsets, CD14^＋ monocyte human leukocyte antigen （locus） DR （HLA-DR） and patients＇ 28-day survival rate of the two groups were observed and evaluated. Results： The survival rate was significantly higher in the immunotherapy group （63.9%; 23/36） compared with the conventional therapy group （41.2%; 14/34）. The serum TNF- α levels [（1.38±0.50） ng/ml in the immunotherapy group vs （1.88±0.53） ng/ml in the conventional group, P〈0.05] and the serum IL-10 levels [（217.52±15.71） ng/ml vs （101.53±16.57） ng/ml, P〈0.05] were significantly different between the two groups. The serum IgG levels in the immunotherapy group [（17.65±6.81 ） g/L] were significantly higher than in the conventional group [（11.94±5.32） g/L]. There were also significant differences in the expression levels of CD4^＋ T lymphocyte （35%±13% in the immunotherapy group vs 21%±7% in the conventional group, P〈0.05） and CD14^＋ monocyte HLA-DR （50%±5% in the former vs 35%±4% in the latter, P〈0.05）. Conclusions： Immunotherapy with Ulinastatin plus Thymosin- α 1 can enhance the inflammatory response, improve the immune homeostasis, and increase the survival rate of septic patients.

Multi-biomarker strategy for prediction of myocardial dysfunction and mortality in sepsis

Objective:The present study was to evaluate the feasibility of using the multi-biomarker strategy for the prediction of sepsis-induced myocardial dysfunction(SIMD)and mortality in septic patients.Methods:Brain natriuretic peptide(BNP),cardiac troponin I(cTnI),and heart-type fatty acid-binding protein(h-FABP)in 147 septic patients were assayed within 6 h after admission.We also determined the plasma levels of myeloperoxidase(MPO)and pregnancyassociated plasma protein-A(PAPP-A).The receiver operating characteristic(ROC)curve was used to assess the best cutoff values of various single-biomarkers for the diagnosis of SIMD and the prediction of mortality.Also,the ROC curve,net reclassification improvement(NRI),and integrated discrimination improvement(IDI)indices were used to evaluate the feasibility of using multi-biomarkers to predict SIMD and mortality.Results:Our statistics revealed that only h-FABP independently predicted SIMD(P<0.05).The addition of MPO and cTnI to h-FABP for SIMD prediction provided an NRI of 18.7%(P=0.025)and IDI of 3.3%(P=0.033).However,the addition of MPO or cTnI to h-FABP did not significantly improve the predictive ability of h-FABP to SIMD,as evidenced by the area under the curve(AUC),NRI,and IDI(all P>0.05).A history of shock and MPO were independent predictors of mortality in septic patients(both P<0.05).The addition of PAPP-A and h-FABP to MPO resulted in a mortality prediction with NRI of 25.5%(P=0.013)and IDI of 2.9%(P=0.045).However,this study revealed that the addition of h-FABP or PAPP-A to MPO did not significantly improve the ability to predict mortality,as evidenced by the AUC,NRI,and IDI(all P>0.05).Conclusions:The findings of this study indicate that a sensitive and specific strategy for early diagnosis of SIMD and mortality prediction in sepsis should incorporate three biomarkers.

Tie2 mRNA in peripheral blood： a new marker to assess damage of endothelial cells in a rat model of sepsis

Objective： To evaluate the endothelial cell damage by detecting the circulating Tie2 mRNA level in a rat model of sepsis. Methods： The model of sepsis was established by cecal ligation and puncture （CLP） in 90 rats which were divided into 6 groups： normal, sham, CLP-3 h, CLP-6 h, CLP- 12 h and CLP-24 h. Serum biochemical markers were detected by automatic biochemical analyzer. Serum IL-6 was measured with enzyme linked immunosorbent assay. The vascular permeability of liver, kidney, lung and heart was detected with Evans blue. Circulating endothelial cells （CEC） were separated using density gradient separation and counted. Total RNA of whole blood were extracted and the mRNA levels of two endothelial specific genes, Tie2 and vascular endothelial growth factor receptor 2 （VEGFR2）, were measured by quantitative real-time PCR. Results： The level of serum biochemical indexes increased after CLP. The amount of serum IL-6 in CLP-6 h, 12 h,and 24 h group was increased 6.5-fold （P〈 0.05）, 8.4-fold （P〈 0.01 ）, and 13.3-fold （P〈0.001 ） compared with normal group （ 170.68 pg/mli42.46 pg/ml） respectively （F= 14.319, P〈0.001）. Significantly increased organ vasopermeability of liver, kidney, lung and heart was observed after CLP respectively. The number of CEC peaked （11.83±1.94） 3 hours after CLP compared with normal control （5.33±1.21, P〈0.05）, and then decreased gradually （F=54.183, P〈0.001）. The mRNA level of Tie2 in CLP-3 h group （3.47±1.47） was also markedly higher than that in other groups （F=10.640, P〈0.001 ）. Conclusion： Using quantitative real-time PCR to measure the level of Tie2 mRNA in peripheral blood is a simple and relatively sensitive method to evaluate the damage of endothelial cells.

Gene expression of adhesion molecules in pulmonary and hepatic microvascular endothelial cells during sepsis

Objective: To study the gene expression of adhesion molecules in pulmonary and hepatic microvascular endothelial cells during sepsis in mice. Methods: Male mice were subjected to cecal ligation and puncture (CLP) and microvascular endothelial cells in pulmonary and hepatic tissues were harvested at 3 hours (early sepsis) and 12 hours (late sepsis) after CLP, respectively. Gene expression of the adhesion molecules was assessed by reverse transcription polymerase chain reaction (RT PCR). Simultaneously, the alterations of myeloperoxidase (MPO) activity in pulmonary and hepatic tissues were also examined. Results: E selectin mRNA levels markedly increased at 3 hours after CLP in both pulmonary and hepatic microvascular endothelial cells, then they returned to the normal level at 12 hours after CLP. Increases in intercellular adhesion molecule 1 (ICAM 1) mRNA levels were found at 3 hours after CLP in both pulmonary and hepatic microvascular endothelial cells, and these levels became higher at 12 hours after CLP. Adhesion molecule 1 (VCAM 1) mRNA expression of vascular cells also increased significantly at 3 hours and 12 hours after CLP in both pulmonary and hepatic microvascular endothelial cells. The level of VCAM 1 mRNA in hepatic microvascular endothelial cells was higher at 3 hours than that at 12 hours after CLP, while the level of VCAM 1 mRNA in pulmonary microvascular endothelial cells was higher at 12 hours than that at 3 hours after CLP. The MPO activity in pulmonary and hepatic tissues increased at 3 hours after CLP, compared with that of the sham group. They both declined significantly at 12 hours after CLP, but they were still higher than that of the sham group. Conclusions: The up regulation of the gene expression of adhesion molecules in pulmonary and hepatic microvascular endothelial cells is an important step for the migration and accumulation of leukocytes at the site of inflammation, which plays a critical role in organ damage during sepsis. And the contribution of the heterogeneity of endothelial cells in organs vulnerability during sepsis is worth a further investigation.

Effect of bactericidal/permeability increasing protein on sepsis induced by intra abdominal infection in rats

Objective: To investigate the effect and mechanism of bactericidal/permeability increasing protein (BPI) on sepsis induced by intra abdominal infection in rats. Methods: Cecal ligation and puncture (CLP) was made on 20 rats with sepsis induced by intra abdominal infection. BPI or equal volume of physiological saline (PS) was intra abdominally given immediately and 12 h after CLP, respectively (2.5 mg/kg of BPI each time). Plasma endotoxin levels were determined with limulus amebocyte chromogenic assay. Results: (1) The survival time in BPI group was significantly higher than that in PS group. (2) The values of the mean arterial pressure (MAP), the left ventricular systolic pressure (LVSP), the isovolumic ventricular pressure (IP), and the maximal change of left intraventricular pressure (±dp/dtmax) in BPI group, although decreasing, were markedly higher than those in PS group. (3) Plasma glutamic pyruvic transaminase (GPT) and urea nitrogen levels in BPI group, though increasing, were obviously lower than those in PS group. (4) There was no significant change of plasma endotoxin levels in BPI group, while plasma endotoxin levels markedly increased in PS group. Conclusions: BPI has obvious protective effect on sepsis induced by intra abdominal infection, which might be related to its neutralization of endotoxin.