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Stephen F. Lowry, MD
New Brunswick, NJ

Arch Surg. 2002;137:1043.

Modern surgical therapy can restore function to most patients, including many with disabling maladies. Yet, what is there about the presence of infection in these patients that occasionally leads to multiple organ failure and poor outcome?

Once patients become severely infected, their demographics for adverse outcome (age, sex, comorbidities, etc) are reasonably well captured by severity scoring systems. The report by Cabioglu et al supports this concept. Their article also reiterates the theme that outcome prediction can be enhanced (almost in real time) by the analysis of immune cell phenotype. Although their results are at some variance with those of previous reports in this journal,^1-2 Cabioglu and colleagues surmise that adverse clinical outcome correlates with an attenuation of immune cell proinflammatory mediator influence (T_H1) compared with the T_H2 phenotype. Unfortunately, the authors neither address the methodological and data variances from previous reports nor provide much in the way of mechanistic discussion as to how this immunological "anergy" (their term) develops or resolves.

They observed that this anergic state was noted at the very outset of severe infection, and no ex-vivo stimulation was required to detect the phenotype. Here again, the relationship to antecedent stresses and morbidities begs consideration, especially since this basal phenotype is seldom observed in the noninfectious, stressed state. Is acute stress a necessary prelude to the adverse phenotype of infection? What confounding genetic or metabolic influences promote this early determination of immune cell function? Finally, and perhaps most important, can those influences be manipulated to circumvent the therapeutic nihilism implied by the current observations? Only time will tell whether the observations of Cabioglu and colleagues will provide useful mechanistic insights or new diagnostic opportunities.

REFERENCES
1. Berguer R, Bravo N, Bowyer M, Egan C, Knolmayer T, Ferrick D. Major surgery suppresses maximal production of helper T-cell type 1 cytokines without potentiating the release of helper T-cell type 2 cytokines. Arch Surg. 1999;134:540-544. FREE FULL TEXT 2. Wick M, Kollig E, Muhr G, Koller M. The potential pattern of circulating lymphocytes T_H1/T_H2 is not altered after multiple injuries. Arch Surg. 2000;135:1309-1314. FREE FULL TEXT

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Decreased Cytokine Expression in Peripheral Blood Leukocytes of Patients With Severe Sepsis
Neslihan Cabioglu, Sema Bilgic, Gunnur Deniz, Esin Aktas, Yalcyn Seyhun, Akif Turna, Kayhan Gunay, and Figen Esen
Arch Surg. 2002;137(9):1037-1043.
ABSTRACT | FULL TEXT