451
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Tan K, Harazim M, Simpson A, Tan YC, Gunawan G, Robledo KP, Whitehead C, Tang B, Mclean A, Nalos M. Association Between Premorbid Beta-Blocker Exposure and Sepsis Outcomes-The Beta-Blockers in European and Australian/American Septic Patients (BEAST) Study. Crit Care Med 2021; 49:1493-1503. [PMID: 33938711 DOI: 10.1097/ccm.0000000000005034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the effect of premorbid β-blocker exposure on mortality and organ dysfunction in sepsis. DESIGN Retrospective observational study. SETTING ICUs in Australia, the Czech Republic, and the United States. PATIENTS Total of 4,086 critical care patients above 18 years old with sepsis between January 2014 and December 2018. INTERVENTION Premorbid beta-blocker exposure. MEASUREMENTS AND MAIN RESULTS One thousand five hundred fifty-six patients (38%) with premorbid β-blocker exposure were identified. Overall ICU mortality rate was 15.1%. In adjusted models, premorbid β-blocker exposure was associated with decreased ICU (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97; p = 0.025) and hospital (adjusted odds ratio, 0.83; 95% CI, 0.71-0.99; p = 0.033) mortality. The risk reduction in ICU mortality of 16% was significant (hazard ratio, 0.84, 95% CI, 0.71-0.99; p = 0.037). In particular, exposure to noncardioselective β-blocker before septic episode was associated with decreased mortality. Sequential Organ Failure Assessment score analysis showed that premorbid β-blocker exposure had potential benefits in reducing respiratory and neurologic dysfunction. CONCLUSIONS This study suggests that β-blocker exposure prior to sepsis, especially to noncardioselective β blockers, may be associated with better outcome. The findings suggest prospective evaluation of β-blocker use in the management of sepsis.
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Affiliation(s)
- Kaiquan Tan
- 1 Nepean Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia. 2 Medical Intensive Care Unit, University Hospital and Biomedicine Centre, Pilsen, Charles University Prague, Czech Republic. 3 Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia. 4 Department of Computer Science, Yale University, New Haven, CT. 5 Medistra Hospital, Jakarta, Indonesia. 6 NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia. 7 Centre for immunology and allergy research, Westmead Millennium Institute, Westmead, NSW, Australia
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452
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Wendel Garcia PD, Caccioppola A, Coppola S, Pozzi T, Ciabattoni A, Cenci S, Chiumello D. Latent class analysis to predict intensive care outcomes in Acute Respiratory Distress Syndrome: a proposal of two pulmonary phenotypes. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:154. [PMID: 33888134 PMCID: PMC8060783 DOI: 10.1186/s13054-021-03578-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/13/2021] [Indexed: 02/07/2023]
Abstract
Background Acute respiratory distress syndrome remains a heterogeneous syndrome for clinicians and researchers difficulting successful tailoring of interventions and trials. To this moment, phenotyping of this syndrome has been approached by means of inflammatory laboratory panels. Nevertheless, the systemic and inflammatory expression of acute respiratory distress syndrome might not reflect its respiratory mechanics and gas exchange. Methods Retrospective analysis of a prospective cohort of two hundred thirty-eight patients consecutively admitted patients under mechanical ventilation presenting with acute respiratory distress syndrome. All patients received standardized monitoring of clinical variables, respiratory mechanics and computed tomography scans at predefined PEEP levels. Employing latent class analysis, an unsupervised structural equation modelling method, on respiratory mechanics, gas-exchange and computed tomography-derived gas- and tissue-volumes at a PEEP level of 5cmH2O, distinct pulmonary phenotypes of acute respiratory distress syndrome were identified. Results Latent class analysis was applied to 54 respiratory mechanics, gas-exchange and CT-derived gas- and tissue-volume variables, and a two-class model identified as best fitting. Phenotype 1 (non-recruitable) presented lower respiratory system elastance, alveolar dead space and amount of potentially recruitable lung volume than phenotype 2 (recruitable). Phenotype 2 (recruitable) responded with an increase in ventilated lung tissue, compliance and PaO2/FiO2 ratio (p < 0.001), in addition to a decrease in alveolar dead space (p < 0.001), to a standardized recruitment manoeuvre. Patients belonging to phenotype 2 (recruitable) presented a higher intensive care mortality (hazard ratio 2.9, 95% confidence interval 1.7–2.7, p = 0.001). Conclusions The present study identifies two ARDS phenotypes based on respiratory mechanics, gas-exchange and computed tomography-derived gas- and tissue-volumes. These phenotypes are characterized by distinctly diverse responses to a standardized recruitment manoeuvre and by a diverging mortality. Given multicentre validation, the simple and rapid identification of these pulmonary phenotypes could facilitate enrichment of future prospective clinical trials addressing mechanical ventilation strategies in ARDS. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03578-6.
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Affiliation(s)
- Pedro D Wendel Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Alessio Caccioppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy
| | - Tommaso Pozzi
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Arianna Ciabattoni
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Stefano Cenci
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, San Paolo University Hospital, Via Di Rudinì, Milan, Italy. .,Department of Health Sciences, University of Milan, Milan, Italy. .,Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
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453
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Meini S, Sozio E, Bertolino G, Sbrana F, Ripoli A, Pallotto C, Viaggi B, Andreini R, Attanasio V, Rescigno C, Atripaldi L, Leonardi S, Bernardo M, Tascini C. D-Dimer as Biomarker for Early Prediction of Clinical Outcomes in Patients With Severe Invasive Infections Due to Streptococcus Pneumoniae and Neisseria Meningitidis. Front Med (Lausanne) 2021; 8:627830. [PMID: 33937280 PMCID: PMC8081958 DOI: 10.3389/fmed.2021.627830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/23/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; no current clinical measure adequately reflects the concept of dysregulated response. Coagulation plays a pivotal role in the normal response to pathogens (immunothrombosis), thus the evolution toward sepsis-induced coagulopathy could be individuate through coagulation/fibrinolysis-related biomarkers. We focused on the role of D-dimer assessed within 24 h after admission in predicting clinical outcomes in a cohort of 270 patients hospitalized in a 79 months period for meningitis and/or bloodstream infections due to Streptococcus pneumoniae (n = 162) or Neisseria meningitidis (n = 108). Comparisons were performed with unpaired t-test, Mann-Whitney-test or chi-squared-test with continuity correction, as appropriate, and multivariable logistic regression analysis was performed with Bayesian model averaging. In-hospital mortality was 14.8% for the overall population, significantly higher in S. pneumoniae than in N. meningitidis patients: 19.1 vs. 8.3%, respectively (p = 0.014). At univariable logistic regression analysis the following variables were significantly associated with in-hospital mortality: pneumococcal etiology, female sex, age, ICU admission, SOFA score, septic shock, MODS, and D-dimer levels. At multivariable analysis D-dimer showed an effect only in N. meningitidis subgroup: as 500 ng/mL of D-dimer increased, the probability of unfavorable outcome increased on average by 4%. Median D-dimer was significantly higher in N. meningitidis than in S. pneumoniae patients (1,314 vs. 1,055 ng/mL, p = 0.009). For N. meningitidis in-hospital mortality was 0% for D-dimer <500 ng/mL, very low (3.5%) for D-dimer <7,000 ng/mL, and increased to 26.1% for D-dimer >7,000 ng/mL. Kaplan-Meier analysis of in-hospital mortality showed for N. meningitidis infections a statistically significant difference for D-dimer >7,000 ng/mL compared to values <500 ng/mL (p = 0.021) and 500-3,000 ng/mL (p = 0.002). For S. pneumoniae the mortality risk resulted always high, over 10%, irrespective by D-dimer values. In conclusion, D-dimer is rapid to be obtained, at low cost and available everywhere, and can help stratify the risk of in-hospital mortality and complications in patients with invasive infections due to N. meningitidis: D-dimer <500 ng/mL excludes any further complications, and a cut-off of 7,000 ng/mL seems able to predict a significantly increased mortality risk from much <10% to over 25%.
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Affiliation(s)
- Simone Meini
- Internal Medicine Unit, Felice Lotti Hospital of Pontedera, Azienda Unità Sanitaria Locale Toscana Nord-Ovest, Pisa, Italy
| | - Emanuela Sozio
- Infectious Disease Unit, Department of Medicine, University of Udine, Udine, Italy
| | | | | | | | - Carlo Pallotto
- Infectious Diseases Unit 1, Santa Maria Annunziata Hospital, Azienda Unità Sanitaria Locale Toscana Centro, Florence, Italy.,Section of Infectious Diseases, Department of Medicine, University of Perugia, Perugia, Italy
| | - Bruno Viaggi
- Neuro Intensive Care Unit, Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Roberto Andreini
- Internal Medicine Unit, Felice Lotti Hospital of Pontedera, Azienda Unità Sanitaria Locale Toscana Nord-Ovest, Pisa, Italy
| | - Vittorio Attanasio
- First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Carolina Rescigno
- First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Luigi Atripaldi
- Central Laboratory, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Silvia Leonardi
- Central Laboratory, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Mariano Bernardo
- Central Laboratory, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Carlo Tascini
- Infectious Disease Unit, Department of Medicine, University of Udine, Udine, Italy.,First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
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454
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Schenck EJ, Hoffman KL, Cusick M, Kabariti J, Sholle ET, Campion TR. Critical carE Database for Advanced Research (CEDAR): An automated method to support intensive care units with electronic health record data. J Biomed Inform 2021; 118:103789. [PMID: 33862230 DOI: 10.1016/j.jbi.2021.103789] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/12/2021] [Accepted: 04/10/2021] [Indexed: 12/28/2022]
Abstract
Patients treated in an intensive care unit (ICU) are critically ill and require life-sustaining organ failure support. Existing critical care data resources are limited to a select number of institutions, contain only ICU data, and do not enable the study of local changes in care patterns. To address these limitations, we developed the Critical carE Database for Advanced Research (CEDAR), a method for automating extraction and transformation of data from an electronic health record (EHR) system. Compared to an existing gold standard of manually collected data at our institution, CEDAR was statistically similar in most measures, including patient demographics and sepsis-related organ failure assessment (SOFA) scores. Additionally, CEDAR automated data extraction obviated the need for manual collection of 550 variables. Critically, during the spring 2020 COVID-19 surge in New York City, a modified version of CEDAR supported pandemic response efforts, including clinical operations and research. Other academic medical centers may find value in using the CEDAR method to automate data extraction from EHR systems to support ICU activities.
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Affiliation(s)
- Edward J Schenck
- Weill Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Katherine L Hoffman
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States
| | - Marika Cusick
- Information Technologies & Services Department, Weill Cornell Medicine, New York, NY, United States
| | - Joseph Kabariti
- Information Technologies & Services Department, Weill Cornell Medicine, New York, NY, United States
| | - Evan T Sholle
- Information Technologies & Services Department, Weill Cornell Medicine, New York, NY, United States
| | - Thomas R Campion
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States; Information Technologies & Services Department, Weill Cornell Medicine, New York, NY, United States; Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States; Clinical & Translational Science Center, Weill Cornell Medicine, New York, NY, United States
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455
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Barker G, Leeuwenburgh C, Brusko T, Moldawer L, Reddy ST, Guirgis FW. Lipid and Lipoprotein Dysregulation in Sepsis: Clinical and Mechanistic Insights into Chronic Critical Illness. J Clin Med 2021; 10:1693. [PMID: 33920038 PMCID: PMC8071007 DOI: 10.3390/jcm10081693] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
In addition to their well-characterized roles in metabolism, lipids and lipoproteins have pleiotropic effects on the innate immune system. These undergo clinically relevant alterations during sepsis and acute inflammatory responses. High-density lipoprotein (HDL) plays an important role in regulating the immune response by clearing bacterial toxins, supporting corticosteroid release, decreasing platelet aggregation, inhibiting endothelial cell apoptosis, reducing the monocyte inflammatory response, and inhibiting expression of endothelial cell adhesion molecules. It undergoes quantitative as well as qualitative changes which can be measured using the HDL inflammatory index (HII). Pro-inflammatory, or dysfunctional HDL (dysHDL) lacks the ability to perform these functions, and we have also found it to independently predict adverse outcomes and organ failure in sepsis. Another important class of lipids known as specialized pro-resolving mediators (SPMs) positively affect the escalation and resolution of inflammation in a temporal fashion. These undergo phenotypic changes in sepsis and differ significantly between survivors and non-survivors. Certain subsets of sepsis survivors go on to have perilous post-hospitalization courses where this inflammation continues in a low grade fashion. This is associated with immunosuppression in a syndrome of persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The continuous release of tissue damage-related patterns and viral reactivation secondary to immunosuppression feed this chronic cycle of inflammation. Animal data indicate that dysregulation of endogenous lipids and SPMs play important roles in this process. Lipids and their associated pathways have been the target of many clinical trials in recent years which have not shown mortality benefit. These results are limited by patient heterogeneity and poor animal models. Considerations of sepsis phenotypes and novel biomarkers in future trials are important factors to be considered in future research. Further characterization of lipid dysregulation and chronic inflammation during sepsis will aid mortality risk stratification, detection of sepsis, and inform individualized pharmacologic therapies.
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Affiliation(s)
- Grant Barker
- Department of Emergency Medicine, College of Medicine-Jacksonville, University of Florida, 655 West 8th Street, Jacksonville, FL 32209, USA;
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, College of Medicine, University of Florida, Gainesville, FL 32603, USA;
| | - Todd Brusko
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL 32610, USA;
| | - Lyle Moldawer
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL 32608, USA;
| | - Srinivasa T. Reddy
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Faheem W. Guirgis
- Department of Emergency Medicine, College of Medicine-Jacksonville, University of Florida, 655 West 8th Street, Jacksonville, FL 32209, USA;
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456
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Lee EE, Song KH, Hwang W, Ham SY, Jeong H, Kim JH, Oh HS, Kang YM, Lee EB, Kim NJ, Chin BS, Park JK. Pattern of inflammatory immune response determines the clinical course and outcome of COVID-19: unbiased clustering analysis. Sci Rep 2021; 11:8080. [PMID: 33850271 PMCID: PMC8044143 DOI: 10.1038/s41598-021-87668-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/30/2021] [Indexed: 12/15/2022] Open
Abstract
The objective of the study was to identify distinct patterns in inflammatory immune responses of COVID-19 patients and to investigate their association with clinical course and outcome. Data from hospitalized COVID-19 patients were retrieved from electronic medical record. Supervised k-means clustering of serial C-reactive protein levels (CRP), absolute neutrophil counts (ANC), and absolute lymphocyte counts (ALC) was used to assign immune responses to one of three groups. Then, relationships between patterns of inflammatory responses and clinical course and outcome of COVID-19 were assessed in a discovery and validation cohort. Unbiased clustering analysis grouped 105 patients of a discovery cohort into three distinct clusters. Cluster 1 (hyper-inflammatory immune response) was characterized by high CRP levels, high ANC, and low ALC, whereas Cluster 3 (hypo-inflammatory immune response) was associated with low CRP levels and normal ANC and ALC. Cluster 2 showed an intermediate pattern. All patients in Cluster 1 required oxygen support whilst 61% patients in Cluster 2 and no patient in Cluster 3 required supplementary oxygen. Two (13.3%) patients in Cluster 1 died, whereas no patient in Clusters 2 and 3 died. The results were confirmed in an independent validation cohort of 116 patients. We identified three different patterns of inflammatory immune response to COVID-19. Hyper-inflammatory immune responses with elevated CRP, neutrophilia, and lymphopenia are associated with a severe disease and a worse outcome. Therefore, targeting the hyper-inflammatory response might improve the clinical outcome of COVID-19.
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Affiliation(s)
- Eunyoung Emily Lee
- Division of Rheumatology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Gyeonggi-do, Korea
| | - Kyoung-Ho Song
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Woochang Hwang
- Data Science for Knowledge Creation Research Center, Seoul National University, Seoul, Korea
| | - Sin Young Ham
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Hyeonju Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Jeong-Han Kim
- Division of Infectious Diseases, Department of Internal Medicine, Armed Forces Capital Hospital, Gyeonggi-do, Korea
| | - Hong Sang Oh
- Division of Infectious Diseases, Department of Internal Medicine, Armed Forces Capital Hospital, Gyeonggi-do, Korea
| | - Yu Min Kang
- Department of Infectious Diseases, Myongji Hospital, Gyeonggi-do, Korea.,Department of Medical Education, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Nam Joong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Bum Sik Chin
- Division of Infectious Diseases, Department of Internal Medicine, National Medical Center, Euljiro 245, Jung-gu, Seoul, 04564, Korea.
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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457
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Ding M, Luo Y. Unsupervised phenotyping of sepsis using nonnegative matrix factorization of temporal trends from a multivariate panel of physiological measurements. BMC Med Inform Decis Mak 2021; 21:95. [PMID: 33836745 PMCID: PMC8033653 DOI: 10.1186/s12911-021-01460-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sepsis is a highly lethal and heterogeneous disease. Utilization of an unsupervised method may identify novel clinical phenotypes that lead to targeted therapies and improved care. METHODS Our objective was to derive clinically relevant sepsis phenotypes from a multivariate panel of physiological data using subgraph-augmented nonnegative matrix factorization. We utilized data from the Medical Information Mart for Intensive Care III database of patients who were admitted to the intensive care unit with sepsis. The extracted data contained patient demographics, physiological records, sequential organ failure assessment scores, and comorbidities. We applied frequent subgraph mining to extract subgraphs from physiological time series and performed nonnegative matrix factorization over the subgraphs to derive patient clusters as phenotypes. Finally, we profiled these phenotypes based on demographics, physiological patterns, disease trajectories, comorbidities and outcomes, and performed functional validation of their clinical implications. RESULTS We analyzed a cohort of 5782 patients, derived three novel phenotypes of distinct clinical characteristics and demonstrated their prognostic implications on patient outcome. Subgroup 1 included relatively less severe/deadly patients (30-day mortality, 17%) and was the smallest-in-size group (n = 1218, 21%). It was characterized by old age (mean age, 73 years), a male majority (male-to-female ratio, 59-to-41), and complex chronic conditions. Subgroup 2 included the most severe/deadliest patients (30-day mortality, 28%) and was the second-in-size group (n = 2036, 35%). It was characterized by a male majority (male-to-female ratio, 60-to-40), severe organ dysfunction or failure compounded by a wide range of comorbidities, and uniquely high incidences of coagulopathy and liver disease. Subgroup 3 included the least severe/deadly patients (30-day mortality, 10%) and was the largest group (n = 2528, 44%). It was characterized by low age (mean age, 60 years), a balanced gender ratio (male-to-female ratio, 50-to-50), the least complicated conditions, and a uniquely high incidence of neurologic disease. These phenotypes were validated to be prognostic factors of mortality for sepsis patients. CONCLUSIONS Our results suggest that these phenotypes can be used to develop targeted therapies based on phenotypic heterogeneity and algorithms designed for monitoring, validating and intervening clinical decisions for sepsis patients.
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Affiliation(s)
- Menghan Ding
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
| | - Yuan Luo
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
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458
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Banerjee A, Chen S, Fatemifar G, Zeina M, Lumbers RT, Mielke J, Gill S, Kotecha D, Freitag DF, Denaxas S, Hemingway H. Machine learning for subtype definition and risk prediction in heart failure, acute coronary syndromes and atrial fibrillation: systematic review of validity and clinical utility. BMC Med 2021; 19:85. [PMID: 33820530 PMCID: PMC8022365 DOI: 10.1186/s12916-021-01940-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/12/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Machine learning (ML) is increasingly used in research for subtype definition and risk prediction, particularly in cardiovascular diseases. No existing ML models are routinely used for cardiovascular disease management, and their phase of clinical utility is unknown, partly due to a lack of clear criteria. We evaluated ML for subtype definition and risk prediction in heart failure (HF), acute coronary syndromes (ACS) and atrial fibrillation (AF). METHODS For ML studies of subtype definition and risk prediction, we conducted a systematic review in HF, ACS and AF, using PubMed, MEDLINE and Web of Science from January 2000 until December 2019. By adapting published criteria for diagnostic and prognostic studies, we developed a seven-domain, ML-specific checklist. RESULTS Of 5918 studies identified, 97 were included. Across studies for subtype definition (n = 40) and risk prediction (n = 57), there was variation in data source, population size (median 606 and median 6769), clinical setting (outpatient, inpatient, different departments), number of covariates (median 19 and median 48) and ML methods. All studies were single disease, most were North American (n = 61/97) and only 14 studies combined definition and risk prediction. Subtype definition and risk prediction studies respectively had limitations in development (e.g. 15.0% and 78.9% of studies related to patient benefit; 15.0% and 15.8% had low patient selection bias), validation (12.5% and 5.3% externally validated) and impact (32.5% and 91.2% improved outcome prediction; no effectiveness or cost-effectiveness evaluations). CONCLUSIONS Studies of ML in HF, ACS and AF are limited by number and type of included covariates, ML methods, population size, country, clinical setting and focus on single diseases, not overlap or multimorbidity. Clinical utility and implementation rely on improvements in development, validation and impact, facilitated by simple checklists. We provide clear steps prior to safe implementation of machine learning in clinical practice for cardiovascular diseases and other disease areas.
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Affiliation(s)
- Amitava Banerjee
- Institute of Health Informatics, University College London, 222 Euston Road, London, NW1 2DA, UK.
- Health Data Research UK, University College London, London, UK.
- University College London Hospitals NHS Trust, 235 Euston Road, London, UK.
- Barts Health NHS Trust, The Royal London Hospital, Whitechapel Rd, London, UK.
| | - Suliang Chen
- Institute of Health Informatics, University College London, 222 Euston Road, London, NW1 2DA, UK
- Health Data Research UK, University College London, London, UK
| | - Ghazaleh Fatemifar
- Institute of Health Informatics, University College London, 222 Euston Road, London, NW1 2DA, UK
- Health Data Research UK, University College London, London, UK
| | | | - R Thomas Lumbers
- Institute of Health Informatics, University College London, 222 Euston Road, London, NW1 2DA, UK
- Health Data Research UK, University College London, London, UK
- University College London Hospitals NHS Trust, 235 Euston Road, London, UK
| | - Johanna Mielke
- Bayer AG, Division Pharmaceuticals, Open Innovation & Digital Technologies, Wuppertal, Germany
| | - Simrat Gill
- University of Birmingham Institute of Cardiovascular Sciences and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Daniel F Freitag
- Bayer AG, Division Pharmaceuticals, Open Innovation & Digital Technologies, Wuppertal, Germany
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, 222 Euston Road, London, NW1 2DA, UK
- Health Data Research UK, University College London, London, UK
- The Alan Turing Institute, London, UK
| | - Harry Hemingway
- Institute of Health Informatics, University College London, 222 Euston Road, London, NW1 2DA, UK
- Health Data Research UK, University College London, London, UK
- University College London Hospitals Biomedical Research Centre (UCLH BRC), London, UK
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459
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The Range of Cardiogenic Shock Survival by Clinical Stage: Data From the Critical Care Cardiology Trials Network Registry. Crit Care Med 2021; 49:1293-1302. [PMID: 33861557 DOI: 10.1097/ccm.0000000000004948] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Cardiogenic shock presents with variable severity. Categorizing cardiogenic shock into clinical stages may improve risk stratification and patient selection for therapies. We sought to determine whether a structured implementation of the 2019 Society for Cardiovascular Angiography and Interventions clinical cardiogenic shock staging criteria that is ascertainable in clinical registries discriminates mortality in a contemporary population with or at-risk for cardiogenic shock. DESIGN We developed a pragmatic application of the Society for Cardiovascular Angiography and Interventions cardiogenic shock staging criteria-A (at-risk), B (beginning), C (classic cardiogenic shock), D (deteriorating), or E (extremis)-and examined outcomes by stage. SETTING The Critical Care Cardiology Trials Network is an investigator-initiated multicenter research collaboration coordinated by the TIMI Study Group (Boston, MA). Consecutive admissions with or at-risk for cardiogenic shock during two annual 2-month collection periods (2017-2019) were analyzed. PATIENTS Patients with or at-risk for cardiogenic shock. MEASUREMENTS AND MAIN RESULTS Of 8,240 CICU admissions reviewed, 1,991 (24%) had or were at-risk for cardiogenic shock. Distributions across the five stages were as follows: A: 33%; B: 7%; C: 16%; D: 23%; and E: 21%. Overall in-hospital mortality among patients with established cardiogenic shock was 39%; however, mortality varied from only 15.8% to 32.1% to 62.5% across stages C, D, and E (Cochran-Armitage ptrend < 0.0001). The Society for Cardiovascular Angiography and Interventions stages improved mortality prediction beyond the Sequential Organ Failure Assessment and Intra-Aortic Balloon Pumpin Cardiogenic Shock II scores. CONCLUSIONS Although overall mortality in cardiogenic shock remains high, it varies considerably based on clinical stage, identifying stage C as relatively lower risk. We demonstrate a pragmatic adaptation of the Society for Cardiovascular Angiography and Interventions cardiogenic shock stages that effectively stratifies mortality risk and could be leveraged for future clinical research.
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460
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Editorial: Septic shock: what we should know… or almost! Curr Opin Anaesthesiol 2021; 34:69-70. [PMID: 33652453 DOI: 10.1097/aco.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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461
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Safety-driven design of machine learning for sepsis treatment. J Biomed Inform 2021; 117:103762. [PMID: 33798716 DOI: 10.1016/j.jbi.2021.103762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/28/2021] [Accepted: 03/22/2021] [Indexed: 11/20/2022]
Abstract
Machine learning (ML) has the potential to bring significant clinical benefits. However, there are patient safety challenges in introducing ML in complex healthcare settings and in assuring the technology to the satisfaction of the different regulators. The work presented in this paper tackles the urgent problem of proactively assuring ML in its clinical context as a step towards enabling the safe introduction of ML into clinical practice. In particular, the paper considers the use of deep Reinforcement Learning, a type of ML, for sepsis treatment. The methodology starts with the modelling of a clinical workflow that integrates the ML model for sepsis treatment recommendations. Then safety analysis is carried out based on the clinical workflow, identifying hazards and safety requirements for the ML model. In this paper the design of the ML model is enhanced to satisfy the safety requirements for mitigating a major clinical hazard: sudden change of vasopressor dose. A rigorous evaluation is conducted to show how these requirements are met. A safety case is presented, providing a basis for regulators to make a judgement on the acceptability of introducing the ML model into sepsis treatment in a healthcare setting. The overall argument is broad in considering the wider patient safety considerations, but the detailed rationale and supporting evidence presented relate to this specific hazard. Whilst there are no agreed regulatory approaches to introducing ML into healthcare, the work presented in this paper has shown a possible direction for overcoming this barrier and exploit the benefits of ML without compromising safety.
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462
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Petros S, Siegemund R, Siegemund A. Increased activated protein C to protein C ratio in sepsis and cirrhosis. Thromb Res 2021; 202:74-76. [PMID: 33770538 DOI: 10.1016/j.thromres.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/28/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Sirak Petros
- Medical ICU, University Medical Center of Leipzig, Germany.
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463
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Kudo D, Goto T, Uchimido R, Hayakawa M, Yamakawa K, Abe T, Shiraishi A, Kushimoto S. Coagulation phenotypes in sepsis and effects of recombinant human thrombomodulin: an analysis of three multicentre observational studies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:114. [PMID: 33741010 PMCID: PMC7978458 DOI: 10.1186/s13054-021-03541-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/10/2021] [Indexed: 12/29/2022]
Abstract
Background A recent randomised trial showed that recombinant thrombomodulin did not benefit patients who had sepsis with coagulopathy and organ dysfunction. Several recent studies suggested presence of clinical phenotypes in patients with sepsis and heterogenous treatment effects across different sepsis phenotypes. We examined the latent phenotypes of sepsis with coagulopathy and the associations between thrombomodulin treatment and the 28-day and in-hospital mortality for each phenotype. Methods This was a secondary analysis of multicentre registries containing data on patients (aged ≥ 16 years) who were admitted to intensive care units for severe sepsis or septic shock in Japan. Three multicentre registries were divided into derivation (two registries) and validation (one registry) cohorts. Phenotypes were derived using k-means with coagulation markers, platelet counts, prothrombin time/international normalised ratios, fibrinogen, fibrinogen/fibrin-degradation-products (FDP), D-dimer, and antithrombin activities. Associations between thrombomodulin treatment and survival outcomes (28-day and in-hospital mortality) were assessed in the derived clusters using a generalised estimating equation. Results Four sepsis phenotypes were derived from 3694 patients in the derivation cohort. Cluster dA (n = 323) had severe coagulopathy with high FDP and D-dimer levels, severe organ dysfunction, and high mortality. Cluster dB had severe disease with moderate coagulopathy. Clusters dC and dD had moderate and mild disease with and without coagulopathy, respectively. Thrombomodulin was associated with a lower 28-day (adjusted risk difference [RD]: − 17.8% [95% CI − 28.7 to − 6.9%]) and in-hospital (adjusted RD: − 17.7% [95% CI − 27.6 to − 7.8%]) mortality only in cluster dA. Sepsis phenotypes were similar in the validation cohort, and thrombomodulin treatment was also associated with lower 28-day (RD: − 24.9% [95% CI − 49.1 to − 0.7%]) and in-hospital mortality (RD: − 30.9% [95% CI − 55.3 to − 6.6%]). Conclusions We identified four coagulation marker-based sepsis phenotypes. The treatment effects of thrombomodulin varied across sepsis phenotypes. This finding will facilitate future trials of thrombomodulin, in which a sepsis phenotype with high FDP and D-dimer can be targeted. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03541-5.
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Affiliation(s)
- Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ryo Uchimido
- Intensive Care Unit, Tokyo Medical and Dental University Medical Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Kita 14 Nishi-5, Kita-ku, Sapporo, 060-8648, Japan
| | - Kazuma Yamakawa
- Division of Emergency Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, 569-8686, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, 300-2622, Japan.,Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, 305-8577, Japan
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929 Higashimachi, Kamogawa, 296-8602, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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464
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Ronco C, Reis T. Continuous renal replacement therapy and extended indications. Semin Dial 2021; 34:550-560. [PMID: 33711166 DOI: 10.1111/sdi.12963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Extracorporeal blood purification (EBP) techniques provide support for critically ill patients with single or multiple organ dysfunction. Continuous renal replacement therapy (CRRT) is the modality of choice for kidney support for those patients and orchestrates the interactions between the different artificial organ support systems. Intensive care teams should be familiar with the concept of sequential extracorporeal therapy and plan on how to incorporate new treatment modalities into their daily practices. Importantly, scientific evidence should guide the decision-making process at the bedside and provide robust arguments to justify the costs of implementing new EBP treatments. In this narrative review, we explore the extended indications for CRRT as an adjunctive treatment to provide support for the heart, lung, liver, and immune system. We detail practicalities on how to run the treatments and how to tackle the most frequent complications regarding each of the therapies, whether applied alone or integrated. The physicochemical processes and technologies involved at the molecular level encompassing the interactions between the molecules, membranes, and resins are spotlighted. A clinical case will illustrate the timing for the initiation, maintenance, and discontinuation of EBP techniques.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy.,Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, Brazil
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Clínica de Doenças Renais de Brasília, Molecular Pharmacology Laboratory, University of Brasília, Brasilia, Brazil
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465
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Webster AJ, Gaitskell K, Turnbull I, Cairns BJ, Clarke R. Characterisation, identification, clustering, and classification of disease. Sci Rep 2021; 11:5405. [PMID: 33686097 PMCID: PMC7940639 DOI: 10.1038/s41598-021-84860-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/17/2021] [Indexed: 12/25/2022] Open
Abstract
The importance of quantifying the distribution and determinants of multimorbidity has prompted novel data-driven classifications of disease. Applications have included improved statistical power and refined prognoses for a range of respiratory, infectious, autoimmune, and neurological diseases, with studies using molecular information, age of disease incidence, and sequences of disease onset (“disease trajectories”) to classify disease clusters. Here we consider whether easily measured risk factors such as height and BMI can effectively characterise diseases in UK Biobank data, combining established statistical methods in new but rigorous ways to provide clinically relevant comparisons and clusters of disease. Over 400 common diseases were selected for analysis using clinical and epidemiological criteria, and conventional proportional hazards models were used to estimate associations with 12 established risk factors. Several diseases had strongly sex-dependent associations of disease risk with BMI. Importantly, a large proportion of diseases affecting both sexes could be identified by their risk factors, and equivalent diseases tended to cluster adjacently. These included 10 diseases presently classified as “Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified”. Many clusters are associated with a shared, known pathogenesis, others suggest likely but presently unconfirmed causes. The specificity of associations and shared pathogenesis of many clustered diseases provide a new perspective on the interactions between biological pathways, risk factors, and patterns of disease such as multimorbidity.
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Affiliation(s)
- A J Webster
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - K Gaitskell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - I Turnbull
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - B J Cairns
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - R Clarke
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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466
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Bergmann CB, Beckmann N, Salyer CE, Hanschen M, Crisologo PA, Caldwell CC. Potential Targets to Mitigate Trauma- or Sepsis-Induced Immune Suppression. Front Immunol 2021; 12:622601. [PMID: 33717127 PMCID: PMC7947256 DOI: 10.3389/fimmu.2021.622601] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/11/2021] [Indexed: 12/12/2022] Open
Abstract
In sepsis and trauma, pathogens and injured tissue provoke a systemic inflammatory reaction which can lead to overwhelming inflammation. Concurrent with the innate hyperinflammatory response is adaptive immune suppression that can become chronic. A current key issue today is that patients who undergo intensive medical care after sepsis or trauma have a high mortality rate after being discharged. This high mortality is thought to be associated with persistent immunosuppression. Knowledge about the pathophysiology leading to this state remains fragmented. Immunosuppressive cytokines play an essential role in mediating and upholding immunosuppression in these patients. Specifically, the cytokines Interleukin-10 (IL-10), Transforming Growth Factor-β (TGF-β) and Thymic stromal lymphopoietin (TSLP) are reported to have potent immunosuppressive capacities. Here, we review their ability to suppress inflammation, their dynamics in sepsis and trauma and what drives the pathologic release of these cytokines. They do exert paradoxical effects under certain conditions, which makes it necessary to evaluate their functions in the context of dynamic changes post-sepsis and trauma. Several drugs modulating their functions are currently in clinical trials in the treatment of other pathologies. We provide an overview of the current literature on the effects of IL-10, TGF-β and TSLP in sepsis and trauma and suggest therapeutic approaches for their modulation.
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Affiliation(s)
- Christian B Bergmann
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Nadine Beckmann
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Christen E Salyer
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Marc Hanschen
- Experimental Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter A Crisologo
- Division of Podiatric Medicine and Surgery, Critical Care, and Acute Care Surgery, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Charles C Caldwell
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, United States.,Division of Research, Shriners Hospital for Children, Cincinnati, OH, United States
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467
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Ma EY, Kim JW, Lee Y, Cho SW, Kim H, Kim JK. Combined unsupervised-supervised machine learning for phenotyping complex diseases with its application to obstructive sleep apnea. Sci Rep 2021; 11:4457. [PMID: 33627761 PMCID: PMC7904925 DOI: 10.1038/s41598-021-84003-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/10/2021] [Indexed: 12/24/2022] Open
Abstract
Unsupervised clustering models have been widely used for multimetric phenotyping of complex and heterogeneous diseases such as diabetes and obstructive sleep apnea (OSA) to more precisely characterize the disease beyond simplistic conventional diagnosis standards. However, the number of clusters and key phenotypic features have been subjectively selected, reducing the reliability of the phenotyping results. Here, to minimize such subjective decisions for highly confident phenotyping, we develop a multimetric phenotyping framework by combining supervised and unsupervised machine learning. This clusters 2277 OSA patients to six phenotypes based on their multidimensional polysomnography (PSG) data. Importantly, these new phenotypes show statistically different comorbidity development for OSA-related cardio-neuro-metabolic diseases, unlike the conventional single-metric apnea–hypopnea index-based phenotypes. Furthermore, the key features of highly comorbid phenotypes were identified through supervised learning rather than subjective choice. These results can also be used to automatically phenotype new patients and predict their comorbidity risks solely based on their PSG data. The phenotyping framework based on the combination of unsupervised and supervised machine learning methods can also be applied to other complex, heterogeneous diseases for phenotyping patients and identifying important features for high-risk phenotypes.
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Affiliation(s)
- Eun-Yeol Ma
- Department of Industrial and Systems Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Jeong-Whun Kim
- Department of Otorhinolaryngology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Youngmin Lee
- Department of Industrial and Systems Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Sung-Woo Cho
- Department of Otorhinolaryngology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Heeyoung Kim
- Department of Industrial and Systems Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea.
| | - Jae Kyoung Kim
- Department of Mathematical Sciences, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea.
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468
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Banerjee S, Mohammed A, Wong HR, Palaniyar N, Kamaleswaran R. Machine Learning Identifies Complicated Sepsis Course and Subsequent Mortality Based on 20 Genes in Peripheral Blood Immune Cells at 24 H Post-ICU Admission. Front Immunol 2021; 12:592303. [PMID: 33692779 PMCID: PMC7937924 DOI: 10.3389/fimmu.2021.592303] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 01/28/2021] [Indexed: 01/08/2023] Open
Abstract
A complicated clinical course for critically ill patients admitted to the intensive care unit (ICU) usually includes multiorgan dysfunction and subsequent death. Owing to the heterogeneity, complexity, and unpredictability of the disease progression, ICU patient care is challenging. Identifying the predictors of complicated courses and subsequent mortality at the early stages of the disease and recognizing the trajectory of the disease from the vast array of longitudinal quantitative clinical data is difficult. Therefore, we attempted to perform a meta-analysis of previously published gene expression datasets to identify novel early biomarkers and train the artificial intelligence systems to recognize the disease trajectories and subsequent clinical outcomes. Using the gene expression profile of peripheral blood cells obtained within 24 h of pediatric ICU (PICU) admission and numerous clinical data from 228 septic patients from pediatric ICU, we identified 20 differentially expressed genes predictive of complicated course outcomes and developed a new machine learning model. After 5-fold cross-validation with 10 iterations, the overall mean area under the curve reached 0.82. Using a subset of the same set of genes, we further achieved an overall area under the curve of 0.72, 0.96, 0.83, and 0.82, respectively, on four independent external validation sets. This model was highly effective in identifying the clinical trajectories of the patients and mortality. Artificial intelligence systems identified eight out of twenty novel genetic markers (SDC4, CLEC5A, TCN1, MS4A3, HCAR3, OLAH, PLCB1, and NLRP1) that help predict sepsis severity or mortality. While these genes have been previously associated with sepsis mortality, in this work, we show that these genes are also implicated in complex disease courses, even among survivors. The discovery of eight novel genetic biomarkers related to the overactive innate immune system, including neutrophil function, and a new predictive machine learning method provides options to effectively recognize sepsis trajectories, modify real-time treatment options, improve prognosis, and patient survival.
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Affiliation(s)
- Shayantan Banerjee
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, India
| | - Akram Mohammed
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Nades Palaniyar
- Translational Medicine, Peter Gilgan Center for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
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469
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Stahl K, Bode C, David S. [Extracorporeal Strategies in Sepsis Treatment: Role of Therapeutic Plasma Exchange]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:101-110. [PMID: 33607671 DOI: 10.1055/a-1105-0572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Mortality in sepsis remains high. Various techniques for extracorporeal cytokine removal have been investigated as additional therapeutic measures in sepsis and septic shock. OBJECTIVES To summarize a selection of extracorporeal blood purification techniques, with a special focus on therapeutic plasma exchange, and their current evidence in clinical use. METHODS Non-systematic literature review. RESULTS Various extracorporeal blood purification techniques with different levels of evidence regarding cytokine removal, vasopressor sparing effects and reduction of mortality are currently in clinical use. Most extensively studied modalities include high-volume hemofiltration/dialysis with and without high cut-off filters a well as hemoadsorption techniques (including CytoSorb, and polymyxin-B filters). Despite partly encouraging observations regarding removal of inflammatory cytokines and hemodynamic stabilization, results from randomized studies did not show an effect on survival. Due to use of donor plasma as substitution fluid, therapeutic plasma exchange represents the only modality able to additionally replace protective and consumed factors. CONCLUSIONS The use of extracorporeal blood purification methods cannot be recommended for sepsis patients outside of clinical trials given the current lack of evidence of their efficacy. Future investigations should aim to homogenize the studied patient collective in respect to clinical sepsis severity, time point of intervention and different inflammatory (sub-)phenotypes.
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470
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Association of clinical sub-phenotypes and clinical deterioration in COVID-19: further cluster analyses. Intensive Care Med 2021; 47:482-484. [PMID: 33604760 PMCID: PMC7891487 DOI: 10.1007/s00134-021-06363-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
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471
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Nakamori Y, Park EJ, Shimaoka M. Immune Deregulation in Sepsis and Septic Shock: Reversing Immune Paralysis by Targeting PD-1/PD-L1 Pathway. Front Immunol 2021; 11:624279. [PMID: 33679715 PMCID: PMC7925640 DOI: 10.3389/fimmu.2020.624279] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/29/2020] [Indexed: 12/13/2022] Open
Abstract
Sepsis remains a major problem for human health worldwide, thereby manifesting high rates of morbidity and mortality. Sepsis, once understood as a monophasic sustained hyperinflammation, is currently recognized as a dysregulated host response to infection, with both hyperinflammation and immunoparalysis occurring simultaneously from the earliest stages of sepsis, involving multiple organ dysfunctions. Despite the recent progress in the understanding of the pathophysiology underlying sepsis, no specific treatment to restore immune dysregulation in sepsis has been validated in clinical trials. In recent years, treatment for immune checkpoints such as the programmed cell death protein 1/programmed death ligand (PD-1/PD-L) pathway in tumor-infiltrating T-lymphocytes has been successful in the field of cancer immune therapy. As immune-paralysis in sepsis involves exhausted T-lymphocytes, future clinical applications of checkpoint inhibitors for sepsis are expected. In addition, the functions of PD-1/PD-L on innate lymphoid cells and the role of exosomal forms of PD-L1 warrant further research. Looking back on the history of repeatedly failed clinical trials of immune modulatory therapies for sepsis, sepsis must be recognized as a difficult disease entity for performing clinical trials. A major obstacle that could prevent effective clinical trials of drug candidates is the disease complexity and heterogeneities; clinically diagnosed sepsis could contain multiple sepsis subgroups that suffer different levels of hyper-inflammation and immune-suppression in distinct organs. Thus, the selection of appropriate more homogenous sepsis subgroup is the key for testing the clinical efficacy of experimental therapies targeting specific pathways in either hyperinflammation and/or immunoparalysis. An emerging technology such as artificial intelligence (AI) may help to identify an immune paralysis subgroup who would best be treated by PD-1/PD-L1 pathway inhibitors.
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Affiliation(s)
- Yuki Nakamori
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Mie, Japan
| | - Eun Jeong Park
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Mie, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Mie, Japan
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472
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Fohner AE, Greene JD, Lawson BL, Chen JH, Kipnis P, Escobar GJ, Liu VX. Assessing clinical heterogeneity in sepsis through treatment patterns and machine learning. J Am Med Inform Assoc 2021; 26:1466-1477. [PMID: 31314892 DOI: 10.1093/jamia/ocz106] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To use unsupervised topic modeling to evaluate heterogeneity in sepsis treatment patterns contained within granular data of electronic health records. MATERIALS AND METHODS A multicenter, retrospective cohort study of 29 253 hospitalized adult sepsis patients between 2010 and 2013 in Northern California. We applied an unsupervised machine learning method, Latent Dirichlet Allocation, to the orders, medications, and procedures recorded in the electronic health record within the first 24 hours of each patient's hospitalization to uncover empiric treatment topics across the cohort and to develop computable clinical signatures for each patient based on proportions of these topics. We evaluated how these topics correlated with common sepsis treatment and outcome metrics including inpatient mortality, time to first antibiotic, and fluids given within 24 hours. RESULTS Mean age was 70 ± 17 years with hospital mortality of 9.6%. We empirically identified 42 clinically recognizable treatment topics (eg, pneumonia, cellulitis, wound care, shock). Only 43.1% of hospitalizations had a single dominant topic, and a small minority (7.3%) had a single topic comprising at least 80% of their overall clinical signature. Across the entire sepsis cohort, clinical signatures were highly variable. DISCUSSION Heterogeneity in sepsis is a major barrier to improving targeted treatments, yet existing approaches to characterizing clinical heterogeneity are narrowly defined. A machine learning approach captured substantial patient- and population-level heterogeneity in treatment during early sepsis hospitalization. CONCLUSION Using topic modeling based on treatment patterns may enable more precise clinical characterization in sepsis and better understanding of variability in sepsis presentation and outcomes.
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Affiliation(s)
- Alison E Fohner
- Division of Research, Kaiser Permanente, Oakland, California, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - John D Greene
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Brian L Lawson
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Jonathan H Chen
- Division of Biomedical Informatics Research, Stanford University, Stanford, California, USA
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | | | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, California, USA
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473
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Rodríguez A, Ruiz-Botella M, Martín-Loeches I, Jimenez Herrera M, Solé-Violan J, Gómez J, Bodí M, Trefler S, Papiol E, Díaz E, Suberviola B, Vallverdu M, Mayor-Vázquez E, Albaya Moreno A, Canabal Berlanga A, Sánchez M, Del Valle Ortíz M, Ballesteros JC, Martín Iglesias L, Marín-Corral J, López Ramos E, Hidalgo Valverde V, Vidaur Tello LV, Sancho Chinesta S, Gonzáles de Molina FJ, Herrero García S, Sena Pérez CC, Pozo Laderas JC, Rodríguez García R, Estella A, Ferrer R. Deploying unsupervised clustering analysis to derive clinical phenotypes and risk factors associated with mortality risk in 2022 critically ill patients with COVID-19 in Spain. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:63. [PMID: 33588914 PMCID: PMC7883885 DOI: 10.1186/s13054-021-03487-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The identification of factors associated with Intensive Care Unit (ICU) mortality and derived clinical phenotypes in COVID-19 patients could help for a more tailored approach to clinical decision-making that improves prognostic outcomes. METHODS Prospective, multicenter, observational study of critically ill patients with confirmed COVID-19 disease and acute respiratory failure admitted from 63 ICUs in Spain. The objective was to utilize an unsupervised clustering analysis to derive clinical COVID-19 phenotypes and to analyze patient's factors associated with mortality risk. Patient features including demographics and clinical data at ICU admission were analyzed. Generalized linear models were used to determine ICU morality risk factors. The prognostic models were validated and their performance was measured using accuracy test, sensitivity, specificity and ROC curves. RESULTS The database included a total of 2022 patients (mean age 64 [IQR 5-71] years, 1423 (70.4%) male, median APACHE II score (13 [IQR 10-17]) and SOFA score (5 [IQR 3-7]) points. The ICU mortality rate was 32.6%. Of the 3 derived phenotypes, the A (mild) phenotype (537; 26.7%) included older age (< 65 years), fewer abnormal laboratory values and less development of complications, B (moderate) phenotype (623, 30.8%) had similar characteristics of A phenotype but were more likely to present shock. The C (severe) phenotype was the most common (857; 42.5%) and was characterized by the interplay of older age (> 65 years), high severity of illness and a higher likelihood of development shock. Crude ICU mortality was 20.3%, 25% and 45.4% for A, B and C phenotype respectively. The ICU mortality risk factors and model performance differed between whole population and phenotype classifications. CONCLUSION The presented machine learning model identified three clinical phenotypes that significantly correlated with host-response patterns and ICU mortality. Different risk factors across the whole population and clinical phenotypes were observed which may limit the application of a "one-size-fits-all" model in practice.
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Affiliation(s)
- Alejandro Rodríguez
- ICU Hospital Universitario Joan XXIII/IISPV/URV, Mallafre Guasch 4, 43007, Tarragona, Spain. .,CIBERESUCICOVID, Barcelona, Spain.
| | - Manuel Ruiz-Botella
- Tarragona Health Data Research Working Group (THeDaR), ICU Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | | | - Jordi Solé-Violan
- ICU Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Josep Gómez
- Tarragona Health Data Research Working Group (THeDaR), ICU Hospital Universitario Joan XXIII, Tarragona, Spain
| | - María Bodí
- ICU Hospital Universitario Joan XXIII/IISPV/URV, Mallafre Guasch 4, 43007, Tarragona, Spain.,CIBERESUCICOVID, Barcelona, Spain
| | - Sandra Trefler
- ICU Hospital Universitario Joan XXIII/IISPV/URV, Mallafre Guasch 4, 43007, Tarragona, Spain
| | | | - Emili Díaz
- ICU Hospital Parc Tauli, Sabadell, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Angel Estella
- ICU Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | - Ricard Ferrer
- ICU Hospital Universitario Vall d'Hebron, Barcelona, Spain
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474
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Giacobbe DR, Signori A, Del Puente F, Mora S, Carmisciano L, Briano F, Vena A, Ball L, Robba C, Pelosi P, Giacomini M, Bassetti M. Early Detection of Sepsis With Machine Learning Techniques: A Brief Clinical Perspective. Front Med (Lausanne) 2021; 8:617486. [PMID: 33644097 PMCID: PMC7906970 DOI: 10.3389/fmed.2021.617486] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/19/2021] [Indexed: 12/15/2022] Open
Abstract
Sepsis is a major cause of death worldwide. Over the past years, prediction of clinically relevant events through machine learning models has gained particular attention. In the present perspective, we provide a brief, clinician-oriented vision on the following relevant aspects concerning the use of machine learning predictive models for the early detection of sepsis in the daily practice: (i) the controversy of sepsis definition and its influence on the development of prediction models; (ii) the choice and availability of input features; (iii) the measure of the model performance, the output, and their usefulness in the clinical practice. The increasing involvement of artificial intelligence and machine learning in health care cannot be disregarded, despite important pitfalls that should be always carefully taken into consideration. In the long run, a rigorous multidisciplinary approach to enrich our understanding in the application of machine learning techniques for the early recognition of sepsis may show potential to augment medical decision-making when facing this heterogeneous and complex syndrome.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Filippo Del Puente
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Sara Mora
- Department of Informatics Bioengineering, Robotics, and Systems Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Luca Carmisciano
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Federica Briano
- Infectious Diseases Unit, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lorenzo Ball
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Mauro Giacomini
- Department of Informatics Bioengineering, Robotics, and Systems Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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475
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Heffernan AJ, Denny KJ. Host Diagnostic Biomarkers of Infection in the ICU: Where Are We and Where Are We Going? Curr Infect Dis Rep 2021; 23:4. [PMID: 33613126 DOI: 10.1007/s11908-021-00747-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
Purpose of Review Early identification of infection in the critically ill patient and initiation of appropriate treatment is key to reducing morbidity and mortality. On the other hand, the indiscriminate use of antimicrobials leads to harms, many of which may be exaggerated in the critically ill population. The current method of diagnosing infection in the intensive care unit relies heavily on clinical gestalt; however, this approach is plagued by biases. Therefore, a reliable, independent biomarker holds promise in the accurate determination of infection. We discuss currently used host biomarkers used in the intensive care unit and review new and emerging approaches to biomarker discovery. Recent Findings White cell count (including total white cell count, left shift, and the neutrophil-leucocyte ratio), C-reactive protein, and procalcitonin are the most common host diagnostic biomarkers for sepsis used in current clinical practice. However, their utility in the initial diagnosis of infection, and their role in the subsequent decision to commence treatment, remains limited. Novel approaches to biomarker discovery that are currently being investigated include combination biomarkers, host 'sepsis signatures' based on differential gene expression, site-specific biomarkers, biomechanical assays, and incorporation of new and pre-existing host biomarkers into machine learning algorithms. Summary To date, no single reliable independent biomarker of infection exists. Whilst new approaches to biomarker discovery hold promise, their clinical utility may be limited if previous mistakes that have afflicted sepsis biomarker research continue to be repeated.
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Affiliation(s)
- Aaron J Heffernan
- School of Medicine, Griffith University, Gold Coast, QLD Australia
- Centre for Translational Anti-infective Pharmacodynamics, Faculty of Medicine, University of Queensland, Herston, QLD Australia
| | - Kerina J Denny
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD Australia
- School of Clinical Medicine, Faculty of Medicine, University of Queensland, Herston, QLD Australia
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476
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Gupta V, Paranzino M, Alnabelsi T, Ayoub K, Eason J, Mullis A, Kotter JR, Parks A, May L, Nerusu S, Dai C, Cleland D, Leung SW, Sorrell VL. 5th generation vs 4th generation troponin T in predicting major adverse cardiovascular events and all-cause mortality in patients hospitalized for non-cardiac indications: A cohort study. PLoS One 2021; 16:e0246332. [PMID: 33561174 PMCID: PMC7872231 DOI: 10.1371/journal.pone.0246332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022] Open
Abstract
Objective The frequency and implications of an elevated cardiac troponin (4th or 5th generation TnT) in patients outside of the emergency department or presenting with non-cardiac conditions is unclear. Methods Consecutive patients aged 18 years or older admitted for a primary non-cardiac condition who had the 4th generation TnT drawn had the 5th generation TnT run on the residual blood sample. Primary and secondary outcomes were all-cause mortality (ACM) and major adverse cardiovascular events (MACE) respectively at 1 year. Results 918 patients were included (mean age 59.8 years, 55% male) in the cohort. 69% had elevated 5th generation TnT while 46% had elevated 4th generation TnT. 5th generation TnT was more sensitive and less specific than 4th generation TnT in predicting both ACM and MACE. The sensitivities for the 5th generation TnT assay were 85% for ACM and 90% for MACE rates, compared to 65% and 70% respectively for the 4th generation assay. 5th generation TnT positive patients that were missed by 4th generation TnT had a higher risk of ACM (27.5%) than patients with both assays negative (27.5% vs 11.1%, p<0.001), but lower than patients who had both assay positive (42.1%). MACE rates were not better stratified using the 5th generation TnT assay. Conclusions In patients admitted for a non-cardiac condition, 5th generation TnT is more sensitive although less specific in predicting MACE and ACM. 5th generation TnT identifies an intermediate risk group for ACM previously missed with the 4th generation assay.
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Affiliation(s)
- Vedant Gupta
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
- * E-mail:
| | - Marc Paranzino
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Talal Alnabelsi
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Karam Ayoub
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Joshua Eason
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Andin Mullis
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - John R. Kotter
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Andrew Parks
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Levi May
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Sethabhisha Nerusu
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Chen Dai
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Daniel Cleland
- Performance Analytics Center of Excellence, University of Kentucky, Lexington, Kentucky, United States of America
| | - Steve Wah Leung
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
| | - Vincent Leigh Sorrell
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky, United States of America
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477
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Pellathy T, Saul M, Clermont G, Dubrawski AW, Pinsky MR, Hravnak M. Accuracy of identifying hospital acquired venous thromboembolism by administrative coding: implications for big data and machine learning research. J Clin Monit Comput 2021; 36:397-405. [PMID: 33558981 DOI: 10.1007/s10877-021-00664-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/20/2021] [Indexed: 12/23/2022]
Abstract
Big data analytics research using heterogeneous electronic health record (EHR) data requires accurate identification of disease phenotype cases and controls. Overreliance on ground truth determination based on administrative data can lead to biased and inaccurate findings. Hospital-acquired venous thromboembolism (HA-VTE) is challenging to identify due to its temporal evolution and variable EHR documentation. To establish ground truth for machine learning modeling, we compared accuracy of HA-VTE diagnoses made by administrative coding to manual review of gold standard diagnostic test results. We performed retrospective analysis of EHR data on 3680 adult stepdown unit patients identifying HA-VTE. International Classification of Diseases, Ninth Revision (ICD-9-CM) codes for VTE were identified. 4544 radiology reports associated with VTE diagnostic tests were screened using terminology extraction and then manually reviewed by a clinical expert to confirm diagnosis. Of 415 cases with ICD-9-CM codes for VTE, 219 were identified with acute onset type codes. Test report review identified 158 new-onset HA-VTE cases. Only 40% of ICD-9-CM coded cases (n = 87) were confirmed by a positive diagnostic test report, leaving the majority of administratively coded cases unsubstantiated by confirmatory diagnostic test. Additionally, 45% of diagnostic test confirmed HA-VTE cases lacked corresponding ICD codes. ICD-9-CM coding missed diagnostic test-confirmed HA-VTE cases and inaccurately assigned cases without confirmed VTE, suggesting dependence on administrative coding leads to inaccurate HA-VTE phenotyping. Alternative methods to develop more sensitive and specific VTE phenotype solutions portable across EHR vendor data are needed to support case-finding in big-data analytics.
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Affiliation(s)
- Tiffany Pellathy
- University of Pittsburgh School of Nursing, 336 Victoria Hall; 3500 Victoria Street, Pittsburgh, PA, 15213, USA.
| | - Melissa Saul
- University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Gilles Clermont
- University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Artur W Dubrawski
- School of Computer Science, Auton Lab, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
| | - Michael R Pinsky
- University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Marilyn Hravnak
- University of Pittsburgh School of Nursing, 336 Victoria Hall; 3500 Victoria Street, Pittsburgh, PA, 15213, USA
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478
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Ferrarese A, Sartori G, Orrù G, Frigo AC, Pelizzaro F, Burra P, Senzolo M. Machine learning in liver transplantation: a tool for some unsolved questions? Transpl Int 2021; 34:398-411. [PMID: 33428298 DOI: 10.1111/tri.13818] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/24/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022]
Abstract
Machine learning has recently been proposed as a useful tool in many fields of Medicine, with the aim of increasing diagnostic and prognostic accuracy. Models based on machine learning have been introduced in the setting of solid organ transplantation too, where prognosis depends on a complex, multidimensional and nonlinear relationship between variables pertaining to the donor, the recipient and the surgical procedure. In the setting of liver transplantation, machine learning models have been developed to predict pretransplant survival in patients with cirrhosis, to assess the best donor-to-recipient match during allocation processes, and to foresee postoperative complications and outcomes. This is a narrative review on the role of machine learning in the field of liver transplantation, highlighting strengths and pitfalls, and future perspectives.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giuseppe Sartori
- Forensic Neuropsychology and Forensic Neuroscience, PhD Program in Mind Brain and Computer Science, Department of General Psychology, Padua University, Padua, Italy
| | - Graziella Orrù
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Anna Chiara Frigo
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Padova, Veneto, Italy
| | - Filippo Pelizzaro
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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479
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DeMerle KM, Kennedy JN, Peck Palmer OM, Brant E, Chang CCH, Dickson RP, Huang DT, Angus DC, Seymour CW. Feasibility of Embedding a Scalable, Virtually Enabled Biorepository in the Electronic Health Record for Precision Medicine. JAMA Netw Open 2021; 4:e2037739. [PMID: 33616663 PMCID: PMC7900864 DOI: 10.1001/jamanetworkopen.2020.37739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Abstract
Importance A cornerstone of precision medicine is the identification and use of biomarkers that help subtype patients for targeted treatment. Such an approach requires the development and subsequent interrogation of large-scale biobanks linked to well-annotated clinical data. Traditional means of creating these data-linked biobanks are costly and lengthy, especially in acute conditions that require time-sensitive clinical data and biospecimens. Objectives To develop a virtually enabled biorepository and electronic health record (EHR)-embedded, scalable cohort for precision medicine (VESPRE) and compare the feasibility, enrollment, and costs of VESPRE with those of a traditional study design in acute care. Design, Setting, and Participants In a prospective cohort study, the EHR-embedded screening alert was generated for 3428 patients, and 2199 patients (64%) were eligible and screened. Of these, 1027 patients (30%) were enrolled. VESPRE was developed for regulatory compliance, feasibility, internal validity, and cost in a prospective cohort of 1027 patients (aged ≥18 years) with sepsis-3 within 6 hours of presentation to the emergency department. The VESPRE infrastructure included (1) automated EHR screening, (2) remnant blood collection for creation of a virtually enabled biorepository, and (3) automated clinical data abstraction. The study was conducted at an academic institution in southwestern Pennsylvania from October 17, 2017, to June 6, 2019. Main Outcomes and Measures Regulatory compliance, enrollment, internal validity of automated screening, biorepository acquisition, and costs. Results Of the 1027 patients enrolled in the study, 549 were included in the proof-of-concept analysis (305 [56%] men); median (SD) age was 59 (17) years. VESPRE collected 12 963 remnant blood and urine samples and demonstrated adequate feasibility for clinical, biomarker, and microbiome analyses. Over the 20-month test, the total cost beyond the existing operations infrastructure was $39 417.50 ($14 880.00 project management, $22 717.50 laboratory supplies/staff, and $1820.00 data management)-approximately $39 per enrolled patient vs $239 per patient for a traditional cohort study. Conclusions and Relevance Results of this study suggest that, in a large US health system that collects data using a common EHR platform and centralized laboratory system, VESPRE, a large-scale, inexpensive EHR-embedded infrastructure for precision medicine can be used. Tested in the sepsis setting, VESPRE appeared to capture a high proportion of eligible patients at low incremental cost.
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Affiliation(s)
- Kimberley M. DeMerle
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason N. Kennedy
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Octavia M. Peck Palmer
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Brant
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert P. Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor
| | - David T. Huang
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Office of Healthcare Innovation, University of Pittsburgh Medicine Center Health System, Pittsburgh, Pennsylvania
- Senior Editor, JAMA
| | - Christopher W. Seymour
- The Clinical Research, Investigation, and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Office of Healthcare Innovation, University of Pittsburgh Medicine Center Health System, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Associate Editor, JAMA
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480
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Tulli G, Toccafondi G. Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal. Diagnosis (Berl) 2021; 8:dx-2020-0142. [PMID: 33544477 DOI: 10.1515/dx-2020-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/13/2020] [Indexed: 11/15/2022]
Abstract
This is a first attempt to integrate the three pillars of infection management: the infection prevention and control (IPC), and surveillance (IPCS), antimicrobial stewardship (AMS), and rapid identification and management of sepsis (RIMS). The new 'Sepsis-3' definition extrapolates the diagnosis of sepsis from our previously slightly naïve concept of a stepwise evolving pattern. In doing so, however, we have placed the transition from infection toward sepsis in the domain of uncertainty and time-dependency. This now demands that clinical judgment be used in the risk stratification of patients with infection, and that pragmatic local solutions be used to prompt clinicians to evaluate formally for sepsis. We feel it is necessary to stimulate the development of a new generation of concepts and models aiming at embracing uncertainty. We see the opportunity for a heuristic approach focusing on the relevant clinical predictors at hand allowing to navigate the uncertainty of infection diagnosis under time constraints. The diverse and situated clinical approaches eventually emerging need to focus on the understanding of infection as the unbalanced interactions of host, pathogen, and environment. In order extend such approach throughout the patient journey we propose a holistic early warning system underpinned by the risk-based categories of hazards and vulnerabilities iteratively fostered by the information gathered by the infection prevention control and surveillance, clinical microbiology, and clinical chemistry services.
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Affiliation(s)
| | - Giulio Toccafondi
- Clinical Risk Management and Patient Safety Center - GRC, Florence, Italy
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481
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Kitsios GD, Yang H, Yang L, Qin S, Fitch A, Wang XH, Fair K, Evankovich J, Bain W, Shah F, Li K, Methé B, Benos PV, Morris A, McVerry BJ. Respiratory Tract Dysbiosis Is Associated with Worse Outcomes in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2021; 202:1666-1677. [PMID: 32717152 DOI: 10.1164/rccm.201912-2441oc] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Host inflammatory responses have been strongly associated with adverse outcomes in critically ill patients, but the biologic underpinnings of such heterogeneous responses have not been defined.Objectives: We examined whether respiratory tract microbiome profiles are associated with host inflammation and clinical outcomes of acute respiratory failure.Methods: We collected oral swabs, endotracheal aspirates (ETAs), and plasma samples from mechanically ventilated patients. We performed 16S ribosomal RNA gene sequencing to characterize upper and lower respiratory tract microbiota and classified patients into host-response subphenotypes on the basis of clinical variables and plasma biomarkers of innate immunity and inflammation. We derived diversity metrics and composition clusters with Dirichlet multinomial models and examined our data for associations with subphenotypes and clinical outcomes.Measurements and Main Results: Oral and ETA microbial communities from 301 mechanically ventilated subjects had substantial heterogeneity in α and β diversity. Dirichlet multinomial models revealed a cluster with low α diversity and enrichment for pathogens (e.g., high Staphylococcus or Pseudomonadaceae relative abundance) in 35% of ETA samples, associated with a hyperinflammatory subphenotype, worse 30-day survival, and longer time to liberation from mechanical ventilation (adjusted P < 0.05), compared with patients with higher α diversity and relative abundance of typical oral microbiota. Patients with evidence of dysbiosis (low α diversity and low relative abundance of "protective" oral-origin commensal bacteria) in both oral and ETA samples (17%, combined dysbiosis) had significantly worse 30-day survival and longer time to liberation from mechanical ventilation than patients without dysbiosis (55%; adjusted P < 0.05).Conclusions: Respiratory tract dysbiosis may represent an important, modifiable contributor to patient-level heterogeneity in systemic inflammatory responses and clinical outcomes.
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Affiliation(s)
- Georgios D Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Center for Medicine and the Microbiome
| | - Haopu Yang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Department of Computational and Systems Biology, and.,Department of Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Libing Yang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Center for Medicine and the Microbiome.,Department of Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shulin Qin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Center for Medicine and the Microbiome
| | | | - Xiao-Hong Wang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center
| | - Katherine Fair
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center
| | - John Evankovich
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center
| | - William Bain
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center
| | - Faraaz Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,School of Medicine, Tsinghua University, Beijing, China; and
| | - Kelvin Li
- Center for Medicine and the Microbiome
| | - Barbara Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Center for Medicine and the Microbiome
| | | | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Center for Medicine and the Microbiome.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Bryan J McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine and University of Pittsburgh Medical Center.,Center for Medicine and the Microbiome
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482
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Ye J, Sanchez-Pinto LN. Three Data-Driven Phenotypes of Multiple Organ Dysfunction Syndrome Preserved from Early Childhood to Middle Adulthood. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2020:1345-1353. [PMID: 33936511 PMCID: PMC8075454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Multiple organ dysfunction syndrome (MODS) is one of the major causes of death and long-term impairment in critically ill patients. MODS is a complex, heterogeneous syndrome consisting of different phenotypes, which has limited the development of MODS-specific therapies and prognostic models. We used an unsupervised learning approach to derive novel phenotypes of MODS based on the type and severity of six individual organ dysfunctions. In a large, multi-center cohort of pediatric, young and middle-aged adults admitted to three different intensive care units, we uncovered and characterized three distinct data-driven phenotypes of MODS which were reproducible across age groups, where independently associated with outcomes and had unique predictors of in-hospital mortality.
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Affiliation(s)
- Jiancheng Ye
- Institute for Public Health and Medicine (IPHAM), Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - L Nelson Sanchez-Pinto
- Depts. of Pediatrics and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
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483
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Chen T, Delano MJ, Chen K, Sperry JL, Namas RA, Lamparello AJ, Deng M, Conroy J, Moldawer LL, Efron PA, Loughran P, Seymour C, Angus DC, Vodovotz Y, Chen W, Billiar TR. A road map from single-cell transcriptome to patient classification for the immune response to trauma. JCI Insight 2021; 6:145108. [PMID: 33320841 PMCID: PMC7934885 DOI: 10.1172/jci.insight.145108] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 01/07/2023] Open
Abstract
Immune dysfunction is an important factor driving mortality and adverse outcomes after trauma but remains poorly understood, especially at the cellular level. To deconvolute the trauma-induced immune response, we applied single-cell RNA sequencing to circulating and bone marrow mononuclear cells in injured mice and circulating mononuclear cells in trauma patients. In mice, the greatest changes in gene expression were seen in monocytes across both compartments. After systemic injury, the gene expression pattern of monocytes markedly deviated from steady state with corresponding changes in critical transcription factors, which can be traced back to myeloid progenitors. These changes were largely recapitulated in the human single-cell analysis. We generalized the major changes in human CD14+ monocytes into 6 signatures, which further defined 2 trauma patient subtypes (SG1 vs. SG2) identified in the whole-blood leukocyte transcriptome in the initial 12 hours after injury. Compared with SG2, SG1 patients exhibited delayed recovery, more severe organ dysfunction, and a higher incidence of infection and noninfectious complications. The 2 patient subtypes were also recapitulated in burn and sepsis patients, revealing a shared pattern of immune response across critical illness. Our data will be broadly useful to further explore the immune response to inflammatory diseases and critical illness.
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Affiliation(s)
- Tianmeng Chen
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Cellular and Molecular Pathology program, Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew J Delano
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Kong Chen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rami A Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley J Lamparello
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Meihong Deng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julia Conroy
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Patricia Loughran
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Seymour
- The Clinical Research, Investigation and Systems Medicine of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- The Clinical Research, Investigation and Systems Medicine of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Wei Chen
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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484
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Schimunek L, Lindberg H, Cohen M, Namas RA, Mi Q, Yin J, Barclay D, El-Dehaibi F, Abboud A, Zamora R, Billiar TR, Vodovotz Y. Computational Derivation of Core, Dynamic Human Blunt Trauma Inflammatory Endotypes. Front Immunol 2021; 11:589304. [PMID: 33537029 PMCID: PMC7848165 DOI: 10.3389/fimmu.2020.589304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/30/2020] [Indexed: 02/03/2023] Open
Abstract
Systemic inflammation ensues following traumatic injury, driving immune dysregulation and multiple organ dysfunction (MOD). While a balanced immune/inflammatory response is ideal for promoting tissue regeneration, most trauma patients exhibit variable and either overly exuberant or overly damped responses that likely drive adverse clinical outcomes. We hypothesized that these inflammatory phenotypes occur in the context of severe injury, and therefore sought to define clinically distinct endotypes of trauma patients based on their systemic inflammatory responses. Using Patient-Specific Principal Component Analysis followed by unsupervised hierarchical clustering of circulating inflammatory mediators obtained in the first 24 h after injury, we segregated a cohort of 227 blunt trauma survivors into three core endotypes exhibiting significant differences in requirement for mechanical ventilation, duration of ventilation, and MOD over 7 days. Nine non-survivors co-segregated with survivors. Dynamic network inference, Fisher Score analysis, and correlations of IL-17A with GM-CSF, IL-10, and IL-22 in the three survivor sub-groups suggested a role for type 3 immunity, in part regulated by Th17 and γδ 17 cells, and related tissue-protective cytokines as a key feature of systemic inflammation following injury. These endotypes may represent archetypal adaptive, over-exuberant, and overly damped inflammatory responses.
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Affiliation(s)
- Lukas Schimunek
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Haley Lindberg
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Maria Cohen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rami A Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Qi Mi
- Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regeneration Medicine, University of Pittsburgh, Pittsburgh, PA, United State
| | - Jinling Yin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Derek Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Fayten El-Dehaibi
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Andrew Abboud
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regeneration Medicine, University of Pittsburgh, Pittsburgh, PA, United State
| | - Timothy Robert Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regeneration Medicine, University of Pittsburgh, Pittsburgh, PA, United State
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regeneration Medicine, University of Pittsburgh, Pittsburgh, PA, United State
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485
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Törnblom S, Nisula S, Vaara ST, Poukkanen M, Andersson S, Pettilä V, Pesonen E. Early prolonged neutrophil activation in critically ill patients with sepsis. Innate Immun 2021; 27:192-200. [PMID: 33461369 PMCID: PMC7882810 DOI: 10.1177/1753425920980078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We hypothesised that plasma concentrations of biomarkers of neutrophil activation and pro-inflammatory cytokines differ according to the phase of rapidly evolving sepsis. In an observational study, we measured heparin-binding protein (HBP), myeloperoxidase (MPO), IL-6 and IL-8 in 167 sepsis patients on intensive care unit admission. We prospectively used the emergence of the first sepsis-associated organ dysfunction (OD) as a surrogate for the sepsis phase. Fifty-five patients (of 167, 33%) developed the first OD > 1 h before, 74 (44%) within ± 1 h, and 38 (23%) > 1 h after intensive care unit admission. HBP and MPO were elevated at a median of 12 h before the first OD, remained high up to 24 h, and were not associated with sepsis phase. IL-6 and IL-8 rose and declined rapidly close to OD emergence. Elevation of neutrophil activation markers HBP and MPO was an early event in the evolution of sepsis, lasting beyond the subsidence of the pro-inflammatory cytokine reaction. Thus, as sepsis biomarkers, HBP and MPO were not as prone as IL-6 and IL-8 to the effect of sample timing.
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Affiliation(s)
- Sanna Törnblom
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Sara Nisula
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Meri Poukkanen
- Department of Anaesthesia and Intensive Care Medicine, Lapland Central Hospital, Finland
| | - Sture Andersson
- New Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Eero Pesonen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
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486
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Carsetti A, Bignami E, Cortegiani A, Donadello K, Donati A, Foti G, Grasselli G, Romagnoli S, Antonelli M, DE Blasio E, Forfori F, Guarracino F, Scolletta S, Tritapepe L, Scudeller L, Cecconi M, Girardis M. Good clinical practice for the use of vasopressor and inotropic drugs in critically ill patients: state-of-the-art and expert consensus. Minerva Anestesiol 2021; 87:714-732. [PMID: 33432794 DOI: 10.23736/s0375-9393.20.14866-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Vasopressors and inotropic agents are widely used in critical care. However, strong evidence supporting their use in critically ill patients is lacking in many clinical scenarios. Thus, the Italian Society of Anesthesia and Intensive Care (SIAARTI) promoted a project aimed to provide indications for good clinical practice on the use of vasopressors and inotropes, and on the management of critically ill patients with shock. A panel of 16 experts in the field of intensive care medicine and hemodynamics has been established. Systematic review of the available literature was performed based on PICO questions. Basing on available evidence, the panel prepared a summary of evidence and then wrote the clinical questions. A modified semi-quantitative RAND/UCLA appropriateness method has been used to determine the appropriateness of specific clinical scenarios. The panel identified 29 clinical questions for the use of vasopressors and inotropes in patients with septic shock and cardiogenic shock. High level of agreement exists among the panel members about appropriateness of inotropes/vasopressors' use in patients with septic shock and cardiogenic shock.
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Affiliation(s)
- Andrea Carsetti
- Anesthesia and Intensive Care Unit, Ospedali Riuniti University Hospital, Ancona, Italy - .,Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy -
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science, Section of Anesthesia, Analgesia, Intensive Care and Emergency, Paolo Giaccone Polyclinic Hospital, University of Palermo, Palermo, Italy
| | - Katia Donadello
- Anesthesia and Intensive Care B Unit, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Ospedali Riuniti University Hospital, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Careggi University Hospital, Florence, Italy
| | - Massimo Antonelli
- Department of Anesthesiology Emergency and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Francesco Forfori
- Department of Anesthesia and Intensive Care, University of Pisa, Pisa Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Pisana University Hospital, Pisa, Italy
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Luigi Tritapepe
- Anesthesia and Intensive Care Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luigia Scudeller
- Scientific Direction, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Milan, Italy and Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, Modena University Hospital, Modena, Italy
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487
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Quadrini KJ, Patti-Diaz L, Maghsoudlou J, Cuomo J, Hedrick MN, McCloskey TW. A flow cytometric assay for HLA-DR expression on monocytes validated as a biomarker for enrollment in sepsis clinical trials. CYTOMETRY PART B-CLINICAL CYTOMETRY 2021; 100:103-114. [PMID: 33432735 DOI: 10.1002/cyto.b.21987] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Decreased expression of HLA-DR on monocytes (mHLA-DR) is a reliable indicator of immunosuppression in patients with sepsis and is correlated with increased risk of secondary infection and mortality. A flow cytometry-based laboratory developed test for the measurement of mHLA-DR in whole blood was validated for clinical trial enrollment, which is considered medical decision-making, for patients with severe sepsis or septic shock. METHODS The BD Quantibrite™ anti-HLA-DR/anti-monocyte reagent measures antibodies bound per cell of HLA-DR on CD14+ monocytes. The mHLA-DR assay was planned to support inclusion/exclusion of patients for a clinical trial and was validated according to New York State Department of Health (NYSDOH) requirements for a new non-malignant leukocyte immunophenotyping assay. RESULTS Normal, healthy donor and sepsis patient samples were stable up to 72 h post-collection in Cyto-Chex BCT phlebotomy tubes. Pre-determined acceptance criteria were met for precision parameters (average %CV ≤ 20%) and global laboratory-to-laboratory comparisons (average %Δ ≤ 20%). The approaches taken to evaluate and report accuracy, analytical specificity and sensitivity, reportable range, reference interval, and the proposed multi-level quality control were accepted by NYSDOH. CONCLUSIONS In this study, the validation strategy necessary when the intended use of assay results changes from exploratory to medical decision making (patient enrollment), which successfully resulted in regulatory approval, is described.
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Affiliation(s)
- Karen J Quadrini
- Department of Research and Development, ICON Laboratory Services, Farmingdale, New York, USA
| | - Lisa Patti-Diaz
- Clinical Flow Cytometry, Department of Translational Pathology and Biomarker Technologies, Bristol-Myers Squibb, Lawrenceville, New Jersey, USA
| | - Jasmin Maghsoudlou
- Department of Research and Development, ICON Laboratory Services, Farmingdale, New York, USA
| | - Joanne Cuomo
- Cellular Immunology, ICON Laboratory Services, Farmingdale, New York, USA
| | - Michael Nathan Hedrick
- Clinical Flow Cytometry, Department of Translational Pathology and Biomarker Technologies, Bristol-Myers Squibb, Lawrenceville, New Jersey, USA
| | - Thomas W McCloskey
- Department of Research and Development, ICON Laboratory Services, Farmingdale, New York, USA
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488
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Donovan K, Shah A, Day J, McKechnie SR. Adjunctive treatments for the management of septic shock - a narrative review of the current evidence. Anaesthesia 2021; 76:1245-1258. [PMID: 33421029 DOI: 10.1111/anae.15369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.
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Affiliation(s)
- K Donovan
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Shah
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - J Day
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S R McKechnie
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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489
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Abstract
Coronaviruses are enveloped non-segmented positive-sense RNA viruses belonging to the family Coronaviridae. The human coronavirus infections are mild; the epidemics of the two β-coronaviruses, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) have caused more than ten thousand cumulative cases in the past twodecades. There is a new public health crisis threatening the world with the emergence and spread of 2019 novel coronavirus (2019-nCoV). The virus originated in bats and was transmitted to humans through yet unknown intermediary animals in Wuhan, Hubei province in China during the month of December 2019. Till date around 7,823,289 reported cases of coronavirus disease 2019 (COVID-2019) and 431,541 reported deaths till date. The disease is transmitted by inhalation or contact with infected droplets with incubation period of 2–14 days. The symptoms are usually fever, sore throat, dry cough, breathlessness, fatigue while many people are asymptomatic. Coronavirus (2019-nCoV) may progress to pneumonia, acute respiratory distress syndrome (ARDS) and can cause multi-organ dysfunction. Currently diagnosis is done by demonstration of the virus in respiratory secretions by special molecular tests like real-time reverse-transcription–polymerase-chain-reaction (RT-PCR), Radiological examinations (chest CT). Common laboratory tests like white cell counts and C-reactive protein (CRP) and measure symptoms can be used as preliminary screening at large scale after lock down the area or country. Treatment is essentially supportive; role of antiviral agents is yet to be established. It is paramount to implement infection control practices by infection source controlling, transmission route blocking, and susceptible population protection. Early preventive measures can be home isolation of suspected cases and those with mild illnesses and strict infection control measures at hospitals that include contact and droplet precautions. The worldwide impact of this Coronavirus new epidemic is yet uncertain.
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490
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Disentangled Hyperspherical Clustering for Sepsis Phenotyping. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-77211-6_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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491
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Chaudhuri S, Long A, Zhang H, Monaghan C, Larkin JW, Kotanko P, Kalaskar S, Kooman JP, van der Sande FM, Maddux FW, Usvyat LA. Artificial intelligence enabled applications in kidney disease. Semin Dial 2021; 34:5-16. [PMID: 32924202 PMCID: PMC7891588 DOI: 10.1111/sdi.12915] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Artificial intelligence (AI) is considered as the next natural progression of traditional statistical techniques. Advances in analytical methods and infrastructure enable AI to be applied in health care. While AI applications are relatively common in fields like ophthalmology and cardiology, its use is scarcely reported in nephrology. We present the current status of AI in research toward kidney disease and discuss future pathways for AI. The clinical applications of AI in progression to end-stage kidney disease and dialysis can be broadly subdivided into three main topics: (a) predicting events in the future such as mortality and hospitalization; (b) providing treatment and decision aids such as automating drug prescription; and (c) identifying patterns such as phenotypical clusters and arteriovenous fistula aneurysm. At present, the use of prediction models in treating patients with kidney disease is still in its infancy and further evidence is needed to identify its relative value. Policies and regulations need to be addressed before implementing AI solutions at the point of care in clinics. AI is not anticipated to replace the nephrologists' medical decision-making, but instead assist them in providing optimal personalized care for their patients.
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Affiliation(s)
- Sheetal Chaudhuri
- Maastricht University Medical CenterMaastrichtThe Netherlands
- Fresenius Medical CareWalthamMAUSA
| | | | | | | | | | - Peter Kotanko
- Renal Research InstituteNew YorkNYUSA
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
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492
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Soussi S, Collins GS, Jüni P, Mebazaa A, Gayat E, Le Manach Y. Evaluation of Biomarkers in Critical Care and Perioperative Medicine: A Clinician’s Overview of Traditional Statistical Methods and Machine Learning Algorithms. Anesthesiology 2021; 134:15-25. [PMID: 33216849 DOI: 10.1097/aln.0000000000003600] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Interest in developing and using novel biomarkers in critical care and perioperative medicine is increasing. Biomarkers studies are often presented with flaws in the statistical analysis that preclude them from providing a scientifically valid and clinically relevant message for clinicians. To improve scientific rigor, the proper application and reporting of traditional and emerging statistical methods (e.g., machine learning) of biomarker studies is required. This Readers' Toolbox article aims to be a starting point to nonexpert readers and investigators to understand traditional and emerging research methods to assess biomarkers in critical care and perioperative medicine.
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493
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da Silva JF, Hernandez-Romieu AC, Browning SD, Bruce BB, Natarajan P, Morris SB, Gold JAW, Neblett Fanfair R, Rogers-Brown J, Rossow J, Szablewski CM, Oosmanally N, D’Angelo MT, Drenzek C, Murphy DJ, Hollberg J, Blum JM, Jansen R, Wright DW, Sewell W, Owens J, Lefkove B, Brown FW, Burton DC, Uyeki TM, Patel PR, Jackson BR, Wong KK. COVID-19 Clinical Phenotypes: Presentation and Temporal Progression of Disease in a Cohort of Hospitalized Adults in Georgia, United States. Open Forum Infect Dis 2021; 8:ofaa596. [PMID: 33537363 PMCID: PMC7798484 DOI: 10.1093/ofid/ofaa596] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The epidemiological features and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) have been described; however, the temporal progression and medical complications of disease among hospitalized patients require further study. Detailed descriptions of the natural history of COVID-19 among hospitalized patients are paramount to optimize health care resource utilization, and the detection of different clinical phenotypes may allow tailored clinical management strategies. METHODS This was a retrospective cohort study of 305 adult patients hospitalized with COVID-19 in 8 academic and community hospitals. Patient characteristics included demographics, comorbidities, medication use, medical complications, intensive care utilization, and longitudinal vital sign and laboratory test values. We examined laboratory and vital sign trends by mortality status and length of stay. To identify clinical phenotypes, we calculated Gower's dissimilarity matrix between each patient's clinical characteristics and clustered similar patients using the partitioning around medoids algorithm. RESULTS One phenotype of 6 identified was characterized by high mortality (49%), older age, male sex, elevated inflammatory markers, high prevalence of cardiovascular disease, and shock. Patients with this severe phenotype had significantly elevated peak C-reactive protein creatinine, D-dimer, and white blood cell count and lower minimum lymphocyte count compared with other phenotypes (P < .01, all comparisons). CONCLUSIONS Among a cohort of hospitalized adults, we identified a severe phenotype of COVID-19 based on the characteristics of its clinical course and poor prognosis. These findings need to be validated in other cohorts, as improved understanding of clinical phenotypes and risk factors for their development could help inform prognosis and tailored clinical management for COVID-19.
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Affiliation(s)
- Juliana F da Silva
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alfonso C Hernandez-Romieu
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Sean D Browning
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Beau B Bruce
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pavithra Natarajan
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sapna B Morris
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Jeremy A W Gold
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robyn Neblett Fanfair
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Jessica Rogers-Brown
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John Rossow
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Christine M Szablewski
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Georgia Department of Public Health, Atlanta, Georgia, USA
| | | | | | - Cherie Drenzek
- Georgia Department of Public Health, Atlanta, Georgia, USA
| | - David J Murphy
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julie Hollberg
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - James M Blum
- Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, USA
| | | | - David W Wright
- Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, USA
- Grady Health System, Atlanta, Georgia, USA
| | | | - Jack Owens
- Phoebe Putney Memorial Hospital, Albany, Georgia, USA
| | | | - Frank W Brown
- Georgia Clinical & Translational Science Alliance, Atlanta, Georgia, USA
- Emory Decatur Hospital, Decatur, Georgia, USA
| | - Deron C Burton
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Timothy M Uyeki
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Priti R Patel
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Brendan R Jackson
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
| | - Karen K Wong
- CDC COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- United States Public Health Service
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494
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Artificial Intelligence in Critical Care. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_174-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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495
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Kausch SL, Lobo JM, Spaeder MC, Sullivan B, Keim-Malpass J. Dynamic Transitions of Pediatric Sepsis: A Markov Chain Analysis. Front Pediatr 2021; 9:743544. [PMID: 34660494 PMCID: PMC8517521 DOI: 10.3389/fped.2021.743544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/06/2021] [Indexed: 12/23/2022] Open
Abstract
Pediatric sepsis is a heterogeneous disease with varying physiological dynamics associated with recovery, disability, and mortality. Using risk scores generated from a sepsis prediction model to define illness states, we used Markov chain modeling to describe disease dynamics over time by describing how children transition among illness states. We analyzed 18,666 illness state transitions over 157 pediatric intensive care unit admissions in the 3 days following blood cultures for suspected sepsis. We used Shannon entropy to quantify the differences in transition matrices stratified by clinical characteristics. The population-based transition matrix based on the sepsis illness severity scores in the days following a sepsis diagnosis can describe a sepsis illness trajectory. Using the entropy based on Markov chain transition matrices, we found a different structure of dynamic transitions based on ventilator use but not age group. Stochastic modeling of transitions in sepsis illness severity scores can be useful in describing the variation in transitions made by patient and clinical characteristics.
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Affiliation(s)
- Sherry L Kausch
- School of Nursing, University of Virginia, Charlottesville, VA, United States.,Center for Advanced Medical Analytics, University of Virginia, Charlottesville, VA, United States
| | - Jennifer M Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Michael C Spaeder
- Center for Advanced Medical Analytics, University of Virginia, Charlottesville, VA, United States.,Department of Pediatrics, Division of Pediatric Critical Care, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Brynne Sullivan
- Center for Advanced Medical Analytics, University of Virginia, Charlottesville, VA, United States.,Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Jessica Keim-Malpass
- School of Nursing, University of Virginia, Charlottesville, VA, United States.,Center for Advanced Medical Analytics, University of Virginia, Charlottesville, VA, United States
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496
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Sevransky JE, Agarwal A, Jabaley CS, Rochwerg B. Standardized Care Is Better Than Individualized Care for the Majority of Critically Ill Patients. Crit Care Med 2021; 49:151-155. [PMID: 33060504 PMCID: PMC8635275 DOI: 10.1097/ccm.0000000000004676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep and Emory Center for Critical Care, Emory University, Atlanta, GA
| | - Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care, and Sleep and Emory Center for Critical Care, Emory University, Atlanta, GA
| | - Craig S Jabaley
- Department of Anesthesiology and Emory Center for Critical Care, Emory University, Atlanta, GA
| | - Bram Rochwerg
- Department of Medicine, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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497
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Rivera EAT, Patel AK, Chamberlain JM, Workman TE, Heneghan JA, Redd D, Morizono H, Kim D, Bost JE, Pollack MM. Criticality: A New Concept of Severity of Illness for Hospitalized Children. Pediatr Crit Care Med 2021; 22:e33-e43. [PMID: 32932406 PMCID: PMC7790867 DOI: 10.1097/pcc.0000000000002560] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To validate the conceptual framework of "criticality," a new pediatric inpatient severity measure based on physiology, therapy, and therapeutic intensity calibrated to care intensity, operationalized as ICU care. DESIGN Deep neural network analysis of a pediatric cohort from the Health Facts (Cerner Corporation, Kansas City, MO) national database. SETTING Hospitals with pediatric routine inpatient and ICU care. PATIENTS Children cared for in the ICU (n = 20,014) and in routine care units without an ICU admission (n = 20,130) from 2009 to 2016. All patients had laboratory, vital sign, and medication data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A calibrated, deep neural network used physiology (laboratory tests and vital signs), therapy (medications), and therapeutic intensity (number of physiology tests and medications) to model care intensity, operationalized as ICU (versus routine) care every 6 hours of a patient's hospital course. The probability of ICU care is termed the Criticality Index. First, the model demonstrated excellent separation of criticality distributions from a severity hierarchy of five patient groups: routine care, routine care for those who also received ICU care, transition from routine to ICU care, ICU care, and high-intensity ICU care. Second, model performance assessed with statistical metrics was excellent with an area under the curve for the receiver operating characteristic of 0.95 for 327,189 6-hour time periods, excellent calibration, sensitivity of 0.817, specificity of 0.892, accuracy of 0.866, and precision of 0.799. Third, the performance in individual patients with greater than one care designation indicated as 88.03% (95% CI, 87.72-88.34) of the Criticality Indices in the more intensive locations was higher than the less intense locations. CONCLUSIONS The Criticality Index is a quantification of severity of illness for hospitalized children using physiology, therapy, and care intensity. This new conceptual model is applicable to clinical investigations and predicting future care needs.
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Affiliation(s)
| | - Anita K Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - T Elizabeth Workman
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Julia A Heneghan
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Douglas Redd
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Hiroki Morizono
- Department of Genomics and Precision Medicine, Children's National Research Institute, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Dongkyu Kim
- Division of Biostatistics and Study Methodology, Department of Pediatrics, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E Bost
- Division of Biostatistics and Study Methodology, Department of Pediatrics, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
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498
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Shannon O. The role of platelets in sepsis. Res Pract Thromb Haemost 2021; 5:27-37. [PMID: 33537527 PMCID: PMC7845078 DOI: 10.1002/rth2.12465] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/06/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022] Open
Abstract
A State of the Art lecture titled "The role of platelets in sepsis" was presented at the ISTH congress in 2020. Sepsis is a life-threatening organ dysfunction caused by a dysregulated and multifaceted host response to infection. Platelets play a significant role in the coordinated immune response to infection and therefore in the inflammation and coagulation dysfunction that contributes to organ damage in sepsis. Thrombocytopenia has a high incidence in sepsis, and it is a marker of poor prognosis. The genesis of thrombocytopenia is likely multifactorial, and unraveling the involved molecular mechanisms will allow development of biomarkers of platelet function in sepsis. Such platelet biomarkers can facilitate study of antiplatelet interventions as immunomodulatory treatment in sepsis. Finally, relevant new data on this topic presented during the 2020 ISTH virtual congress are reviewed.
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Affiliation(s)
- Oonagh Shannon
- Division of Infection MedicineDepartment of Clinical SciencesFaculty of MedicineLund UniversityLundSweden
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499
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Leukocyte glucocorticoid receptor expression and related transcriptomic gene signatures during early sepsis. Clin Immunol 2020; 223:108660. [PMID: 33352295 DOI: 10.1016/j.clim.2020.108660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/04/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The study aimed to understand the molecular mechanisms that might lead to differences in the glucocorticoid response during sepsis. METHODS Patients diagnosed with sepsis (n = 198) and 40 healthy controls were enrolled. Glucocorticoid receptor (GR) expression in circulating leukocytes and plasma levels of adrenocorticotropic hormone and cortisol on days 1 and 7 were measured in all participants. Expression profiling of 16 genes associated with GR expression in peripheral blood mononuclear cells (PBMCs) in 12 healthy controls and 26 patients with sepsis was performed by PCR. RESULTS Cortisol levels were higher in patients with sepsis than in healthy controls on day 1 after admission and recovered to normal levels by day 7. GR expression was gradually downregulated in leukocyte subsets. Non-survivors showed lower GR and higher cortisol levels than survivors. GRα expression was lower in patients with sepsis than in controls, whereas GRβ showed the opposite trend. MicroRNAs related to GR resistance and suppression were altered in PBMCs during sepsis. CONCLUSION Patients with sepsis showed upregulated plasma cortisol levels along with downregulated GR expression on various leukocyte subtypes, portending poor cortisol response and outcome. Changes in GR-regulatory miRNAs may be responsible for GR low expression.
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500
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Kangelaris KN, Clemens R, Fang X, Jauregui A, Liu T, Vessel K, Deiss T, Sinha P, Leligdowicz A, Liu KD, Zhuo H, Alder MN, Wong HR, Calfee CS, Lowell C, Matthay MA. A neutrophil subset defined by intracellular olfactomedin 4 is associated with mortality in sepsis. Am J Physiol Lung Cell Mol Physiol 2020; 320:L892-L902. [PMID: 33355521 DOI: 10.1152/ajplung.00090.2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a heterogeneous syndrome clinically and biologically, but biomarkers of distinct host response pathways for early prognostic information and testing targeted treatments are lacking. Olfactomedin 4 (OLFM4), a matrix glycoprotein of neutrophil-specific granules, defines a distinct neutrophil subset that may be an independent risk factor for poor outcomes in sepsis. We hypothesized that increased percentage of OLFM4+ neutrophils on sepsis presentation would be associated with mortality. In a single-center, prospective cohort study, we enrolled adults admitted to an academic medical center from the emergency department (ED) with suspected sepsis [identified by 2 or greater systemic inflammatory response syndrome (SIRS) criteria and antibiotic receipt] from March 2016 through December 2017, followed by sepsis adjudication according to Sepsis-3. We collected 200 µL of whole blood within 24 h of admission and stained for the neutrophil surface marker CD66b followed by intracellular staining for OLFM4 quantitated by flow cytometry. The predictors for 60-day mortality were 1) percentage of OLFM4+ neutrophils and 2) OLFM4+ neutrophils at a cut point of ≥37.6% determined by the Youden Index. Of 120 enrolled patients with suspected sepsis, 97 had sepsis and 23 had nonsepsis SIRS. The mean percentage of OLFM4+ neutrophils was significantly increased in both sepsis and nonsepsis SIRS patients who died (P ≤ 0.01). Among sepsis patients with elevated OLFM4+ (≥37.6%), 56% died, compared with 18% with OLFM4+ <37.6% (P = 0.001). The association between OLFM4+ and mortality withstood adjustment for age, sex, absolute neutrophil count, comorbidities, and standard measures of severity of illness (SOFA score, APACHE III) (P < 0.03). In summary, OLFM4+ neutrophil percentage is independently associated with 60-day mortality in sepsis and may represent a novel measure of the heterogeneity of host response to sepsis.
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Affiliation(s)
- Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Regina Clemens
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Xiaohui Fang
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Alejandra Jauregui
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Tom Liu
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Kathryn Vessel
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Thomas Deiss
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Pratik Sinha
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Aleksandra Leligdowicz
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen D Liu
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Hanjing Zhuo
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Matthew N Alder
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hector R Wong
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carolyn S Calfee
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
| | - Clifford Lowell
- Department of Laboratory Medicine, University of California, San Francisco, California
| | - Michael A Matthay
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, California.,Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, California
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