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Clinical and biological clusters of sepsis patients using hierarchical clustering. PLoS One 2021; 16:e0252793. [PMID: 34347776 PMCID: PMC8336799 DOI: 10.1371/journal.pone.0252793] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background Heterogeneity in sepsis expression is multidimensional, including highly disparate data such as the underlying disorders, infection source, causative micro-organismsand organ failures. The aim of the study is to identify clusters of patients based on clinical and biological characteristic available at patients’ admission. Methods All patients included in a national prospective multicenter ICU cohort OUTCOMEREA and admitted for sepsis or septic shock (Sepsis 3.0 definition) were retrospectively analyzed. A hierarchical clustering was performed in a training set of patients to build clusters based on a comprehensive set of clinical and biological characteristics available at ICU admission. Clusters were described, and the 28-day, 90-day, and one-year mortality were compared with log-rank rates. Risks of mortality were also compared after adjustment on SOFA score and year of ICU admission. Results Of the 6,046 patients with sepsis in the cohort, 4,050 (67%) were randomly allocated to the training set. Six distinct clusters were identified: young patients without any comorbidities, admitted in ICU for community-acquired pneumonia (n = 1,603 (40%)); young patients without any comorbidities, admitted in ICU for meningitis or encephalitis (n = 149 (4%)); elderly patients with COPD, admitted in ICU for bronchial infection with few organ failures (n = 243 (6%)); elderly patients, with several comorbidities and organ failures (n = 1,094 (27%)); patients admitted after surgery, with a nosocomial infection (n = 623 (15%)); young patients with immunosuppressive conditions (e.g., AIDS, chronic steroid therapy or hematological malignancy) (n = 338 (8%)). Clusters differed significantly in early or late mortality (p < .001), even after adjustment on severity of organ dysfunctions (SOFA) and year of ICU admission. Conclusions Clinical and biological features commonly available at ICU admission of patients with sepsis or septic shock enabled to set up six clusters of patients, with very distinct outcomes. Considering these clusters may improve the care management and the homogeneity of patients in future studies.
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Affiliation(s)
- David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Centre, Kingston, ON, Canada
- Roslin Institute, University of Edinburgh, Easter Bush, Edinburgh, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, United Kingdom
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - J Kenneth Baillie
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Centre, Kingston, ON, Canada
- Roslin Institute, University of Edinburgh, Easter Bush, Edinburgh, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, United Kingdom
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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103
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Xu N, Guo H, Li X, Zhao Q, Li J. A Five-Genes Based Diagnostic Signature for Sepsis-Induced ARDS. Pathol Oncol Res 2021; 27:580801. [PMID: 34393665 PMCID: PMC8357742 DOI: 10.3389/pore.2021.580801] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/26/2021] [Indexed: 01/10/2023]
Abstract
Background: Acute respiratory distress syndrome (ARDS) is a frequent and serious complication of sepsis without specific and sensitive diagnostic signatures. Methods: The mRNA profiles, including 60 blood samples with sepsis-induced ARDS and 86 blood samples with sepsis alone, were obtained from the Gene Expression Omnibus (GEO). The differently expressed genes (DEGs) were analyzed by limma package of R language. Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were carried out using the clusterProfiler package of R. Eventually, multivariate logistic regression model was established through the glm function of R, and support vector machine (SVM) model was constructed via the e1071 package of R. Results: A total of 242 DEGs in GSE32707 and 102 DEGs in GSE66890 were identified. Notably, five genes exhibited significant differences between the two datasets and were considered to be closely associated with the occurrence of ARDS induced by sepsis. Furthermore, functional enrichment analysis based on the DEGs showed there were 80 overlapped GO terms and one KEGG pathway which were significantly enriched in the two datasets. The logistic regression model and SVM model constructed could efficiently distinguish sepsis patients with or without ARDS. Conclusion: In brief, our study suggested that NKG7, SPTA1, FGL2, RGS2, and IFI27 might be potential diagnostic signatures for sepsis-induced ARDS, which contributed to the future exploration in mechanism of ARDS occurrence and development.
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Affiliation(s)
- Ning Xu
- Department of Emergency, Hebei General Hospital, Shijiazhuang, China
| | - Hui Guo
- Department of Emergency, Hebei General Hospital, Shijiazhuang, China
| | - Xurui Li
- Department of General Practice, Hebei General Hospital, Shijiazhuang, China
| | - Qian Zhao
- Department of Emergency, Hebei General Hospital, Shijiazhuang, China
| | - Jianguo Li
- Department of Emergency, Hebei General Hospital, Shijiazhuang, China
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104
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Darden DB, Ghita GL, Wang Z, Stortz JA, Lopez MC, Cox MC, Hawkins RB, Rincon JC, Kelly LS, Fenner BP, Ozrazgat-Baslanti T, Leeuwenburgh C, Bihorac A, Loftus TJ, Moore FA, Brakenridge SC, Baker HV, Bacher R, Mohr AM, Moldawer LL, Efron PA. Chronic Critical Illness Elicits a Unique Circulating Leukocyte Transcriptome in Sepsis Survivors. J Clin Med 2021; 10:3211. [PMID: 34361995 PMCID: PMC8348105 DOI: 10.3390/jcm10153211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Surgical sepsis has evolved into two major subpopulations: patients who rapidly recover, and those who develop chronic critical illness (CCI). Our primary aim was to determine whether CCI sepsis survivors manifest unique blood leukocyte transcriptomes in late sepsis that differ from transcriptomes among sepsis survivors with rapid recovery. In a prospective cohort study of surgical ICU patients, genome-wide expression analysis was conducted on total leukocytes in human whole blood collected on days 1 and 14 from sepsis survivors who rapidly recovered or developed CCI, defined as ICU length of stay ≥ 14 days with persistent organ dysfunction. Both sepsis patients who developed CCI and those who rapidly recovered exhibited marked changes in genome-wide expression at day 1 which remained abnormal through day 14. Although summary changes in gene expression were similar between CCI patients and subjects who rapidly recovered, CCI patients exhibited differential expression of 185 unique genes compared with rapid recovery patients at day 14 (p < 0.001). The transcriptomic patterns in sepsis survivors reveal an ongoing immune dyscrasia at the level of the blood leukocyte transcriptome, consistent with persistent inflammation and immune suppression. Furthermore, the findings highlight important genes that could compose a prognostic transcriptomic metric or serve as therapeutic targets among sepsis patients that develop CCI.
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Affiliation(s)
- Dijoia B. Darden
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Gabriela L. Ghita
- Department of Biostatistics, University of Florida, Gainesville, FL 32610, USA; (G.L.G.); (Z.W.); (R.B.)
| | - Zhongkai Wang
- Department of Biostatistics, University of Florida, Gainesville, FL 32610, USA; (G.L.G.); (Z.W.); (R.B.)
| | - Julie A. Stortz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Maria-Cecilia Lopez
- Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA; (M.-C.L.); (H.V.B.)
| | - Michael C. Cox
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Russell B. Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Jaimar C. Rincon
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Lauren S. Kelly
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Brittany P. Fenner
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Tezcan Ozrazgat-Baslanti
- Department of Aging and Geriatric Research, University of Florida, Gainesville, FL 32610, USA; (T.O.-B.); (C.L.)
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, University of Florida, Gainesville, FL 32610, USA; (T.O.-B.); (C.L.)
| | - Azra Bihorac
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Tyler J. Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Frederick A. Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Scott C. Brakenridge
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Henry V. Baker
- Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA; (M.-C.L.); (H.V.B.)
| | - Rhonda Bacher
- Department of Biostatistics, University of Florida, Gainesville, FL 32610, USA; (G.L.G.); (Z.W.); (R.B.)
| | - Alicia M. Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Lyle L. Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
| | - Philip A. Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.B.D.); (J.A.S.); (M.C.C.); (R.B.H.); (J.C.R.); (L.S.K.); (B.P.F.); (T.J.L.); (F.A.M.); (S.C.B.); (A.M.M.); (L.L.M.)
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105
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Ma P, Liu J, Shen F, Liao X, Xiu M, Zhao H, Zhao M, Xie J, Wang P, Huang M, Li T, Duan M, Qian K, Peng Y, Zhou F, Xin X, Wan X, Wang Z, Li S, Han J, Li Z, Ding G, Deng Q, Zhang J, Zhu Y, Ma W, Wang J, Kang Y, Zhang Z. Individualized resuscitation strategy for septic shock formalized by finite mixture modeling and dynamic treatment regimen. Crit Care 2021; 25:243. [PMID: 34253228 PMCID: PMC8273991 DOI: 10.1186/s13054-021-03682-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Septic shock comprises a heterogeneous population, and individualized resuscitation strategy is of vital importance. The study aimed to identify subclasses of septic shock with non-supervised learning algorithms, so as to tailor resuscitation strategy for each class. METHODS Patients with septic shock in 25 tertiary care teaching hospitals in China from January 2016 to December 2017 were enrolled in the study. Clinical and laboratory variables were collected on days 0, 1, 2, 3 and 7 after ICU admission. Subclasses of septic shock were identified by both finite mixture modeling and K-means clustering. Individualized fluid volume and norepinephrine dose were estimated using dynamic treatment regime (DTR) model to optimize the final mortality outcome. DTR models were validated in the eICU Collaborative Research Database (eICU-CRD) dataset. RESULTS A total of 1437 patients with a mortality rate of 29% were included for analysis. The finite mixture modeling and K-means clustering robustly identified five classes of septic shock. Class 1 (baseline class) accounted for the majority of patients over all days; class 2 (critical class) had the highest severity of illness; class 3 (renal dysfunction) was characterized by renal dysfunction; class 4 (respiratory failure class) was characterized by respiratory failure; and class 5 (mild class) was characterized by the lowest mortality rate (21%). The optimal fluid infusion followed the resuscitation/de-resuscitation phases with initial large volume infusion and late restricted volume infusion. While class 1 transitioned to de-resuscitation phase on day 3, class 3 transitioned on day 1. Classes 1 and 3 might benefit from early use of norepinephrine, and class 2 can benefit from delayed use of norepinephrine while waiting for adequate fluid infusion. CONCLUSIONS Septic shock comprises a heterogeneous population that can be robustly classified into five phenotypes. These classes can be easily identified with routine clinical variables and can help to tailor resuscitation strategy in the context of precise medicine.
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Affiliation(s)
- Penglin Ma
- Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, People's Republic of China
| | - Jingtao Liu
- Department of Critical Care Medicine, The 8th Medical Center of Chinese, PLA General Hospital, Beijing, 100091, People's Republic of China
| | - Feng Shen
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, People's Republic of China
| | - Xuelian Liao
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Ming Xiu
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Jing Xie
- General Intensive Care Unit Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Peng Wang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Man Huang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Kejian Qian
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Yue Peng
- Department of Critical Care Medicine, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xianyao Wan
- The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - ZongYu Wang
- Department of Intensive Care, Peking University Third Hospital, Beijing, People's Republic of China
| | - Shusheng Li
- Department of Emergency, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jianwei Han
- Department of Critical Care Medicine, The 8th medical Center of Chinese, PLA General Hospital, Beijing, People's Republic of China
| | - Zhenliang Li
- Department of Critical Care, Beijing PingGu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guolei Ding
- Intensive Care Unit, The Hospital of Shunyi District, Beijing, People's Republic of China
| | - Qun Deng
- Department of Critical Care Medicine, The 4th Medical Center of Chinese, PLA General Hospital, Beijing, People's Republic of China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, People's Republic of China
| | - Yue Zhu
- Department of Critical Care, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenjing Ma
- Department of Critical Care, Beijing Miyun Hospital, Beijing, People's Republic of China
| | - Jingwen Wang
- Intensive Care Unit, Beijing Changping District Hospital, Beijing, People's Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, People's Republic of China.
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Nunnally ME, Ferrer R, Martin GS, Martin-Loeches I, Machado FR, De Backer D, Coopersmith CM, Deutschman CS. The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis. Intensive Care Med Exp 2021; 9:34. [PMID: 34212256 PMCID: PMC8249046 DOI: 10.1186/s40635-021-00400-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/07/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To identify priorities for administrative, epidemiologic and diagnostic research in sepsis. Design As a follow-up to a previous consensus statement about sepsis research, members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis. Methods Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified through a consensus process. Results The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?; (2) What is the epidemiology of sepsis susceptibility and response to treatment?; (3) What information identifies organ dysfunction?; (4) How can we screen for sepsis in various settings?; (5) How do we identify septic shock?; and (6) What in-hospital clinical information is associated with important outcomes in patients with sepsis? Conclusions There is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritize initiatives to improve an understanding of individual patient and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care.
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Affiliation(s)
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation (SODIR) Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Grady Memorial Hospital and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | | | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,The Feinstein Institute for Medical Research/ Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
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107
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Ren X. Potential Endotype Transition for Coronavirus Disease 2019-Related Sepsis With Longitudinal Transcriptome Profiling. Crit Care Med 2021; 49:e719-e720. [PMID: 33769770 DOI: 10.1097/ccm.0000000000004975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Xinyong Ren
- Department of Emergency Medicine, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People's Republic of China
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108
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Endothelial Dysfunction and Neutrophil Degranulation as Central Events in Sepsis Physiopathology. Int J Mol Sci 2021; 22:ijms22126272. [PMID: 34200950 PMCID: PMC8230689 DOI: 10.3390/ijms22126272] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/02/2021] [Accepted: 06/08/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a major health problem worldwide. It is a time-dependent disease, with a high rate of morbidity and mortality. In this sense, an early diagnosis is essential to reduce these rates. The progressive increase of both the incidence and prevalence of sepsis has translated into a significant socioeconomic burden for health systems. Currently, it is the leading cause of noncoronary mortality worldwide and represents one of the most prevalent pathologies both in hospital emergency services and in intensive care units. In this article, we review the role of both endothelial dysfunction and neutrophil dysregulation in the physiopathology of this disease. The lack of a key symptom in sepsis makes it difficult to obtain a quick and accurate diagnosis of this condition. Thus, it is essential to have fast and reliable diagnostic tools. In this sense, the use of biomarkers can be a very important alternative when it comes to achieving these goals. Both new biomarkers and treatments related to endothelial dysfunction and neutrophil dysregulation deserve to be further investigated in order to open new venues for the diagnosis, treatment and prognosis of sepsis.
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109
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Characterizing the Patients, Hospitals, and Data Quality of the eICU Collaborative Research Database. Crit Care Med 2021; 48:1737-1743. [PMID: 33044284 DOI: 10.1097/ccm.0000000000004633] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The eICU Collaborative Research Database is a publicly available repository of granular data from more than 200,000 ICU admissions. The quantity and variety of its entries hold promise for observational critical care research. We sought to understand better the data available within this resource to guide its future use. DESIGN We conducted a descriptive analysis of the eICU Collaborative Research Database, including patient, practitioner, and hospital characteristics. We investigated the completeness of demographic and hospital data, as well as those values required to calculate an Acute Physiology and Chronic Health Evaluation score. We also assessed the rates of ventilation, intubation, and dialysis, and looked for potential errors in the vital sign data. SETTING American ICUs that participated in the Philips Healthcare eICU program between 2014 and 2015. PATIENTS A total of 139,367 individuals who were admitted to one of the 335 participating ICUs between 2014 and 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Most encounters were from small- and medium-sized hospitals, and managed by nonintensivists. The median ICU length of stay was 1.57 days (interquartile range, 0.82-2.97 d). The median Acute Physiology and Chronic Health Evaluation IV-predicted ICU mortality was 2.2%, with an observed mortality of 5.4%. Rates of ventilation (20-33%), intubation (15-24%), and dialysis (3-5%) varied according to the query method used. Most vital sign readings fell into realistic ranges, with manually curated data less likely to contain implausible results than automatically entered data. CONCLUSIONS Data in the eICU Collaborative Research Database are for the most part complete and plausible. Some ambiguity exists in determining which encounters are associated with various interventions, most notably mechanical ventilation. Caution is warranted in extrapolating findings from the eICU Collaborative Research Database to larger ICUs with higher acuity.
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110
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Schuurman AR, Reijnders TDY, Kullberg RFJ, Butler JM, van der Poll T, Wiersinga WJ. Sepsis: deriving biological meaning and clinical applications from high-dimensional data. Intensive Care Med Exp 2021; 9:27. [PMID: 33961170 PMCID: PMC8105470 DOI: 10.1186/s40635-021-00383-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/19/2021] [Indexed: 02/06/2023] Open
Abstract
The pathophysiology of sepsis is multi-facetted and highly complex. As sepsis is a leading cause of global mortality that still lacks targeted therapies, increased understanding of its pathogenesis is vital for improving clinical care and outcomes. An increasing number of investigations seeks to unravel the complexity of sepsis through high-dimensional data analysis, enabled by advances in -omics technologies. Here, we summarize progress in the following major -omics fields: genomics, epigenomics, transcriptomics, proteomics, lipidomics, and microbiomics. We describe what these fields can teach us about sepsis, and highlight current trends and future challenges. Finally, we focus on multi-omics integration, and discuss the challenges in deriving biological meaning and clinical applications from these types of data.
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Affiliation(s)
- Alex R Schuurman
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands.,Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands
| | - Tom D Y Reijnders
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands.,Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands
| | - Robert F J Kullberg
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands.,Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands
| | - Joe M Butler
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands.,Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands.,Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands. .,Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Noord-Holland, Amsterdam, 1105 AZ, The Netherlands.
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111
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Devadoss D, Daly G, Manevski M, Houserova D, Hussain SS, Baumlin N, Salathe M, Borchert G, Langley RJ, Chand HS. A long noncoding RNA antisense to ICAM-1 is involved in allergic asthma associated hyperreactive response of airway epithelial cells. Mucosal Immunol 2021; 14:630-639. [PMID: 33122732 PMCID: PMC8081750 DOI: 10.1038/s41385-020-00352-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 10/11/2020] [Accepted: 10/14/2020] [Indexed: 02/04/2023]
Abstract
Epithelial cells of the conducting airways are a pivotal first line of defense against airborne pathogens and allergens that orchestrate inflammatory responses and mucociliary clearance. Nonetheless, the molecular mechanisms responsible for epithelial hyperreactivity associated with allergic asthma are not completely understood. Transcriptomic analysis of human airway epithelial cells (HAECs), differentiated in-vitro at air-liquid interface (ALI), showed 725 differentially expressed immediate-early transcripts, including putative long noncoding RNAs (lncRNAs). A novel lncRNA on the antisense strand of ICAM-1 or LASI was identified, which was induced in LPS-primed HAECs along with mucin MUC5AC and its transcriptional regulator SPDEF. LPS-primed expression of LASI, MUC5AC, and SPDEF transcripts were higher in ex-vivo cultured asthmatic HAECs that were further augmented by LPS treatment. Airway sections from asthmatics with increased mucus load showed higher LASI expression in MUC5AC+ goblet cells following multi-fluorescent in-situ hybridization and immunostaining. LPS- or IL-13-induced LASI transcripts were mostly enriched in the nuclear/perinuclear region and were associated with increased ICAM-1, IL-6, and CXCL-8 expression. Blocking LASI expression reduced the LPS or IL-13-induced epithelial inflammatory factors and MUC5AC expression, suggesting that the novel lncRNA LASI could play a key role in LPS-primed trained airway epithelial responses that are dysregulated in allergic asthma.
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Affiliation(s)
- Dinesh Devadoss
- Department of Immunology and Nano-Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL-33199
| | - Grant Daly
- Department of Pharmacology, University of South Alabama, Mobile, AL-36688
| | - Marko Manevski
- Department of Immunology and Nano-Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL-33199
| | - Dominika Houserova
- Department of Pharmacology, University of South Alabama, Mobile, AL-36688
| | - Shah S. Hussain
- Medicine-Pulmonary/Allergy/Critical Care, University of Alabama at Birmingham, Birmingham, AL-35233
| | - Nathalie Baumlin
- Miller School of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami, Miami, FL-33136,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS-66160
| | - Matthias Salathe
- Miller School of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami, Miami, FL-33136,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS-66160
| | - Glen Borchert
- Department of Pharmacology, University of South Alabama, Mobile, AL-36688
| | - Raymond J. Langley
- Department of Pharmacology, University of South Alabama, Mobile, AL-36688
| | - Hitendra S. Chand
- Department of Immunology and Nano-Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL-33199
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112
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Horvat CM, Simon DW, Aldewereld Z, Evans I, Aneja R, Carcillo JA. Merging Pediatric Index of Mortality (a physiologic instability measure), lactate, and Systemic Inflammation Mortality Risk to better predict outcome in pediatric sepsis. J Pediatr (Rio J) 2021; 97:256-259. [PMID: 33242412 PMCID: PMC9432282 DOI: 10.1016/j.jped.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Christopher M Horvat
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Dennis W Simon
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Zachary Aldewereld
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Idris Evans
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Rajesh Aneja
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA.
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113
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DeMerle KM, Angus DC, Baillie JK, Brant E, Calfee CS, Carcillo J, Chang CCH, Dickson R, Evans I, Gordon AC, Kennedy J, Knight JC, Lindsell CJ, Liu V, Marshall JC, Randolph AG, Scicluna BP, Shankar-Hari M, Shapiro NI, Sweeney TE, Talisa VB, Tang B, Thompson BT, Tsalik EL, van der Poll T, van Vught LA, Wong HR, Yende S, Zhao H, Seymour CW. Sepsis Subclasses: A Framework for Development and Interpretation. Crit Care Med 2021; 49:748-759. [PMID: 33591001 PMCID: PMC8627188 DOI: 10.1097/ccm.0000000000004842] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sepsis is defined as a dysregulated host response to infection that leads to life-threatening acute organ dysfunction. It afflicts approximately 50 million people worldwide annually and is often deadly, even when evidence-based guidelines are applied promptly. Many randomized trials tested therapies for sepsis over the past 2 decades, but most have not proven beneficial. This may be because sepsis is a heterogeneous syndrome, characterized by a vast set of clinical and biologic features. Combinations of these features, however, may identify previously unrecognized groups, or "subclasses" with different risks of outcome and response to a given treatment. As efforts to identify sepsis subclasses become more common, many unanswered questions and challenges arise. These include: 1) the semantic underpinning of sepsis subclasses, 2) the conceptual goal of subclasses, 3) considerations about study design, data sources, and statistical methods, 4) the role of emerging data types, and 5) how to determine whether subclasses represent "truth." We discuss these challenges and present a framework for the broader study of sepsis subclasses. This framework is intended to aid in the understanding and interpretation of sepsis subclasses, provide a mechanism for explaining subclasses generated by different methodologic approaches, and guide clinicians in how to consider subclasses in bedside care.
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Affiliation(s)
- Kimberley M DeMerle
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Derek C Angus
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - J Kenneth Baillie
- Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Emily Brant
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Idris Evans
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jason Kennedy
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julian C Knight
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | | | - Vincent Liu
- Kaiser Permanente Division of Research, Oakland, CA
| | - John C Marshall
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, St Thomas' Hospital, London, United Kingdom
- School of Immunology and Microbial Sciences, Kings College London, London, United Kingdom
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | - Victor B Talisa
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin Tang
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, NSW, Australia
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ephraim L Tsalik
- Department of Medicine, Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH
| | - Sachin Yende
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Christopher W Seymour
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
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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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115
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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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Velly L, Volant S, Fitting C, Ghazali DA, Salipante F, Mayaux J, Monsel G, Cavaillon JM, Hausfater P. Optimal combination of early biomarkers for infection and sepsis diagnosis in the emergency department: The BIPS study. J Infect 2021; 82:11-21. [PMID: 33610685 DOI: 10.1016/j.jinf.2021.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To define the best combination of biomarkers for the diagnosis of infection and sepsis in the emergency room. METHODS In this prospective study, consecutive patients with a suspicion of infection in the emergency room were included. Eighteen different biomarkers measured in plasma, and twelve biomarkers measured on monocytes, neutrophils, B and T-lymphocytes were studied and the best combinations determined by a gradient tree boosting approach. RESULTS Overall, 291 patients were included and analysed, 148 with bacterial infection, and 47 with viral infection. The best biomarker combination which first allowed the diagnosis of bacterial infection, included HLA-DR (human leukocyte antigen DR) on monocytes, MerTk (Myeloid-epithelial-reproductive tyrosine kinase) on neutrophils and plasma metaloproteinase-8 (MMP8) with an area under the curve (AUC) = 0.94 [95% confidence interval (IC95): 0.91;0.97]. Among patients in whom a bacterial infection was excluded, the combination of CD64 expression, and CD24 on neutrophils and CX3CR1 on monocytes ended to an AUC = 0.98 [0.96;1] to define those with a viral infection. CONCLUSION In a convenient cohort of patients admitted with a suspicion of infection, two different combinations of plasma and cell surface biomarkers were performant to identify bacterial and viral infection.
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Affiliation(s)
- Laetitia Velly
- Emergency Department, Pitié-Salpêtrière Hospital, Groupe Hospitalier Sorbonne Université, AP-PH, Paris, France; Cytokines & Inflammation unit, Institut Pasteur, Paris France; Sorbonne-Université, GRC-14 BIOSFAST, UMR 1166, Paris France
| | - Steven Volant
- Hub de Bioinformatique et Biostatistique - Département Biologie Computationnelle, Institut Pasteur, USR 3756 CNRS, Paris, France
| | | | - Daniel Aiham Ghazali
- Emergency Department, Pitié-Salpêtrière Hospital, Groupe Hospitalier Sorbonne Université, AP-PH, Paris, France; INSERM IAME (Infection, Antimicrobials, Modeling, Evolution), INSERM UMR1137, Paris-Diderot University
| | | | - Julien Mayaux
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S ») and Sorbonne Université, INSERM, UMR_S 1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Gentiane Monsel
- Infectious Disease Department, Pitié-Salpêtrière Hospital, Groupe Hospitalier Sorbonne Université, AP-PH, Paris, France
| | | | - Pierre Hausfater
- Emergency Department, Pitié-Salpêtrière Hospital, Groupe Hospitalier Sorbonne Université, AP-PH, Paris, France; Sorbonne-Université, GRC-14 BIOSFAST, UMR 1166, Paris France.
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Rethinking animal models of sepsis - working towards improved clinical translation whilst integrating the 3Rs. Clin Sci (Lond) 2021; 134:1715-1734. [PMID: 32648582 PMCID: PMC7352061 DOI: 10.1042/cs20200679] [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: 05/21/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022]
Abstract
Sepsis is a major worldwide healthcare issue with unmet clinical need. Despite extensive animal research in this area, successful clinical translation has been largely unsuccessful. We propose one reason for this is that, sometimes, the experimental question is misdirected or unrealistic expectations are being made of the animal model. As sepsis models can lead to a rapid and substantial suffering – it is essential that we continually review experimental approaches and undertake a full harm:benefit impact assessment for each study. In some instances, this may require refinement of existing sepsis models. In other cases, it may be replacement to a different experimental system altogether, answering a mechanistic question whilst aligning with the principles of reduction, refinement and replacement (3Rs). We discuss making better use of patient data to identify potentially useful therapeutic targets which can subsequently be validated in preclinical systems. This may be achieved through greater use of construct validity models, from which mechanistic conclusions are drawn. We argue that such models could provide equally useful scientific data as face validity models, but with an improved 3Rs impact. Indeed, construct validity models may not require sepsis to be modelled, per se. We propose that approaches that could support and refine clinical translation of research findings, whilst reducing the overall welfare burden on research animals.
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Validation of Inflammopathic, Adaptive, and Coagulopathic Sepsis Endotypes in Coronavirus Disease 2019. Crit Care Med 2021; 49:e170-e178. [PMID: 33201004 DOI: 10.1097/ccm.0000000000004786] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Complex critical syndromes like sepsis and coronavirus disease 2019 may be composed of underling "endotypes," which may respond differently to treatment. The aim of this study was to test whether a previously defined bacterial sepsis endotypes classifier recapitulates the same clinical and immunological endotypes in coronavirus disease 2019. DESIGN Prospective single-center observational cohort study. SETTING Patients were enrolled in Athens, Greece, and blood was shipped to Inflammatix (Burlingame, CA) for analysis. PATIENTS Adult patients within 24 hours of hospital admission with coronavirus disease 2019 confirmed by polymerase chain reaction and chest radiography. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We studied 97 patients with coronavirus disease 2019, of which 50 went on to severe respiratory failure (SRF) and 16 died. We applied a previously defined 33-messenger RNA classifier to assign endotype (Inflammopathic, Adaptive, or Coagulopathic) to each patient. We tested endotype status against other clinical parameters including laboratory values, severity scores, and outcomes. Patients were assigned as Inflammopathic (29%), Adaptive (44%), or Coagulopathic (27%), similar to our prior study in bacterial sepsis. Adaptive patients had lower rates of SRF and no deaths. Coagulopathic and Inflammopathic endotypes had 42% and 18% mortality rates, respectively. The Coagulopathic group showed highest d-dimers, and the Inflammopathic group showed highest C-reactive protein and interleukin-6 levels. CONCLUSIONS Our predefined 33-messenger RNA endotypes classifier recapitulated immune phenotypes in viral sepsis (coronavirus disease 2019) despite its prior training and validation only in bacterial sepsis. Further work should focus on continued validation of the endotypes and their interaction with immunomodulatory therapy.
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Schinkel M, Virk HS, Nanayakkara PWB, van der Poll T, Wiersinga WJ. What Sepsis Researchers Can Learn from COVID-19. Am J Respir Crit Care Med 2021; 203:125-127. [PMID: 33125253 PMCID: PMC7781118 DOI: 10.1164/rccm.202010-4023le] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michiel Schinkel
- Center for Experimental and Molecular Medicine (C.E.M.M.) Amsterdam, the Netherlands
| | - Harjeet S Virk
- Center for Experimental and Molecular Medicine (C.E.M.M.) Amsterdam, the Netherlands
| | | | - Tom van der Poll
- Amsterdam UMC, location Academic Medical Center Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Amsterdam UMC, location Academic Medical Center Amsterdam, the Netherlands
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Wong HR, Hart KW, Lindsell CJ, Sweeney TE. External Corroboration That Corticosteroids May Be Harmful to Septic Shock Endotype A Patients. Crit Care Med 2021; 49:e98-e101. [PMID: 33156120 PMCID: PMC7746624 DOI: 10.1097/ccm.0000000000004709] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We previously reported gene expression-based endotypes of pediatric septic shock, endotypes A and B, and that corticosteroid exposure was independently associated with increased mortality among pediatric endotype A patients. The Vasopressin vs Norepinephrine as Initial Therapy in Septic Shock trial tested the efficacy of vasopressin as initial vasopressor therapy for septic shock among adult patients, when compared with norepinephrine. Patients who reached a prespecified dose of either vasopressor were further randomized to receive hydrocortisone or placebo. A proportion of patients in the Vasopressin vs Norepinephrine as Initial Therapy in Septic Shock trial had transcriptomic data generated at baseline using whole blood-derived messenger RNA. We used the publicly available transcriptomic data from the Vasopressin vs Norepinephrine as Initial Therapy in Septic Shock trial to assign the study subjects to pediatric septic shock endotype A or B, and tested the hypothesis that hydrocortisone treatment is associated with increased mortality among patients in endotype A. DESIGN Secondary analysis of publicly available transcriptomic data. SETTING Multiple adult ICUs. PATIENTS Adults with septic shock randomized to hydrocortisone (n = 47) or placebo (n = 50). INTERVENTIONS Randomization to the Vasopressin vs Norepinephrine as Initial Therapy in Septic Shock trial experimental arms. MEASUREMENTS AND MAIN RESULTS Endotype A patients receiving hydrocortisone had a mortality rate of 46%, whereas endotype A patients receiving placebo had a mortality rate of 22% (p = 0.105). In contrast, the mortality rates for endotype B patients receiving hydrocortisone or placebo were 19% and 22%, respectively. The odds of death were more than three times greater in endotype A patients receiving hydrocortisone than endotype A patients receiving placebo (p = 0.05). CONCLUSIONS This exploratory analysis provides further evidence that corticosteroid exposure may be associated with increased mortality among septic shock endotype A patients.
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Affiliation(s)
- Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Iglesias J, Vassallo AV, Liesenfeld O, Levine JS, Patel VV, Sullivan JB, Cavanaugh JB, Elbaga Y, Sweeney TE. A 33-mRNA Classifier Is Able to Produce Inflammopathic, Adaptive, and Coagulopathic Endotypes with Prognostic Significance: The Outcomes of Metabolic Resuscitation Using Ascorbic Acid, Thiamine, and Glucocorticoids in the Early Treatment of Sepsis (ORANGES) Trial. J Pers Med 2020; 11:jpm11010009. [PMID: 33374697 PMCID: PMC7822486 DOI: 10.3390/jpm11010009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/03/2020] [Accepted: 12/20/2020] [Indexed: 01/21/2023] Open
Abstract
Background: Retrospective analysis of the transcriptomic host response in sepsis has demonstrated that sepsis can be separated into three endotypes—inflammatory (IE), adaptive (AE), and coagulopathic (CE), which have demonstrated prognostic significance. We undertook a prospective transcriptomic host response analysis in a subgroup of patients enrolled in the Outcomes of Metabolic Resuscitation Using Ascorbic Acid, Thiamine, and Glucocorticoids in the Early Treatment of Sepsis (ORANGES) trial. Methods: Blood was obtained from 51 patients and profiled using a pre-established 33-mRNA classifier to determine sepsis endotypes. Endotypes were compared to therapy subgroups and clinical outcomes. Results: We redemonstrated a statistically significant difference in mortality between IE, AE, and CE patients, with CE patients demonstrating the highest mortality (40%), and AE patients the lowest mortality (5%, p = 0.032). A higher CE score was a predictor of mortality; coronary artery disease (CAD) and elevated CE scores were associated with an increase in mortality (CAD: HR = 12.3, 95% CI 1.5–101; CE score: HR = 15.5 95% CI 1.15–211). Kaplan–Meier (KM) analysis of the entire cohort (n = 51) demonstrated a decrease survival in the CE group, p = 0.026. KM survival analysis of hydrocortisone, ascorbic acid, and thiamine (HAT) therapy and control patients not receiving steroids (n = 45) showed CE and IE was associated with a decrease in survival (p = 0.003); of interest, there was no difference in survival in CE patients after stratifying by HAT therapy (p = 0.18). These findings suggest a possible treatment effect of corticosteroids, HAT therapy, endotype, and outcome. Conclusion: This subset of patients from the ORANGES trial confirmed previous retrospective findings that a 33-mRNA classifier can group patients into IE, AE, and CE endotypes having prognostic significance. A novel finding of this study identifying an association between endotype and corticosteroid therapy warrants further study in support of future diagnostic use of the endotyping classifier.
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Affiliation(s)
- Jose Iglesias
- Department of Critical Care, Department of Nephrology, Community Medical Center, Toms River, NJ 08755, USA
- Department of Nephrology, Jersey Shore University Medical Center, Hackensack Meridian School of Medicine at Seton Hall Neptune, Nutley, NJ 07110, USA
- Correspondence: (J.I.); (A.V.V.)
| | - Andrew V. Vassallo
- Department of Pharmacy, Community Medical Center, Toms River, NJ 08755, USA; (V.V.P.); (J.B.C.)
- Correspondence: (J.I.); (A.V.V.)
| | | | - Jerrold S. Levine
- Department of Medicine Section of Nephrology, University of Illinois at Chicago, Chicago, IL 60612, USA;
- Jesse Brown Veterans Affairs Medical Center, Chicago, IL 60612, USA
| | - Vishal V. Patel
- Department of Pharmacy, Community Medical Center, Toms River, NJ 08755, USA; (V.V.P.); (J.B.C.)
| | - Jesse B. Sullivan
- School of Pharmacy & Health Sciences, Fairleigh Dickinson University, Florham Park, NJ 07932, USA;
| | - Joseph B. Cavanaugh
- Department of Pharmacy, Community Medical Center, Toms River, NJ 08755, USA; (V.V.P.); (J.B.C.)
| | - Yasmine Elbaga
- Department of Pharmacy, Monmouth Medical Center Southern Campus, Lakewood, NJ 08701, USA;
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Thair SA, He YD, Hasin-Brumshtein Y, Sakaram S, Pandya R, Toh J, Rawling D, Remmel M, Coyle S, Dalekos GN, Koutsodimitropoulos I, Vlachogianni G, Gkeka E, Karakike E, Damoraki G, Antonakos N, Khatri P, Giamarellos-Bourboulis EJ, Sweeney TE. Transcriptomic similarities and differences in host response between SARS-CoV-2 and other viral infections. iScience 2020; 24:101947. [PMID: 33437935 PMCID: PMC7786129 DOI: 10.1016/j.isci.2020.101947] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/11/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023] Open
Abstract
The pandemic 2019 novel coronavirus disease (COVID-19) shares certain clinical characteristics with other acute viral infections. We studied the whole-blood transcriptomic host response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using RNAseq from 24 healthy controls and 62 prospectively enrolled patients with COVID-19. We then compared these data to non-COVID-19 viral infections, curated from 23 independent studies profiling 1,855 blood samples covering six viruses (influenza, respiratory syncytial virus (RSV), human rhinovirus (HRV), severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1), Ebola, dengue). We show gene expression changes in COVID-19 versus non-COVID-19 viral infections are highly correlated (r = 0.74, p < 0.001). However, we also found 416 genes specific to COVID-19. Inspection of top genes revealed dynamic immune evasion and counter host responses specific to COVID-19. Statistical deconvolution of cell proportions maps many cell type proportions concordantly shifting. Discordantly increased in COVID-19 were CD56bright natural killer cells and M2 macrophages. The concordant and discordant responses mapped out here provide a window to explore the pathophysiology of the host response to SARS-CoV-2.
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Affiliation(s)
- Simone A Thair
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | - Yudong D He
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | | | - Suraj Sakaram
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | - Rushika Pandya
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | - Jiaying Toh
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, Palo Alto, CA 94305, USA.,Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - David Rawling
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | - Melissa Remmel
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | - Sabrina Coyle
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
| | - George N Dalekos
- Department of Internal Medicine, University of Thessaly, Larissa General Hospital, Greece
| | | | | | - Eleni Gkeka
- Intensive Care Unit, AHEPA Thessaloniki General Hospital, Greece
| | - Eleni Karakike
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, 124 62 Athens, Greece
| | - Georgia Damoraki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, 124 62 Athens, Greece
| | - Nikolaos Antonakos
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, 124 62 Athens, Greece
| | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, Palo Alto, CA 94305, USA.,Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | | | - Timothy E Sweeney
- Inflammatix, Inc., 863 Mitten Road, Suite 104, Burlingame, CA 94010, USA
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Kyriazopoulou E, Giamarellos-Bourboulis EJ. Monitoring immunomodulation in patients with sepsis. Expert Rev Mol Diagn 2020; 21:17-29. [PMID: 33183116 DOI: 10.1080/14737159.2020.1851199] [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] [Indexed: 12/23/2022]
Abstract
Introduction: This review aims to summarize current progress of the last ten years in the development of biomarkers used for classifying the immune response of the septic host and for monitoring the efficacy of the applied adjunctive immunotherapy.Areas covered: An extensive search of the literature was performed. In this review the authors discuss available biomarkers of host immune response in sepsis toward two directions; immunosuppression and hyperinflammation. Ferritin, sCD163, sIL-2 ra, and IL-18 may help in the diagnosis of macrophage activation syndrome (MAS) complicating sepsis whereas lymphopenia, decreased HLA-DR expression on monocytes, overexpression of Programmed cell death protein-1 (PD-1)/Programmed death-ligand 1 (PD-L1) and IL-10 are indicators of sepsis-induced immunosuppression. Novel approaches in the classification of immune state in sepsis include Myeloid-Derived Suppressor Cells (MDSC) and specific endotypes, defined by gene expression and molecular techniques.Expert opinion: HLA-DR and ferritin are the most commonly used biomarkers to monitor immunomodulation in clinical practice whereas developing specific sepsis endotypes is the future target. New immunotherapy trials in sepsis need to incorporate biomarkers for a personalized treatment.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, ATTIKON University Hospital, Athens, Greece
| | - Evangelos J Giamarellos-Bourboulis
- 4 Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, ATTIKON University Hospital, Athens, Greece
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Shankar R, Leimanis ML, Newbury PA, Liu K, Xing J, Nedveck D, Kort EJ, Prokop JW, Zhou G, Bachmann AS, Chen B, Rajasekaran S. Gene expression signatures identify paediatric patients with multiple organ dysfunction who require advanced life support in the intensive care unit. EBioMedicine 2020; 62:103122. [PMID: 33248372 PMCID: PMC7704404 DOI: 10.1016/j.ebiom.2020.103122] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/21/2020] [Accepted: 10/26/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) occurs in the setting of a variety of pathologies including infection and trauma. Some patients decompensate and require Veno-Arterial extra corporeal membrane oxygenation (ECMO) as a palliating manoeuvre for recovery of cardiopulmonary function. The molecular mechanisms driving progression from MODS to cardiopulmonary collapse remain incompletely understood, and no biomarkers have been defined to identify those MODS patients at highest risk for progression to requiring ECMO support. METHODS Whole blood RNA-seq profiling was performed for 23 MODS patients at three time points during their ICU stay (at diagnosis of MODS, 72 hours after, and 8 days later), as well as four healthy controls undergoing routine sedation. Of the 23 MODS patients, six required ECMO support (ECMO patients). The predictive power of conventional demographic and clinical features was quantified for differentiating the MODS and ECMO patients. We then compared the performance of markers derived from transcriptomic profiling including [1] transcriptomically imputed leukocyte subtype distribution, [2] relevant published gene signatures and [3] a novel differential gene expression signature computed from our data set. The predictive power of our novel gene expression signature was then validated using independently published datasets. FINDING None of the five demographic characteristics and 14 clinical features, including The Paediatric Logistic Organ Dysfunction (PELOD) score, could predict deterioration of MODS to ECMO at baseline. From previously published sepsis signatures, only the signatures positively associated with patient's mortality could differentiate ECMO patients from MODS patients, when applied to our transcriptomic dataset (P-value ranges from 0.01 to 0.04, Student's test). Deconvolution of bulk RNA-Seq samples suggested that lower neutrophil counts were associated with increased risk of progression from MODS to ECMO (P-value = 0.03, logistic regression, OR=2.82 [95% CI 0.63 - 12.45]). A total of 30 genes were differentially expressed between ECMO and MODS patients at baseline (log2 fold change ≥ 1 or ≤ -1 with false discovery rate ≤ 0.01). These genes are involved in protein maintenance and epigenetic-related processes. Further univariate analysis of these 30 genes suggested a signature of seven DE genes associated with ECMO (OR > 3.0, P-value ≤ 0.05, logistic regression). Notably, this contains a set of histone marker genes, including H1F0, HIST2H3C, HIST1H2AI, HIST1H4, HIST1H2BL and HIST1H1B, that were highly expressed in ECMO. A risk score derived from expression of these genes differentiated ECMO and MODS patients in our dataset (AUC = 0.91, 95% CI 0.79-1.00, P-value = 7e-04, logistic regression) as well as validation dataset (AUC= 0.73, 95% CI 0.53-0.93, P-value = 2e-02, logistic regression). INTERPRETATION This study demonstrates that transcriptomic features can serve as indicators of severity that could be superior to traditional methods of ascertaining acuity in MODS patients. Analysis of expression of signatures identified in this study could help clinicians in the diagnosis and prognostication of MODS patients after arrival to the Hospital.
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Affiliation(s)
- Rama Shankar
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Mara L Leimanis
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503, USA.
| | - Patrick A Newbury
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
| | - Ke Liu
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Jing Xing
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Derek Nedveck
- Office of Research, Spectrum Health, 15 Michigan Street NE, Grand Rapids, MI 49503, USA
| | - Eric J Kort
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; DeVos Cardiovascular Program, Van Andel Research Institute and Fredrik Meijer Heart and Vascular Institute/Spectrum Health, Grand Rapids, MI 49503, USA; Pediatric Hospitalist Medicine, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503, USA.
| | - Jeremy W Prokop
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Guoli Zhou
- Biomedical Research Informatics Core (BRIC), Clinical and Translational Sciences Institute (CTSI), Michigan State University, East Lansing, MI 48824, USA.
| | - André S Bachmann
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Bin Chen
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Department of Pharmacology and Toxicology, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA.
| | - Surender Rajasekaran
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA; Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, 100 Michigan Street NE, Grand Rapids, MI 49503, USA; Office of Research, Spectrum Health, 15 Michigan Street NE, Grand Rapids, MI 49503, USA.
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125
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Matthay MA, Arabi YM, Siegel ER, Ware LB, Bos LDJ, Sinha P, Beitler JR, Wick KD, Curley MAQ, Constantin JM, Levitt JE, Calfee CS. Phenotypes and personalized medicine in the acute respiratory distress syndrome. Intensive Care Med 2020; 46:2136-2152. [PMID: 33206201 PMCID: PMC7673253 DOI: 10.1007/s00134-020-06296-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022]
Abstract
Although the acute respiratory distress syndrome (ARDS) is well defined by the development of acute hypoxemia, bilateral infiltrates and non-cardiogenic pulmonary edema, ARDS is heterogeneous in terms of clinical risk factors, physiology of lung injury, microbiology, and biology, potentially explaining why pharmacologic therapies have been mostly unsuccessful in treating ARDS. Identifying phenotypes of ARDS and integrating this information into patient selection for clinical trials may increase the chance for efficacy with new treatments. In this review, we focus on classifying ARDS by the associated clinical disorders, physiological data, and radiographic imaging. We consider biologic phenotypes, including plasma protein biomarkers, gene expression, and common causative microbiologic pathogens. We will also discuss the issue of focusing clinical trials on the patient's phase of lung injury, including prevention, administration of therapy during early acute lung injury, and treatment of established ARDS. A more in depth understanding of the interplay of these variables in ARDS should provide more success in designing and conducting clinical trials and achieving the goal of personalized medicine.
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Affiliation(s)
- Michael A Matthay
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA.
- Cardiovascular Research Institute, University of California, San Francisco, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA.
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Emily R Siegel
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lieuwe D J Bos
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Infection and Immunity, Amsterdam, The Netherlands
| | - Pratik Sinha
- Department of Anesthesiology, Washington University, Saint Louis, MO, USA
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean-Michel Constantin
- Department of Anesthesia and Critical Care, La Pitié Salpetriere Hospital, University Paris-Sorbonne, Paris, France
| | - Joseph E Levitt
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Carolyn S Calfee
- Department of Anesthesia, University of California San Francisco, San Francisco, CA, USA
- Cardiovascular Research Institute, University of California, San Francisco, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA
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126
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Disseminated Intravascular Coagulation Is an Independent Predictor of Adverse Outcomes in Children in the Emergency Department with Suspected Sepsis. J Pediatr 2020; 225:198-206.e2. [PMID: 32553867 PMCID: PMC7529972 DOI: 10.1016/j.jpeds.2020.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the impact of early disseminated intravascular coagulation (DIC) on illness severity in children using a database of emergency department ED encounters for children with suspected sepsis, in view of similar associations in adults. STUDY DESIGN Laboratory and clinical data were extracted from a registry of emergency department encounters of children with suspected sepsis between April 1, 2012, and June 26, 2017. International Society of Thrombosis and Hemostasis DIC scores were calculated from laboratory values obtained within 24 hours of emergency department admission. Univariate logistic regression, multivariable logistic regression, and Cox regression were used to assess the influence of DIC scores on vasopressor use (primary outcome), mortality, ventilator requirement, pediatric intensive care unit admission, and hospital duration (secondary outcomes). The optimal DIC score cutoff for outcome prediction was determined. RESULTS Of 1653 eligible patients, 284 had DIC scores within 24 hours, including 92 who required vasopressors and 23 who died within 1 year. An initial DIC score of ≥3 was the most sensitive and specific DIC score for predicting adverse outcomes. Those with a DIC score of ≥3 vs <3 had increased odds of vasopressor use in both univariate (OR, 4.48; 95% CI, 2.63-7.62; P < .001) and multivariable (OR, 3.78; 95% CI, 1.82-7.85; P < .001) analyses. Additionally, those with a DIC score of ≥3 vs <3 had increased 1-year mortality with a hazard ratio of 3.55 (95% CI, 1.46-8.64; P = .005). CONCLUSIONS A DIC score of ≥3 was an independent predictor for both vasopressor use and mortality in this pediatric cohort, distinct from the adult overt DIC score cutoff of ≥5.
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Laterre PF, Levy MM, Wittebole X, Dugernier T, Francois B, Opal SM. Should we continue to test soluble thrombomodulin, or other systemic anticoagulants, as a life-saving therapy for sepsis-induced coagulopathy? Anaesth Crit Care Pain Med 2020; 38:419-421. [PMID: 31585759 DOI: 10.1016/j.accpm.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Pierre-Francois Laterre
- St. Luc Clinical Coordinating Center, Department of Critical Care Medicine, St Luc University Hospital, Université Catholique de Louvain, avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - Mitchell M Levy
- Ocean State Clinical Coordinating Center of Rhode Island Hospital, Providence, RI, USA
| | - Xavier Wittebole
- St. Luc Clinical Coordinating Center, Department of Critical Care Medicine, St Luc University Hospital, Université Catholique de Louvain, avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Thierry Dugernier
- St. Luc Clinical Coordinating Center, Department of Critical Care Medicine, St Luc University Hospital, Université Catholique de Louvain, avenue Hippocrate 10, 1200 Brussels, Belgium; Department of Critical Care, Clinique St. Pierre, Ottignies, Belgium
| | - Bruno Francois
- InsermCIC-1435 & UMR-1092, department of critical care, CHU Dupuytren, 87000, Limoges, France
| | - Steven M Opal
- Ocean State Clinical Coordinating Center of Rhode Island Hospital, Providence, RI, USA
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Abstract
Supplemental Digital Content is available in the text. Objectives: Identify alterations in gene expression unique to systemic and kidney-specific pathophysiologic processes using whole-genome analyses of RNA isolated from the urinary cells of sepsis patients. Design: Prospective cohort study. Setting: Quaternary care academic hospital. Patients: A total of 266 sepsis and 82 control patients enrolled between January 2015 and February 2018. Interventions: Whole-genome transcriptomic analysis of messenger RNA isolated from the urinary cells of sepsis patients within 12 hours of sepsis onset and from control subjects. Measurements and Main Results: The differentially expressed probes that map to known genes were subjected to feature selection using multiple machine learning techniques to find the best subset of probes that differentiates sepsis from control subjects. Using differential expression augmented with machine learning ensembles, we identified a set of 239 genes in urine, which show excellent effectiveness in classifying septic patients from those with chronic systemic disease in both internal and independent external validation cohorts. Functional analysis indexes disrupted biological pathways in early sepsis and reveal key molecular networks driving its pathogenesis. Conclusions: We identified unique urinary gene expression profile in early sepsis. Future studies need to confirm whether this approach can complement blood transcriptomic approaches for sepsis diagnosis and prognostication.
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Subphenotypes in critical care: translation into clinical practice. THE LANCET RESPIRATORY MEDICINE 2020; 8:631-643. [PMID: 32526190 DOI: 10.1016/s2213-2600(20)30124-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/06/2020] [Accepted: 03/05/2020] [Indexed: 12/14/2022]
Abstract
Despite progress in the supportive care available for critically ill patients, few advances have been made in the search for effective disease-modifying therapeutic options. The fact that many trials in critical care medicine have not identified a treatment benefit is probably due, in part, to the underlying heterogeneity of critical care syndromes. Numerous approaches have been proposed to divide populations of critically ill patients into more meaningful subgroups (subphenotypes), some of which might be more useful than others. Subclassification systems driven by clinical features and biomarkers have been proposed for acute respiratory distress syndrome, sepsis, acute kidney injury, and pancreatitis. Identifying the systems that are most useful and biologically meaningful could lead to a better understanding of the pathophysiology of critical care syndromes and the discovery of new treatment targets, and allow recruitment in future therapeutic trials to focus on predicted responders. This Review discusses proposed subphenotypes of critical illness syndromes and highlights the issues that will need to be addressed to translate subphenotypes into clinical practice.
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130
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Cahan EM, Khatri P. Data Heterogeneity: The Enzyme to Catalyze Translational Bioinformatics? J Med Internet Res 2020; 22:e18044. [PMID: 32784182 PMCID: PMC7450370 DOI: 10.2196/18044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/18/2020] [Accepted: 06/03/2020] [Indexed: 02/01/2023] Open
Abstract
Up to 95% of novel interventions demonstrating significant effects at the bench fail to translate to the bedside. In recent years, the windfalls of “big data” have afforded investigators more substrate for research than ever before. However, issues with translation have persisted: although countless biomarkers for diagnostic and therapeutic targeting have been proposed, few of these generalize effectively. We assert that inadequate heterogeneity in datasets used for discovery and validation causes their nonrepresentativeness of the diversity observed in real-world patient populations. This nonrepresentativeness is contrasted with advantages rendered by the solicitation and utilization of data heterogeneity for multisystemic disease modeling. Accordingly, we propose the potential benefits of models premised on heterogeneity to promote the Institute for Healthcare Improvement’s Triple Aim. In an era of personalized medicine, these models can confer higher quality clinical care for individuals, increased access to effective care across all populations, and lower costs for the health care system.
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Affiliation(s)
- Eli M Cahan
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States.,School of Medicine, New York University, New York, NY, United States
| | - Purvesh Khatri
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA, United States.,Department of Biomedical Data Sciences, School of Medicine, Stanford University, Stanford, CA, United States
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Sanchez-Pinto LN, Stroup EK, Pendergrast T, Pinto N, Luo Y. Derivation and Validation of Novel Phenotypes of Multiple Organ Dysfunction Syndrome in Critically Ill Children. JAMA Netw Open 2020; 3:e209271. [PMID: 32780121 PMCID: PMC7420303 DOI: 10.1001/jamanetworkopen.2020.9271] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Multiple organ dysfunction syndrome (MODS) is a dynamic and heterogeneous process associated with high morbidity and mortality in critically ill children. OBJECTIVE To determine whether data-driven phenotypes of MODS based on the trajectories of 6 organ dysfunctions have prognostic and therapeutic relevance in critically ill children. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 20 827 pediatric intensive care encounters among 14 285 children admitted to 2 large academic pediatric intensive care units (PICUs) between January 2010 and August 2016. Patients were excluded if they were older than 21 years or had undergone cardiac surgery. The 6 subscores of the pediatric Sequential Organ Failure Assessment (pSOFA) score were calculated for the first 3 days, including the subscores for respiratory, cardiovascular, coagulation, hepatic, neurologic, and renal dysfunctions. MODS was defined as a pSOFA subscore of at least 2 in at least 2 organs. Encounters were split in a 80:20 ratio for derivation and validation, respectively. The trajectories of the 6 subscores were used to derive a set of data-driven phenotypes of MODS using subgraph-augmented nonnegative matrix factorization in the derivation set. Data analysis was conducted from March to October 2019. EXPOSURES The primary exposure was phenotype membership. In the subset of patients with vasoactive-dependent shock, the interaction between hydrocortisone and phenotype membership and its association with outcomes were examined in a matched cohort. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included persistent MODS on day 7, and vasoactive-free, ventilator-free, and hospital-free days. Regression analysis was used to adjust for age, severity of illness, immunocompromised status, and study site. RESULTS There were 14 285 patients with 20 827 encounters (median [interquartile range] age 5.2 years [1.5-12.7] years; 11 409 [54.8%; 95% CI, 54.1%-55.5%] male patients). Of these, 5297 encounters (25.4%; 95% CI, 24.8%-26.0%) were with patients who had MODS, of which 5054 (95.4%) met the subgraph count threshold and were included in the analysis. Subgraph augmented nonnegative matrix factorization uncovered 4 data-driven phenotypes of MODS, characterized by a combination of neurologic, respiratory, coagulation, and cardiovascular dysfunction, as follows: phenotype 1, severe, persistent encephalopathy (1019 patients [19.2%]); phenotype 2, moderate, resolving hypoxemia (1828 patients [34.5%]); phenotype 3, severe, persistent hypoxemia and shock (1012 patients [19.1%]); and phenotype 4, moderate, persistent thrombocytopenia and shock (1195 patients [22.6%]). These phenotypes were reproducible in a validation set of encounters, had distinct clinical characteristics, and were independently associated with outcomes. For example, using phenotype 2 as reference, the adjusted hazard ratios (aHRs) for death by 28 days were as follows: phenotype 1, aHR of 3.0 (IQR, 2.1-4.3); phenotype 3, aHR of 2.8 (IQR, 2.0-4.1); and phenotype 4, aHR of 1.8 (IQR, 1.2-2.6). Interaction analysis in a matched cohort of patients with vasoactive-dependent shock revealed that hydrocortisone had differential treatment association with vasoactive-free days across phenotypes. For example, patients in phenotype 3 who received hydrocortisone had more vasoactive-free days than those who did not (23 days vs 18 days; P for interaction < .001), whereas patients in other phenotypes who received hydrocortisone either had no difference or had less vasoactive-free days. CONCLUSIONS AND RELEVANCE In this study, data-driven phenotyping in critically ill children with MODS uncovered 4 distinct and reproducible phenotypes with prognostic relevance and possible therapeutic relevance. Further validation and characterization of these phenotypes is warranted.
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Affiliation(s)
- L. Nelson Sanchez-Pinto
- Critical Care, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Critical Care Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Emily K. Stroup
- Driskill Graduate Program, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Tricia Pendergrast
- Division of Critical Care Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Neethi Pinto
- Section of Critical Care, Department of Pediatrics, The University of Chicago, Chicago, Illinois
| | - Yuan Luo
- Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Editorial: Diagnosis of infection in immunocompromised patients: from microscopy to next generation sequencing and host gene signatures. Curr Opin Infect Dis 2020; 32:295-299. [PMID: 31169551 DOI: 10.1097/qco.0000000000000567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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133
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Valeriani E, Squizzato A, Gallo A, Porreca E, Vincent JL, Iba T, Hagiwara A, Di Nisio M. Efficacy and safety of recombinant human soluble thrombomodulin in patients with sepsis-associated coagulopathy: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:1618-1625. [PMID: 32237269 DOI: 10.1111/jth.14812] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/02/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The efficacy and safety of recombinant human soluble thrombomodulin (rhsTM) have not been definitively proven. The effects may depend on the presence of sepsis-associated coagulopathy (SAC). OBJECTIVES The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of rhsTM in patients with SAC defined by high international normalized ratio and low platelet count. PATIENTS/METHODS EMBASE, MEDLINE, CENTRAL, and clinicaltrial.gov were searched for randomized controlled trials (RCTs) comparing rhsTM with placebo or no treatment in patients with sepsis. The efficacy outcome was 28-day mortality, and the safety outcome was major bleeding. RESULTS We included 3 RCTs with a total of 1633 patients. Twenty-eight-day mortality was higher in patients with SAC compared with those without SAC (risk ratio [RR] 1.32; 95% confidence intervals [CI], 1.06-1.64). rhsTM was associated with significantly lower 28-day mortality compared with placebo or no treatment in patients with SAC (RR 0.80; 95% CI, 0.65-0.98), but not in those without SAC (RR 1.17; 95% CI, 0.82-1.67) nor in the whole study population (RR 0.88; 95% CI, 0.74-1.04). There was no significant difference in major bleeding between rhsTM and controls in the whole population (RR 1.25; 95% CI, 0.80-1.96), patients with SAC (RR 0.94; 95% CI, 0.45-1.95), and those without SAC (RR 2.26; 95% CI, 0.95-5.35). CONCLUSIONS In patients with sepsis, SAC is associated with higher 28-day mortality. The administration of rhsTM reduced 28-day mortality in patients with SAC, but not in those without SAC.
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Affiliation(s)
- Emanuele Valeriani
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Centre on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Andrea Gallo
- Department of Medicine and Surgery, Research Centre on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Tokyo, Japan
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G. D'Annunzio" University, Chieti-Pescara, Italy
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, the Netherlands
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Rehman A, Baloch NUA, Morrow JP, Pacher P, Haskó G. Targeting of G-protein coupled receptors in sepsis. Pharmacol Ther 2020; 211:107529. [PMID: 32197794 PMCID: PMC7388546 DOI: 10.1016/j.pharmthera.2020.107529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022]
Abstract
The Third International Consensus Definitions (Sepsis-3) define sepsis as life-threatening multi-organ dysfunction caused by a dysregulated host response to infection. Sepsis can progress to septic shock-an even more lethal condition associated with profound circulatory, cellular and metabolic abnormalities. Septic shock remains a leading cause of death in intensive care units and carries a mortality of almost 25%. Despite significant advances in our understanding of the pathobiology of sepsis, therapeutic interventions have not translated into tangible differences in the overall outcome for patients. Clinical trials of antagonists of various pro-inflammatory mediators in sepsis have been largely unsuccessful in the past. Given the diverse physiologic roles played by G-protein coupled receptors (GPCR), modulation of GPCR signaling for the treatment of sepsis has also been explored. Traditional pharmacologic approaches have mainly focused on ligands targeting the extracellular domains of GPCR. However, novel techniques aimed at modulating GPCR intracellularly through aptamers, pepducins and intrabodies have opened a fresh avenue of therapeutic possibilities. In this review, we summarize the diverse roles played by various subfamilies of GPCR in the pathogenesis of sepsis and identify potential targets for pharmacotherapy through these novel approaches.
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Affiliation(s)
- Abdul Rehman
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, United States
| | - Noor Ul-Ain Baloch
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, United States
| | - John P Morrow
- Department of Medicine, Columbia University, New York City, NY, United States
| | - Pál Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
| | - György Haskó
- Department of Anesthesiology, Columbia University, New York City, NY, United States.
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136
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Why Understanding Sepsis Endotypes Is Important for Steroid Trials in Septic Shock. Crit Care Med 2020; 47:1782-1784. [PMID: 31162195 DOI: 10.1097/ccm.0000000000003833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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137
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Abstract
OBJECTIVES Randomized controlled trials in the ICU often fail to show differences in endpoints between groups. We sought to explore reasons for this at a molecular level by analyzing transcriptomic data from a recent negative trial. Our objectives were to determine if randomization successfully balanced transcriptomic features between groups, to assess transcriptomic heterogeneity among the study subjects included, and to determine if the study drug had any effect at the gene expression level. DESIGN Bioinformatics analysis of transcriptomic and clinical data collected in the course of a randomized controlled trial. SETTING Tertiary academic mixed medical-surgical ICU. PATIENTS Adult, critically ill patients expected to require invasive mechanical ventilation more than 48 hours. INTERVENTIONS Lactoferrin or placebo delivered enterally and via an oral swab for up to 28 days. MEASUREMENTS AND MAIN RESULTS We found no major imbalances in transcriptomic features between groups. Unsupervised analysis did not reveal distinct clusters among patients at the time of enrollment. There were marked differences in gene expression between early and later time points. Patients in the lactoferrin group showed changes in the expression of genes associated with immune pathways known to be associated with lactoferrin. CONCLUSIONS In this clinical trial, transcriptomic data provided a useful complement to clinical data, suggesting that the reasons for the negative result were less likely related to the biological efficacy of the study drug, and may instead have been related to poor sensitivity of the clinical outcomes. In larger studies, transcriptomics may also prove useful in predicting response to treatment.
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138
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The Challenge and the Promise of Identifying More Homogeneous Subgroups in Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:1806-1808. [PMID: 31738249 DOI: 10.1097/ccm.0000000000004059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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139
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Cavaillon J, Singer M, Skirecki T. Sepsis therapies: learning from 30 years of failure of translational research to propose new leads. EMBO Mol Med 2020; 12:e10128. [PMID: 32176432 PMCID: PMC7136965 DOI: 10.15252/emmm.201810128] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 12/13/2022] Open
Abstract
Sepsis has been identified by the World Health Organization (WHO) as a global health priority. There has been a tremendous effort to decipher underlying mechanisms responsible for organ failure and death, and to develop new treatments. Despite saving thousands of animals over the last three decades in multiple preclinical studies, no new effective drug has emerged that has clearly improved patient outcomes. In the present review, we analyze the reasons for this failure, focusing on the inclusion of inappropriate patients and the use of irrelevant animal models. We advocate against repeating the same mistakes and propose changes to the research paradigm. We discuss the long-term consequences of surviving sepsis and, finally, list some putative approaches-both old and new-that could help save lives and improve survivorship.
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Affiliation(s)
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care MedicineUniversity College LondonLondonUK
| | - Tomasz Skirecki
- Laboratory of Flow Cytometry and Department of Anesthesiology and Intensive Care MedicineCentre of Postgraduate Medical EducationWarsawPoland
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140
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Abstract
Biomarker panels have the potential to advance the field of critical care medicine by stratifying patients according to prognosis and/or underlying pathophysiology. This article discusses the discovery and validation of biomarker panels, along with their translation to the clinical setting. The current literature on the use of biomarker panels in sepsis, acute respiratory distress syndrome, and acute kidney injury is reviewed.
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Affiliation(s)
- Susan R Conway
- Division of Critical Care Medicine, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA.
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati Children's Research Foundation, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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141
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Mayhew MB, Buturovic L, Luethy R, Midic U, Moore AR, Roque JA, Shaller BD, Asuni T, Rawling D, Remmel M, Choi K, Wacker J, Khatri P, Rogers AJ, Sweeney TE. A generalizable 29-mRNA neural-network classifier for acute bacterial and viral infections. Nat Commun 2020; 11:1177. [PMID: 32132525 PMCID: PMC7055276 DOI: 10.1038/s41467-020-14975-w] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023] Open
Abstract
Improved identification of bacterial and viral infections would reduce morbidity from sepsis, reduce antibiotic overuse, and lower healthcare costs. Here, we develop a generalizable host-gene-expression-based classifier for acute bacterial and viral infections. We use training data (N = 1069) from 18 retrospective transcriptomic studies. Using only 29 preselected host mRNAs, we train a neural-network classifier with a bacterial-vs-other area under the receiver-operating characteristic curve (AUROC) 0.92 (95% CI 0.90–0.93) and a viral-vs-other AUROC 0.92 (95% CI 0.90–0.93). We then apply this classifier, inflammatix-bacterial-viral-noninfected-version 1 (IMX-BVN-1), without retraining, to an independent cohort (N = 163). In this cohort, IMX-BVN-1 AUROCs are: bacterial-vs.-other 0.86 (95% CI 0.77–0.93), and viral-vs.-other 0.85 (95% CI 0.76–0.93). In patients enrolled within 36 h of hospital admission (N = 70), IMX-BVN-1 AUROCs are: bacterial-vs.-other 0.92 (95% CI 0.83–0.99), and viral-vs.-other 0.91 (95% CI 0.82–0.98). With further study, IMX-BVN-1 could provide a tool for assessing patients with suspected infection and sepsis at hospital admission. Diagnosing acute infections based on transcriptional host response shows promise, but generalizability is wanting. Here, the authors use a co-normalization framework to train a classifier to diagnose acute infections and apply it to independent data on a targeted diagnostic platform.
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Affiliation(s)
- Michael B Mayhew
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | | | - Roland Luethy
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | - Uros Midic
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | - Andrew R Moore
- Department of Medicine, Stanford University, Palo Alto, CA, 94305, USA
| | - Jonasel A Roque
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, 94305, USA
| | - Brian D Shaller
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, 94305, USA
| | - Tola Asuni
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, 94305, USA
| | - David Rawling
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | - Melissa Remmel
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | - Kirindi Choi
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | - James Wacker
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA
| | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infections, Stanford University, Palo Alto, CA, 94305, USA.,Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, CA, 94305, USA
| | - Angela J Rogers
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, 94305, USA
| | - Timothy E Sweeney
- Inflammatix, Inc., 863 Mitten Rd, Suite 104, Burlingame, CA, 94010, USA.
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142
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Reyes M, Filbin MR, Bhattacharyya RP, Billman K, Eisenhaure T, Hung DT, Levy BD, Baron RM, Blainey PC, Goldberg MB, Hacohen N. An immune-cell signature of bacterial sepsis. Nat Med 2020; 26:333-340. [PMID: 32066974 DOI: 10.1038/s41591-020-0752-4] [Citation(s) in RCA: 216] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/03/2020] [Indexed: 12/17/2022]
Abstract
Dysregulation of the immune response to bacterial infection can lead to sepsis, a condition with high mortality. Multiple whole-blood gene-expression studies have defined sepsis-associated molecular signatures, but have not resolved changes in transcriptional states of specific cell types. Here, we used single-cell RNA-sequencing to profile the blood of people with sepsis (n = 29) across three clinical cohorts with corresponding controls (n = 36). We profiled total peripheral blood mononuclear cells (PBMCs, 106,545 cells) and dendritic cells (19,806 cells) across all subjects and, on the basis of clustering of their gene-expression profiles, defined 16 immune-cell states. We identified a unique CD14+ monocyte state that is expanded in people with sepsis and validated its power in distinguishing these individuals from controls using public transcriptomic data from subjects with different disease etiologies and from multiple geographic locations (18 cohorts, n = 1,467 subjects). We identified a panel of surface markers for isolation and quantification of the monocyte state and characterized its epigenomic and functional phenotypes, and propose a model for its induction from human bone marrow. This study demonstrates the utility of single-cell genomics in discovering disease-associated cytologic signatures and provides insight into the cellular basis of immune dysregulation in bacterial sepsis.
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Affiliation(s)
- Miguel Reyes
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael R Filbin
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Roby P Bhattacharyya
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Deborah T Hung
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul C Blainey
- Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Marcia B Goldberg
- Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Nir Hacohen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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143
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Dailey PJ, Elbeik T, Holodniy M. Companion and complementary diagnostics for infectious diseases. Expert Rev Mol Diagn 2020; 20:619-636. [PMID: 32031431 DOI: 10.1080/14737159.2020.1724784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Companion diagnostics (CDx) are important in oncology therapeutic decision-making, but specific regulatory-approved CDx for infectious disease treatment are officially lacking. While not approved as CDx, several ID diagnostics are used as CDx. The diagnostics community, manufacturers, and regulatory agencies have made major efforts to ensure that diagnostics for new antimicrobials are available at or near release of new agents. AREAS COVERED This review highlights the status of Complementary and companion diagnostic (c/CDx) in the infectious disease literature, with a focus on genotypic antimicrobial resistance testing against pathogens as a class of diagnostic tests. EXPERT OPINION CRISPR, sepsis markers, and narrow spectrum antimicrobials, in addition to current and emerging technologies, present opportunities for infectious disease c/CDx. Challenges include slow guideline revision, high costs for regulatory approval, lengthy buy in by agencies, discordant pharmaceutical/diagnostic partnerships, and higher treatment costs. The number of patients and available medications used to treat different infectious diseases is well suited to support competing diagnostic tests. However, newer approaches to treatment (for example, narrow spectrum antibiotics), may be well suited for a small number of patients, i.e. a niche market in support of a CDx. The current emphasis is rapid and point-of-care (POC) diagnostic platforms as well as changes in treatment.
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Affiliation(s)
- Peter J Dailey
- School of Public Health, University of California, Berkeley , Berkeley, CA, USA.,The Foundation for Innovative New Diagnostics (FIND) , Geneva, Switzerland
| | - Tarek Elbeik
- VA Palo Alto Health Care System, Department of Veterans Affairs , Palo Alto, CA, USA
| | - Mark Holodniy
- VA Palo Alto Health Care System, Department of Veterans Affairs , Palo Alto, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University , Stanford, CA, USA
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144
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Balamuth F, Alpern ER, Kan M, Shumyatcher M, Hayes K, Lautenbach E, Himes BE. Gene Expression Profiles in Children With Suspected Sepsis. Ann Emerg Med 2020; 75:744-754. [PMID: 31983492 DOI: 10.1016/j.annemergmed.2019.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/09/2019] [Accepted: 09/24/2019] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Sepsis recognition is a clinical challenge in children. We aim to determine whether peripheral blood gene expression profiles are associated with pathogen type and sepsis severity in children with suspected sepsis. METHODS This was a prospective pilot observational study in a tertiary pediatric emergency department with a convenience sample of children enrolled. Participants were older than 56 days and younger than 18 years, had suspected sepsis, and had not received broad-spectrum antibiotics in the previous 4 hours. Primary outcome was source pathogen, defined as confirmed bacterial source from sterile body fluid or confirmed viral source. Secondary outcome was sepsis severity, defined as maximum therapy required for shock reversal in the first 3 hospital days. We drew peripheral blood for ribonucleic acid isolation at the sepsis protocol activation, obtained gene expression measures with the GeneChip Human Gene 2.0 ST Array, and conducted differential expression analysis. RESULTS We collected ribonucleic acid samples from a convenience sample of 122 children with suspected sepsis and 12 healthy controls. We compared the 66 children (54%) with confirmed bacterial or viral infection and found 558 differentially expressed genes, many related to interferon signaling or viral immunity. We did not find statistically significant gene expression differences in patients according to sepsis severity. CONCLUSION The study demonstrates feasibility of evaluating gene expression profiling data in children evaluated for sepsis in the pediatric emergency department setting. Our results suggest that gene expression profiling may facilitate identification of source pathogen in children with suspected sepsis, which could ultimately lead to improved tailoring of sepsis treatment and antimicrobial stewardship.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern School of Medicine, Division of Emergency Medicine, and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mengyuan Kan
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Maya Shumyatcher
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Katie Hayes
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ebbing Lautenbach
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
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145
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Application of unsupervised clustering algorithm and heat-map analysis for selection of lactic acid bacteria isolated from dairy samples based on desired probiotic properties. Lebensm Wiss Technol 2020. [DOI: 10.1016/j.lwt.2019.108839] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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146
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Oved K, Eden E, Gottlieb TM. Unlocking the power of the host response to improve the management of infectious diseases. Future Microbiol 2019; 14:1257-1259. [PMID: 31849234 DOI: 10.2217/fmb-2019-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Kfir Oved
- MeMed, 5 Nahum Het Street, Haifa, Israel
| | - Eran Eden
- MeMed, 5 Nahum Het Street, Haifa, Israel
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Subphenotypes in Patients with Septic Shock Receiving Vitamin C, Hydrocortisone, and Thiamine: A Retrospective Cohort Analysis. Nutrients 2019; 11:nu11122976. [PMID: 31817439 PMCID: PMC6950320 DOI: 10.3390/nu11122976] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/17/2022] Open
Abstract
This study aimed to identify septic phenotypes in patients receiving vitamin C, hydrocortisone, and thiamine using temperature and white blood cell count. Data were obtained from septic shock patients who were also treated using a vitamin C protocol in a medical intensive care unit. Patients were divided into groups according to the temperature measurements as well as white blood cell counts within 24 h before starting the vitamin C protocol. In the study, 127 patients included who met the inclusion criteria. In the cohort, four groups were identified: “Temperature ≥37.1 °C, white blood cell count ≥15.0 1000/mm3” (group A; n = 27), “≥37.1 °C, <15.0 1000/mm3” (group B; n = 30), “<37.1 °C, ≥15.0 1000/mm3” (group C; n = 35) and “<37.1 °C, <15.0 1000/mm3” (group D; n = 35). The intensive care unit mortality rates were 15% for group A, 33% for group B, 34% for group C, and 49% for group D (p = 0.051). The temporal improvement in organ dysfunction and vasopressor dose seemed more apparent in group A patients. Our results suggest that different subphenotypes exist among sepsis patients treated using a vitamin C protocol, and clinical outcomes might be better for patients with the hyperinflammatory subphenotype.
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Rubio I, Osuchowski MF, Shankar-Hari M, Skirecki T, Winkler MS, Lachmann G, La Rosée P, Monneret G, Venet F, Bauer M, Brunkhorst FM, Kox M, Cavaillon JM, Uhle F, Weigand MA, Flohé SB, Wiersinga WJ, Martin-Fernandez M, Almansa R, Martin-Loeches I, Torres A, Giamarellos-Bourboulis EJ, Girardis M, Cossarizza A, Netea MG, van der Poll T, Scherag A, Meisel C, Schefold JC, Bermejo-Martín JF. Current gaps in sepsis immunology: new opportunities for translational research. THE LANCET. INFECTIOUS DISEASES 2019; 19:e422-e436. [DOI: 10.1016/s1473-3099(19)30567-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 12/18/2022]
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A Multicenter Network Assessment of Three Inflammation Phenotypes in Pediatric Sepsis-Induced Multiple Organ Failure. Pediatr Crit Care Med 2019; 20:1137-1146. [PMID: 31568246 PMCID: PMC8121153 DOI: 10.1097/pcc.0000000000002105] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Ongoing adult sepsis clinical trials are assessing therapies that target three inflammation phenotypes including 1) immunoparalysis associated, 2) thrombotic microangiopathy driven thrombocytopenia associated, and 3) sequential liver failure associated multiple organ failure. These three phenotypes have not been assessed in the pediatric multicenter setting. We tested the hypothesis that these phenotypes are associated with increased macrophage activation syndrome and mortality in pediatric sepsis. DESIGN Prospective severe sepsis cohort study comparing children with multiple organ failure and any of these phenotypes to children with multiple organ failure without these phenotypes and children with single organ failure. SETTING Nine PICUs in the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS Children with severe sepsis and indwelling arterial or central venous catheters. INTERVENTIONS Clinical data collection and twice weekly blood sampling until PICU day 28 or discharge. MEASUREMENTS AND MAIN RESULTS Of 401 severe sepsis cases enrolled, 112 (28%) developed single organ failure (0% macrophage activation syndrome 0/112; < 1% mortality 1/112), whereas 289 (72%) developed multiple organ failure (9% macrophage activation syndrome 24/289; 15% mortality 43/289). Overall mortality was higher in children with multiple organ and the phenotypes (24/101 vs 20/300; relative risk, 3.56; 95% CI, 2.06-6.17). Compared to the 188 multiple organ failure patients without these inflammation phenotypes, the 101 multiple organ failure patients with these phenotypes had both increased macrophage activation syndrome (19% vs 3%; relative risk, 7.07; 95% CI, 2.72-18.38) and mortality (24% vs 10%; relative risk, 2.35; 95% CI, 1.35-4.08). CONCLUSIONS These three inflammation phenotypes were associated with increased macrophage activation syndrome and mortality in pediatric sepsis-induced multiple organ failure. This study provides an impetus and essential baseline data for planning multicenter clinical trials targeting these inflammation phenotypes in children.
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Seymour CW, Kerti SJ, Lewis AJ, Kennedy J, Brant E, Griepentrog JE, Zhang X, Angus DC, Chang CCH, Rosengart MR. Murine sepsis phenotypes and differential treatment effects in a randomized trial of prompt antibiotics and fluids. Crit Care 2019; 23:384. [PMID: 31779663 PMCID: PMC6883631 DOI: 10.1186/s13054-019-2655-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/21/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Clinical and biologic phenotypes of sepsis are proposed in human studies, yet it is unknown whether prognostic or drug response phenotypes are present in animal models of sepsis. Using a biotelemetry-enhanced, murine cecal ligation and puncture (CLP) model, we determined phenotypes of polymicrobial sepsis prior to physiologic deterioration, and the association between phenotypes and outcome in a randomized trial of prompt or delayed antibiotics and fluids. METHODS We performed a secondary analysis of male C57BL/6J mice in two observational cohorts and two randomized, laboratory animal experimental trials. In cohort 1, mice (n = 118) underwent biotelemetry-enhanced CLP, and we applied latent class mixed models to determine optimal number of phenotypes using clinical data collected between injury and physiologic deterioration. In cohort 2 (N = 73 mice), inflammatory cytokines measured at 24 h after deterioration were explored by phenotype. In a subset of 46 mice enrolled in two trials from cohort 1, we tested the association of phenotypes with the response to immediate (0 h) vs. delayed (2 to 4 h) antibiotics or fluids initiated after physiologic deterioration. RESULTS Latent class mixture modeling derived a two-class model in cohort 1. Class 2 (N = 97) demonstrated a shorter time to deterioration (mean SD 7.3 (0.9) vs. 9.7 (3.2) h, p < 0.001) and lower heart rate at 7 h after injury (mean (SD) 564 (55) vs. 626 (35) beats per minute, p < 0.001). Overall mortality was similar between phenotypes (p = 0.75). In cohort 2 used for biomarker measurement, class 2 mice had greater plasma concentrations of IL6 and IL10 at 24 h after CLP (p = 0.05). In pilot randomized trials, the effects of sepsis treatment (immediate vs. delayed antibiotics) differed by phenotype (p = 0.03), with immediate treatment associated with greater survival in class 2 mice only. Similar differential treatment effect by class was observed in the trial of immediate vs. delayed fluids (p = 0.02). CONCLUSIONS We identified two sepsis phenotypes in a murine cecal ligation and puncture model, one of which is characterized by faster deterioration and more severe inflammation. Response to treatment in a randomized trial of immediate versus delayed antibiotics and fluids differed on the basis of phenotype.
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Affiliation(s)
- Christopher W. Seymour
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA ,0000 0004 1936 9000grid.21925.3dDepartment of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Samantha J. Kerti
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Anthony J. Lewis
- 0000 0004 1936 9000grid.21925.3dDepartment of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Jason Kennedy
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Emily Brant
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - John E. Griepentrog
- 0000 0004 1936 9000grid.21925.3dDepartment of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Xianghong Zhang
- 0000 0004 1936 9000grid.21925.3dDepartment of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Derek C. Angus
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Chung-Chou H. Chang
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA ,0000 0004 1936 9000grid.21925.3dDepartment of Biostatistics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Matthew R. Rosengart
- 0000 0004 1936 9000grid.21925.3dDepartments of Critical Care Medicine Emergency Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, #639, Pittsburgh, PA 15261 USA ,0000 0004 1936 9000grid.21925.3dClinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh School of Medicine, Pittsburgh, USA ,0000 0004 1936 9000grid.21925.3dDepartment of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
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