Shock

Mechanical Ventilation With Moderate Tidal Volume Exacerbates Extrapulmonary Sepsis-Induced Lung Injury via IL33-WISP1 Signaling Pathway IL-33 and WISP1 play central roles in acute lung injury (ALI) induced by mechanical ventilation with moderate tidal volume (MTV) in the setting of sepsis. Here, we sought to determine the inter-relationship between IL-33 and WISP1 and the associated signaling pathways in this process. We used a two hit model of cecal ligation puncture (CLP) followed by MTV ventilation (4 h 10 ml/kg) in wildtype, IL-33-/- or ST2-/- mice or wildtype mice treated with intratracheal antibodies to WISP1. Macrophages (Raw 264.7 and alveolar macrophages from wildtype or ST2-/- mice) were used to identify specific signaling components. CLP + MTV resulted in ALI that was partially sensitive to genetic ablation of IL-33 or ST2 or antibody neutralization of WISP1. Genetic ablation of IL-33 or ST2 significantly prevented ALI after CLP + MTV and reduced levels of WISP1 in the circulation and BALF. rIL-33 increased WISP1 in alveolar macrophages in an ST2, PI3K/AKT and ERK dependent manner. This WISP1 upregulation and WNT β-catenin activation were sensitive to inhibition of the β-catenin/TCF/CBP/P300 nuclear pathway. We show that IL-33 drives WISP1 upregulation and ALI during MTV in CLP sepsis. The identification of this relationship and the associated signaling pathways reveals a number of possible therapeutic targets to prevent ALI in ventilated sepsis patients. Address reprint requests to Li-Ming Zhang, MD, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, 200 Lothrop Street, UPMC MUH N467, Pittsburgh 15213, PA, USA. E-mail: zhangl1@anes.upmc.edu. Received 22 September, 2020 Revised 13 October, 2020 Accepted 14 December, 2020 Competing interests: The authors declare that they have no competing interest. Funding: This work was supported by National Institute of Health grants [R01-GM-108639, (LMZ)] for the design of the study, collection for analysis and interpretation of data, and writing the manuscript; National Institute of Health grants [R01-HL-22489, (HRT)] for his salary support. Ethics approval and consent to participate: Animal protocols were approved by the Animal Care and Use Committee of the University of Pittsburgh and experiments were performed in strict adherence to the National Institutes of Health Guidelines for the Use of Laboratory Animals. Consent for publication: Not applicable Availability of data and materials: The datasets generated and/or analyzed during the current study are available in the Dr. Billiar Lab of University of Pittsburgh, and the datasets are available from the corresponding author on reasonable request. Authors' contributions: Study concepts and design: SL, MHD, HRT, TRB, BRP, BHP, LMZ; data collection: SL, MHD.; writing up of the first of the paper: SL, TRB, BRP, LMZ; data analysis and interpretation: SL, MHD, HRT, BHP, TRB, BRP, LMZ; statistical analysis: SL, LMZ; manuscript preparation: SL, LMZ; manuscript revision: SL, MHD, HRT, BHP, TRB, BRP, LMZ; manuscript final version approval: SL, MHD, HRT, BHP, TRB, BRP, LMZ. All authors read and approved the final manuscript. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.shockjournal.com). © 2020 by the Shock Society

Hypobaria Exposure Worsens Cardiac Function and Endothelial Injury in an Animal Model of Polytrauma: Implications for Aeromedical Evacuation Background: Aeromedical evacuation can expose traumatically injured patients to low pressure (hypobaria) and hypoxia. Here we sought to assess the impact of hypobaria on inflammation, organ injury, and mortality in a mouse model of polytrauma. Methods: Eight to 12 week-old male C57BL/6J mice were subjected to sham or polytrauma consisting of bowel ischemia by superior mesenteric artery (SMA) occlusion, hindlimb muscle crush, and tibia fracture. Two hours after injury, animals were randomized to undergo either 6 hours of hypobaria or sea-level, room air conditions. At 8 or 24 hours after injury, transthoracic echocardiography was performed. Acute kidney injury (AKI) biomarkers were measured by qRT-PCR. Plasma cytokine and endothelial injury markers were determined by ELISA. Results: Eight hours after traumatic injury, mice exhibited a marked increase in plasma IL-6 (57 vs. 1216 pg/ml), AKI with increased Ngal and Kim-1, and endothelial injury as evidenced by significantly increased plasma hyaluronic acid (96 vs.199 ng/ml), thrombomodulin (23.2 vs. 58.9 ng/ml), syndecan-1 (0.99 vs. 4.34 ng/ml), and E-selectin (38.6 vs. 62.7 ng/ml). The trauma mice also developed cardiac dysfunction with decreased cardiac output and stroke volume at 8 hours post-injury. Hypobaric exposure after polytrauma led to decreased ejection fraction (81.0 vs. 74.2%, p < 0.01) and increased plasma hyaluronic acid (199 vs. 260 ng/ml, p < 0.05), thrombomodulin (58.9 vs. 75.4 ng/ml, p < 0.05), and syndecan-1 (4.34 vs. 8.33 ng/ml, p < 0.001) at 8 hours post-injury. Conclusions: Hypobaria exposure appeared to worsen cardiac dysfunction and endothelial injury following polytrauma and thus may represent a physiological "second hit" following traumatic injury. Address reprint requests to Wei Chao, MD, PhD, Center for Shock, Trauma and Anesthesiology Research, University of Maryland School of Medicine, 660 W. Redwood St. Howard Hall #598A, Baltimore, MD, 21201, USA. E-mail: wchao@som.umaryland.edu Received 18 October, 2020 Revised 12 November, 2020 Accepted 17 December, 2020 Conflict of interest: All authors have declared no conflict of interest. Disclosures: This work was supported in part by the grants from the US Air Force Research (FA8650-17-2-6H12 and FA8650-18-2-6H17) and the National Institutes of Health (R01GM122908, R01GM117233, R35GM124775, R01NS110567, and T32HL007698). The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Air Force, the Department of Defense, or the U.S. Government. Author contribution: K.L. performed the majority of experiments, data analysis and interpretation, and wrote manuscript draft. A.S. contributed to study design, hypobaria chamber assembly, and polytrauma model creation. Y.Y. performed all echocardiography and data analysis. B.W. contributed to study design and direction. J.H. performed BAL collection and analysis. J.Z. assisted with animal husbandry, organ collection, and sample processing. S.W. contributed to technique supervision, data analysis, and figure preparation. G.F., A.C., R.K., and C.M. contributed to data interpretation and manuscript editing. W.C. designed the study, provided direction throughout the experiments, advised on data analysis and interpretation, and finalized the manuscript. © 2020 by the Shock Society

Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated with Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass Introduction: Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass including cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L. Methods: We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on ICU admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 hours after surgery. Lactate area under the curve (AUC) was calculated over the first 6 hours. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD < 18 mm/mm2), high heterogeneity index (MHI > 0.4), and low vessel-by-vessel microvascular flow index (MFIv < 2.6). Results: Thirteen (26%) patients had a low postoperative PVD, 20 patients (40%) had a high MHI, and 26 (52%) patients had a low MFIv. Patients with low perfused vessel density had higher lactate AUC compared to subjects with a normal PVD (22.3 [9.4–31.0] vs. 2.6 [0–8.8]; p < 0.0001). Patients with high microcirculatory heterogeneity had a higher lactate AUC compared to those with a normal MHI (2.5 [0.1–8.2] vs. 13.1 [3.7–31.1]; p < 0.001). We did not find a difference in lactate AUC when comparing high and low MFIv. Conclusion: Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass. Address reprint requests to John C. Greenwood, MD, Department of Emergency Medicine, Hospital of the University of Pennsylvania. 3400 Spruce Street, Philadelphia, PA 19104, USA. E-mail: john.greenwood@pennmedicine.upenn.edu Received 28 October, 2020 Revised 13 November, 2020 Accepted 14 December, 2020 Ethics approval and consent to participate: This study was approved by our institutional review board (IRB # 829765) and informed consent was obtained prior to enrollment. All consent forms were copied in triplicate, one given to the subject, the second placed in the official medical record, the third kept in a secured location within the PI's office. Consent for publication: John C. Greenwood, MD (Corresponding author) consent to the publication of this work if accepted by the journal. Availability of data and materials: All original data and materials are kept in a locally managed REDCap database at the University of Pennsylvania. Deidentified microcirculation data is available online, uploaded to open access Zenodo database found here: https://doi.org/10.5281/zenodo.4106205. Competing interests: None. None of the authors have received any financial support or have a conflict of interest related to Cytocam or Braedius, BV. Funding: Not applicable Authors' contributions: JCG made substantial contributions to the conception or design of the work; the acquisition, analysis, or interpretation of data; drafted the work or substantively revised the manuscript. DHJ made substantial contributions to the conception or design of the work; the analysis and interpretation of data; substantively revised the manuscript. AES made substantial contributions to the acquisition, analysis, or interpretation of data; drafted the work or substantively revised the manuscript. JTG made substantial contributions to the conception or design of the work; drafted the work or substantively revised the manuscript. JH made substantial contributions to the conception or design of the work; drafted the work or substantively revised the manuscript. JH made substantial contributions to the conception or design of the work; drafted the work or substantively revised the manuscript. JH made substantial contributions to the conception or design of the work; drafted the work or substantively revised the manuscript. MAA made substantial contributions to the conception or design of the work; drafted the work or substantively revised the manuscript. TJK made substantial contributions to the conception or design of the work; the analysis, or interpretation of data; drafted the work or substantively revised the manuscript. FSS made substantial contributions to the conception or design of the work; the analysis, or interpretation of data; drafted the work or substantively revised the manuscript. JGTA made substantial contributions to the conception or design of the work; the analysis, or interpretation of data; drafted the work or substantively revised the manuscript. JB made substantial contributions to the conception or design of the work; the analysis, or interpretation of data; drafted the work or substantively revised the manuscript. BSA made substantial contributions to the conception or design of the work; the analysis, or interpretation of data; drafted the work or substantively revised the manuscript. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.shockjournal.com). © 2020 by the Shock Society

Targeting Uric Acid Prevents Brain Injury and Anxiety in a Rat Model of Hemorrhagic Shock Secondary brain injury following hemorrhagic shock (HS) is a frequent complication in patients, even in absence of direct brain trauma, leading to behavioral changes and more specifically anxiety and depression. Despite pre-clinical studies showing inflammation and apoptosis in the brain after HS, none have addressed the impact of circulating mediators. Our group demonstrated an increased uric acid (UA) circulation in rats following HS. Since UA is implicated in endothelial dysfunction and inflammatory response, we hypothesized UA could alter the blood-brain barrier (BBB) and impact the brain. Male Wistar rats were randomly assigned to: SHAM, HS (hemorrhagic shock) and HS + U (hemorrhagic shock + 1.5 mg/kg of uricase). The uricase intervention, specifically targeting UA, was administered during fluid resuscitation. It prevented BBB dysfunction (fluorescein sodium salt permeability and expression of ICAM-1) following HS. As for neuroinflammation, all of the results obtained (MPO activity; Iba1 and GFAP expression) showed a significant increase after HS, also prevented by the uricase. The same pattern was observed after quantification of apoptosis (caspase-3 activity and TUNEL) and neurodegeneration (Fluoro-Jade). Finally, the forced swim, elevated plus maze and social interaction tests detected anxiety-like behavior after HS, which was blunted in rats treated with the uricase. In conclusion, we have identified UA as a new circulatory inflammatory mediator, responsible for brain alterations and anxious behavior after HS in a murine model. The ability to target UA holds the potential of an adjunctive therapeutic solution to reduce brain dysfunction related to hemorrhagic shock in human. Address reprint requests to Emmanuel Charbonney, MD, PhD, Centre de Recherche du Centre Hospitalier de, l'Université de Montréal (CRCHUM), Pavillon R 900, Rue Saint-Denis, Montréal Qc H2X 0A9, Canada. E-mail: emmanuel.charbonney@umontreal.ca Received 7 October, 2020 Revised 23 October, 2020 Accepted 7 December, 2020 Funding and Disclosures Part of the present work has been funded thanks to the Fondation NeuroTrauma Marie-Robert Dr. Emmanuel Charbonney had received financial support for his program of research from Sanofi Genzyme Canada The preliminary data of the present work have been presented as an abstract, at the International 2019 Brain Injury Association's 13th World Congress on Brain Injury, in Toronto AUTHOR CONTRIBUTION STATEMENT SLE, KG, GR and EC, designed the study, supervised and conducted the experiments, analyzed the data and drafted the manuscript. SLE, KG, BB, JB, CL, CB, MAG conducted the animal experiments, processed the molecular and IF experiments, with their analysis. SLE, JB and GR conducted the behavior experiment and their analysis. SLE, KG, FB, GR and EC conducted the analysis, verified the reproducibility of the results and reviewed the final version of the manuscript. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.shockjournal.com). © 2020 by the Shock Society

Circulating Syndecan-1 and Tissue Factor Pathway Inhibitor, Biomarkers of Endothelial Dysfunction, Predict Mortality in Burn Patients Objective: The aim of this study is to evaluate the association between burn injury and admission plasma levels of Syndecan-1 (SDC-1) and Tissue Factor Pathway Inhibitor (TFPI), and their ability to predict 30-day mortality. Background: SDC-1 and TFPI are expressed by vascular endothelium and shed into the plasma as biomarkers of endothelial damage. Admission plasma biomarker levels have been associated with morbidity and mortality in trauma patients, but this has not been well characterized in burn patients. Methods: This cohort study enrolled burn patients admitted to a regional burn center between 2013 and 2017. Blood samples were collected within 4 hours of admission and plasma SDC-1 and TFPI were quantified by ELISA. Demographics and injury characteristics were collected prospectively. The primary outcome was 30-day in-hospital mortality Results: Of 158 patients, 74 met inclusion criteria. Most patients were male with median age of 41.5 years and burn TBSA of 20.5%. The overall mortality rate was 20.3%. Admission SDC-1 and TFPI were significantly higher among deceased patients. Plasma SDC-1 >34 ng/mL was associated with a 32-times higher likelihood of mortality [OR: 32.65 (95% CI, 2.67–399.78); P = 0.006] and a strong predictor of mortality (AUROC 0.92). TFPI was associated with a 9-times higher likelihood of mortality [OR: 9.59 (95% CI, 1.02–89.75); P = 0.002] and a fair predictor of mortality (AUROC 0.68). Conclusions: SDC-1 and TFPI are associated with a higher risk of 30-day mortality. We propose the measurement of SDC-1 on admission to identify burn patients at high risk of mortality. However, further investigation with a larger sample size is warranted. Address reprint requests to Jeffrey W. Shupp, MD, MedStar Washington Hospital Center, The Burn Center, Department of Surgery, 110 Irving St. NW Suite 3B-55, Washington, DC 20010. E-mail: Jeffrey.w.shupp@medstar.net Received 5 October, 2020 Revised 27 October, 2020 Accepted 8 December, 2020 Disclosure of funding: This work was funded by the U.S. Department of Defense (DOD) (W911QY-15-C-0025, and W911NF-17-1-0594). This project was done in partnership with the Department of Health and Human Services; Office of the Assistant Secretary for Preparedness and Response; Biomedical Advanced Research and Development Authority and funding, in part, was provided through Interagency Agreement (750119PR2100075). SYSCOT Study Group Authorship: Melissa M. McLawhorn, RN BSN, Lauren T. Moffatt, PhD, Jeffrey W Shupp, MD, Rachael A Callcut, MD, MSPH, Mitchell J Cohen, MD, Linda R. Petzold, PhD, Jeffrey D. Varner, PhD, Maria Cristina Bravo, PhD, Kathleen E. Brummel-Ziedins, PhD, Kalev Freeman, MD, PhD, Kenneth G. Mann, PhD, Thomas Orfeo, PhD, Aarti Gautam, PhD, Rasha Hammamieh, PhD, Marti Jett, PhD, Anthony E. Pusateri, PhD Disclosure: This project was done in partnership with the Department of Health and Human Services; Office of the Assistant Secretary for Preparedness and Response; Biomedical Advanced Research and Development Authority and funding, in part, was provided through Interagency Agreement (750119PR2100075). The authors report no conflicts of interest. Research protocols were developed as part of the Systems Biology for Biological Responses to Severe Hemorrhage, conducted and supported by the Department of Defense. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2020 by the Shock Society

Toll-Like Receptors, Associated Biochemical Signaling Networks, and S100 Ligands Host cells recognize molecules that signal danger using pattern recognition receptors (PRRs). Toll-Like Receptors (TLRs) are the most studied class of PRRs and detect pathogen associated molecular patterns and danger associated molecular patterns. Cellular TLR activation and signal transduction can therefore contain, combat and clear danger by enabling appropriate gene transcription. Here we review the expression, regulation and function of different TLRs, with an emphasis on TLR-4, and how TLR adaptor protein binding directs intracellular signaling resulting in activation or termination of an innate immune response. Finally, we highlight the recent progress of research on the involvement of S100 proteins as ligands for TLR-4 in inflammatory disease. Address reprint requests to John C. Marshall, MD, St. Michael's Hospital, 4th Floor Bond Wing, Room 4-007, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. E-mail: john.marshall@unityhealth.to Received 25 October, 2020 Revised 12 November, 2020 Accepted 30 November, 2020 Conflicts of Interest: The authors have no conflicts of interest to declare. Grant Funding Source: Canadian Institutes of Health Research (MOP 129493) © 2020 by the Shock Society

Bone Marrow-Derived Mononuclear Cell Transplantation can Reduce Systemic Inflammation and Endothelial Glycocalyx Damage in Sepsis Bone marrow-derived mononuclear cells (BMMNCs) secrete anti-inflammatory mediators that protect against acute inflammation. Current evidence suggests that BMMNC transplantation can reduce acute tissue injury caused by systemic inflammation and lung dysfunction. This study evaluated the role of BMMNCs in reducing systemic inflammatory responses to vascular endothelial injury in sepsis. Bone marrow cells were harvested from the tibias and femurs of twelve-week-old male Wistar rats; BMMNCs were separated by density centrifugation. Additional rats underwent cecal ligation and puncture (CLP) or similar sham surgery. BMMNCs were injected intravenously 30 min after CLP. The Sham and CLP Control groups were administered PBS. The seven-day survival rate improved markedly in the CLP-BMMNC group compared with that in the Control group. BMMNCs markedly suppressed the serum levels of pro-inflammatory mediators such as tumor necrosis factor-alpha, interleukin-6, and histone H3 at 3, 6, and 12 h after CLP. In the CLP-BMMNC group, the serum levels of syndecan-1, the main component of the vascular endothelial glycocalyx layer, were notably lower than those in the Control group 6 h after CLP. Histological analysis revealed improvement of morphological damages in the CLP-BMMNC group. Ultrastructural analysis revealed that the glycocalyx structure was maintained and the continuity of the vascular endothelial glycocalyx layer was preserved in the BMMNC group, compared to the case for the Control group at 6 and 12 h. Therefore, BMMNC transplantation may provide reduced systemic inflammation and endothelial glycocalyx damage, dramatically improving the survival of rats. These findings provide insights into formulating potential therapeutic strategies against sepsis. Address reprint requests to Tsunehiro Matsubara, MD, Osaka University Graduate School of Medicine Department of Traumatology and Acute Critical Care Center, 2-15 Yamadaoka, Suita-city, Osaka 565-0871, Japan. E-mail: tsunehiro1231@live.jp Received 1 August, 2020 Revised 10 September, 2020 Accepted 9 December, 2020 Conflicts of Interest and Source of Funding: This study received a Grant-in-Aid for Young Scientists from The Ministry of Education, Culture, Sports, Science and Technology, Japan. The authors declare no conflicts of interest. © 2020 by the Shock Society

Neutrophil-To-Lymphocyte Ratio And Covid-19 No abstract available

Pharmacological and Genetic Inhibition of Translocator Protein 18 kDa Ameliorated Neuroinflammation in Murine Endotoxemia Model Sepsis-associated encephalopathy (SAE) is a diffuse brain dysfunction associated with sepsis. The development of an effective strategy for early diagnosis and therapeutic intervention is essential for the prevention of poor prognosis of SAE. Translocator protein 18 kDa (TSPO) is a mitochondrial protein implicated in steroidogenesis and inflammatory responses. Despite accumulating evidence that implicates TSPO in the neuroinflammatory response of the central nervous system, the possible role of TSPO in SAE remains unclear. Aim of this study is to address a role of TSPO in neuroinflammation using mice 24 h after systemic injection of lipopolysaccharide (LPS), which consistently demonstrated microglial activation and behavioral inhibition. Quantitative polymerase chain reaction analysis revealed that hippocampal TSPO expression was induced following the systemic LPS injection, associated with an increase in pro-inflammatory cytokines such as tumor necrosis factor-α and interleukin-1β. Interestingly, pretreatment with the TSPO antagonist, ONO-2952, or germ-line deletion of the TSPO gene exhibited an anti-inflammatory effect with significant suppression of LPS-induced production of those cytokines. These effects demonstrated by the ONO-2952 or TSPO knockout were associated with significant recovery from behavioral inhibition, as shown by improved locomotor activity in the open field analysis. Histological analysis revealed that ONO-2952 pretreatment suppressed the LPS-induced activation of TSPO-expressing microglia in the hippocampus of mice. Collectively, these results suggest that TSPO plays a critical role in the SAE mouse model. Based on this finding, monitoring TSPO activity, as well as the progress of endotoxemia and its sequelae in the animal model, would deepen our understanding of the underlying molecular mechanism of SAE. Address reprint requests to Hidenori Aizawa, MD, PhD, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553 Japan. E-mail: haizawa@hiroshima-u.ac.jp Received 24 September, 2020 Revised 12 October, 2020 Accepted 23 November, 2020 Disclosure: The authors declare that they have no conflicts of interest. Funding: This research was supported by a Grant-in-Aid for Scientific Research on Innovative Areas (JP19H05723) from the Ministry of Education, Culture, Sports, Science and Technology (MEXT) to HA; a Grant-in-Aid for 'Integrated Research on Depression, Dementia and Development Disorders (20dm0107093)' carried out under the Strategic Research Program for Brain Sciences by AMED to SY and a Grant-in-Aid for Scientific Research C (18K08888) to KH. © 2020 by the Shock Society

HIF-1α and Hypoxia Responsive Genes are Differentially Expressed in Leukocytes from Survivors and Non-Survivors Patients during Clinical Sepsis Hypoxia inducible factor 1 alpha (HIF-1α) is linked to the metabolic and immune alterations in septic patients. Stabilization of HIF-1α by hypoxia or inflammation promotes the expression of several genes related to glycolytic metabolism, angiogenesis, coagulation, cell proliferation and apoptosis. Here we analyzed public available blood transcriptome datasets from septic patients and evaluated by PCR array the expression of HIF-1α and other hypoxia responsive genes in peripheral blood mononuclear cells (PBMC) from patients with sepsis secondary to community acquired infections. Samples were collected at ICU admission (D0, n=29) and after 7 days follow-up (D7, n = 18); healthy volunteers (n = 10) were included as controls. Hypoxia and glycolysis were among the top scored molecular signatures in the transcriptome datasets. PCR array showed that 24 out of 78 analyzed genes were modulated in septic patients compared to healthy volunteers; most of them (23/24) were downregulated at admission. This same pattern was observed in surviving patients, while non-survivors presented more upregulated genes. EGLN1, EGLN2 and HIF1AN, inhibitors of HIF-1α activation were downregulated in patients, regardless of the outcome, while HIF-1α and other target genes, such as PDK1 and HMOX1, expression were higher in non-survivors than in survivors, mainly at D7. Non-survivor patients also presented a higher SOFA score and lower PaO2/FiO2 ratio. Our results indicate a differential modulation of hypoxia pathway in leukocytes between septic patients who survived and those who did not survive with an increased intensity at D7, which is possibly influenced by disease severity and may affect the immune response in sepsis. Address reprint requests to Reinaldo Salomao, MD, PhD, Division of Infectious Diseases, Escola Paulista de Medicina, Hospital São Paulo, Universidade Federal de São Paulo, Rua Pedro de Toledo, 669, 10th Floor, Sao Paulo, SP, 04039-032, Brazil. E-mail: rsalomao@unifesp.br Received 25 September, 2020 Revised 19 October, 2020 Accepted 6 November, 2020 Funding: This work was supported by FAPESP (Grant 2017/21052-0). RS is the recipient of a Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq) fellowship. BLF has a scholarship from FAPESP (2016/13855-2). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.shockjournal.com). © 2020 by the Shock Society

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,