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Turcato G, Zaboli A, Sibilio S, Brigo F. Estimated plasma volume status is a simple and quick tool that could help define the severity of patients with infection on arrival at the emergency department. Am J Med Sci 2024; 367:343-351. [PMID: 38354776 DOI: 10.1016/j.amjms.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/18/2023] [Accepted: 02/08/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Infectious states are subtle and rapidly evolving conditions observed daily in the emergency department (ED), and their prognostic evaluation remains a complex clinical challenge. Recently, estimated plasma volume status (ePVS) has been suggested to have a prognostic role in conditions where volemic alteration is central to the pathophysiology. The aim of this study was to verify whether ePVS recorded at ED admission can provide prognostic indications of 30-day mortality in patients with infection. METHODS A prospective observational study was performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital. All patients with infection were enrolled. ePVS values were derived from haemoglobin and haematocrit measured on the immediate arrival of patients in the ED. The predictive power of ePVS for 30-day mortality was assessed using a multivariate model adjusted for severity, comorbidity and urgency. Kaplan-Meier analysis was also performed. RESULTS Of the 949 patients with infection enrolled in the study (47.9%, SOFA ≥2), 8.9% (84/949) died at 30 days. The median ePVS value was higher in patients who died at 30 days than in patients who survived (5.83 vs. 4.61, p < 0.001). Multivariate analysis revealed that ePVS in both continuous and categorical form around the median was an independent risk factor for 30-day mortality even after adjusting for severity, comorbidity and urgency. Kaplan-Meier analysis confirmed an increased risk of death in patients with high ePVS values. CONCLUSIONS ePVS recorded on ED admission of patients with infection was an independent predictor of risk for 30-day mortality.
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Affiliation(s)
- Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy.
| | - Arian Zaboli
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy; Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Serena Sibilio
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy; Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Francesco Brigo
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria; Department of Neurology, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy
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Turcato G, Zaboli A, Sibilio S, Parodi M, Mian M, Brigo F. The role of lactate-to-albumin ratio to predict 30-day risk of death in patients with sepsis in the emergency department: a decision tree analysis. Curr Med Res Opin 2024; 40:345-352. [PMID: 38305238 DOI: 10.1080/03007995.2024.2314740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/01/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Accurately estimating the prognosis of septic patients on arrival in the emergency department (ED) is clinically challenging. The lactate-to-albumin ratio (LAR) has recently been proposed to improve the predictive performance of septic patients admitted to the ICU. OBJECTIVES This study aims to assess whether the LAR could be used as an early prognostic marker of 30-day mortality in patients with sepsis in the ED. METHODS A prospective observational study was conducted in the ED of the Hospital of Merano. All patients with a diagnosis of sepsis were considered. The LAR was recorded on arrival in the ED. The primary outcome measure was mortality at 30 days. The predictive role of the LAR for mortality was evaluated with the area under the ROC curve, logistic regression adjusted for the Charlson Comorbidity Index value, National Early Warning Score, and Sequential Organ Failure score, and with decision tree analysis. RESULTS 459 patients were enrolled, of whom 17% (78/459) died at 30 days. The median LAR of the patients who died at 30 days (0.78 [0.45-1.19]) was significantly higher than the median LAR of survivors (0.42 [0.27-0.65]) (p < 0.001). The discriminatory ability of the LAR for death at 30 days was 0.738, higher than that of lactate alone (0.692), and slightly lower than that of albumin alone (0.753). The decision trees confirmed the role of the LAR as an independent risk factor for mortality. CONCLUSION The LAR can be used as an index to better predict the 30-day risk of death in septic patients.
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Affiliation(s)
- Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Santorso, Italy
| | - Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy
| | - Serena Sibilio
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Marta Parodi
- Department of Internal Medicine, Intermediate Care Unit, Santorso, Italy
| | - Michael Mian
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy
- College of Health Care-Professions Claudiana, Bozen, Italy
| | - Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy
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Turcato G, Zaboli A, Sibilio S, Fanni Canelles M, Rella E, Giudiceandrea A, Pfeifer N, Brigo F. Prognostic Role of Serum Albumin in Predicting 30-Day Mortality in Patients with Infections in Emergency Department: A Prospective Study. J Clin Med 2023; 12:jcm12103447. [PMID: 37240554 DOI: 10.3390/jcm12103447] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Infections in emergency departments (EDs) are insidious clinical conditions characterised by high rates of hospitalisation and mortality in the short-to-medium term. The serum albumin, recently demonstrated as a prognostic biomarker in septic patients in intensive care units, could be an early marker of severity upon arrival of infected patients in the ED. AIM To confirm the possible prognostic role of the albumin concentration recorded upon arrival of patients with infection. METHODS A prospective single-centre study was performed in the ED of the General Hospital of Merano, Italy, between 1 January 2021 and 31 December 2021. All enrolled patients with infection were tested for serum albumin concentration. The primary outcome measure was 30-day mortality. The predictive role of albumin was assessed by logistic regression and decision tree analysis adjusted for Charlson comorbidity index, national early warning score, and sequential organ failure assessment (SOFA) score. RESULTS 962 patients with confirmed infection were enrolled. The median SOFA score was 1 (0-3) and the mean serum albumin level was 3.7 g/dL (SD 0.6). Moreover, 8.9% (86/962) of patients died within 30 days. Albumin was an independent risk factor for 30-day mortality with an adjusted hazard ratio of 3.767 (95% CI 2.192-6.437), p < 0.001. Decision tree analysis indicated that at low SOFA scores, albumin had a good predictive ability, indicating a progressive mortality risk reduction in concentrations above 2.75 g/dL (5.2%) and 3.52 g/dL (2%). CONCLUSIONS Serum albumin levels at ED admission are predictive of 30-day mortality in infected patients, showing better predictive abilities in patients with low-to-medium SOFA scores.
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Affiliation(s)
- Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), 36014 Santorso, Italy
| | - Arian Zaboli
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
| | - Serena Sibilio
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
| | - Massimiliano Fanni Canelles
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
| | - Eleonora Rella
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
| | - Alberto Giudiceandrea
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
| | - Norbert Pfeifer
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
| | - Francesco Brigo
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 5020 Salzburg, Austria
- Department of Neurology, Hospital of Merano-Meran (SABES-ASDAA), 39012 Merano-Meran, Italy
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Beadle JL, Perman SM, Pennington J, Gaieski DF. An investigation of temperature and fever burdens in patients with sepsis admitted from the emergency department to the hospital. Acute Med Surg 2023; 10:e902. [PMID: 37929070 PMCID: PMC10622605 DOI: 10.1002/ams2.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Aim We sought to collect granular data on temperature burden to further explore existing conflicting information on the relationship between temperature alterations and outcomes in patients with sepsis requiring hospital admission. Methods This was a prospective cohort study that enrolled a convenience sample of patients with sepsis or septic shock admitted to the hospital from the emergency department (ED). A "unit of temperature burden (UTB)" was defined as >1°C (1.8°F) above or below 37°C (98.6°F) for 1 min. Fever burden was defined as the number of UTBs >38°C (100.4°F). The primary objective was to calculate the fever burden in patients with sepsis during their ED stay. This was analyzed for patients who present to triage febrile or hypothermic and also for those who developed temperature abnormalities during their ED stay. The secondary objectives were correlating fever and hypothermia burden with in-hospital mortality, Systemic Inflammatory Response Syndrome (SIRS) criteria, and the quick Sequential (Sepsis-Associated) Organ Failure Assessment (qSOFA) score and identification of patients who may benefit from early implementation of targeted temperature management. Results A total of 256 patients met the inclusion criteria. The mean age of patients was 60.1 ± 18.4 years; 46% were female and 29.6% were black. The median (interquartile range [IQR]) fever burden for the fever in triage cohort (n = 99) was 364.6 (174.3-716.8) UTB and for the no fever in triage cohort (n = 157) was 179.3 (80.9-374.0) UTB (p = 0.005). The two groups had similar in-hospital mortality (6.1 vs 8.3%; p = 0.5). The median fever burden for the fever anytime cohort was 303.8 (IQR 138.8-607.9) UTB and they had lower mortality than the no fever anytime cohort (4.7% vs 11.2%; p = 0.052). Patients with fever at triage had higher mean SIRS criteria than those without (2.8 vs 2.0; p < 0.001) while qSOFA points were similar (p = 0.199). A total of 27 patients had hypothermia during their ED stay and these patients were older with higher mean SIRS criteria. Conclusions Patients with sepsis and septic shock have a significant temperature burden in the ED. When comparing patients who had fever at any time during their ED stay with those who never had a fever, a trend toward an inverse relationship between fever burden and mortality was found.
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Affiliation(s)
| | | | | | - David F. Gaieski
- Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
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Montague B, Summers A, Bhawal R, Anderson ET, Kraus-Malett S, Zhang S, Goggs R. Identifying potential biomarkers and therapeutic targets for dogs with sepsis using metabolomics and lipidomics analyses. PLoS One 2022; 17:e0271137. [PMID: 35802586 PMCID: PMC9269464 DOI: 10.1371/journal.pone.0271137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/23/2022] [Indexed: 11/19/2022] Open
Abstract
Sepsis is a diagnostic and therapeutic challenge and is associated with morbidity and a high risk of death. Metabolomic and lipidomic profiling in sepsis can identify alterations in metabolism and might provide useful insights into the dysregulated host response to infection, but investigations in dogs are limited. We aimed to use untargeted metabolomics and lipidomics to characterize metabolic pathways in dogs with sepsis to identify therapeutic targets and potential diagnostic and prognostic biomarkers. In this prospective observational cohort study, we examined the plasma metabolomes and lipidomes of 20 healthy control dogs and compared them with those of 21 client-owned dogs with sepsis. Patient data including signalment, physical exam findings, clinicopathologic data and clinical outcome were recorded. Metabolites were identified using an untargeted mass spectrometry approach and pathway analysis identified multiple enriched metabolic pathways including pyruvaldehyde degradation; ketone body metabolism; the glucose-alanine cycle; vitamin-K metabolism; arginine and betaine metabolism; the biosynthesis of various amino acid classes including the aromatic amino acids; branched chain amino acids; and metabolism of glutamine/glutamate and the glycerophospholipid phosphatidylethanolamine. Metabolites were identified with high discriminant abilities between groups which could serve as potential biomarkers of sepsis including 13,14-Dihydro-15-keto Prostaglandin A2; 12(13)-DiHOME (12,13-dihydroxy-9Z-octadecenoic acid); and 9-HpODE (9-Hydroxyoctadecadienoic acid). Metabolites with higher abundance in samples from nonsurvivors than survivors included 3-(2-hydroxyethyl) indole, indoxyl sulfate and xanthurenic acid. Untargeted lipidomic profiling revealed multiple sphingomyelin species (SM(d34:0)+H; SM(d36:0)+H; SM(d34:0)+HCOO; and SM(d34:1D3)+HCOO); lysophosphatidylcholine molecules (LPC(18:2)+H) and lipophosphoserine molecules (LPS(20:4)+H) that were discriminating for dogs with sepsis. These biomarkers could aid in the diagnosis of dogs with sepsis, provide prognostic information, or act as potential therapeutic targets.
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Affiliation(s)
- Brett Montague
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - April Summers
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Ruchika Bhawal
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York, United States of America
| | - Elizabeth T. Anderson
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York, United States of America
| | - Sydney Kraus-Malett
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Sheng Zhang
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York, United States of America
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
- * E-mail:
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Zhang N, Aiyasiding X, Li WJ, Liao HH, Tang QZ. Neutrophil degranulation and myocardial infarction. Cell Commun Signal 2022; 20:50. [PMID: 35410418 PMCID: PMC8996539 DOI: 10.1186/s12964-022-00824-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/26/2021] [Indexed: 11/21/2022] Open
Abstract
Myocardial infarction (MI) is one of the most common cardiac emergencies with high morbidity and is a leading cause of death worldwide. Since MI could develop into a life-threatening emergency and could also seriously affect the life quality of patients, continuous efforts have been made to create an effective strategy to prevent the occurrence of MI and reduce MI-related mortality. Numerous studies have confirmed that neutrophils play important roles in inflammation and innate immunity, which provide the first line of defense against microorganisms by producing inflammatory cytokines and chemokines, releasing reactive oxygen species, and degranulating components of neutrophil cytoplasmic granules to kill pathogens. Recently, researchers reported that neutrophils are closely related to the severity and prognosis of patients with MI, and neutrophil to lymphocyte ratio in post-MI patients had predictive value for major adverse cardiac events. Neutrophils have been increasingly recognized to exert important functions in MI. Especially, granule proteins released by neutrophil degranulation after neutrophil activation have been suggested to involve in the process of MI. This article reviewed the current research progress of neutrophil granules in MI and discusses neutrophil degranulation associated diagnosis and treatment strategies. Video abstract
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Affiliation(s)
- Nan Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China.,Cardiovascular Research Institute of Wuhan University, Wuhan, 430060, People's Republic of China.,Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, 430060, People's Republic of China
| | - Xiahenazi Aiyasiding
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China.,Cardiovascular Research Institute of Wuhan University, Wuhan, 430060, People's Republic of China.,Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, 430060, People's Republic of China
| | - Wen-Jing Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China.,Cardiovascular Research Institute of Wuhan University, Wuhan, 430060, People's Republic of China.,Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, 430060, People's Republic of China
| | - Hai-Han Liao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China. .,Cardiovascular Research Institute of Wuhan University, Wuhan, 430060, People's Republic of China. .,Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, 430060, People's Republic of China.
| | - Qi-Zhu Tang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People's Republic of China. .,Cardiovascular Research Institute of Wuhan University, Wuhan, 430060, People's Republic of China. .,Hubei Key Laboratory of Metabolic and Chronic Diseases, Wuhan, 430060, People's Republic of China.
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Sathe NA, Bhatraju PK, Mikacenic C, Morrell ED, Mabrey FL, Liles WC, Wurfel MM. Relationships Between Age, Soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1), and Mortality Among Critically Ill Adults: A Cohort Study. Shock 2022; 57:205-211. [PMID: 34812186 PMCID: PMC8969235 DOI: 10.1097/shk.0000000000001888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Innate immune dysregulation may contribute to age-related differences in outcomes among critically ill adults. Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is an important innate immune marker with prognostic value in sepsis, but age-related differences have not been studied. METHODS This was a prospective cohort from a large tertiary care hospital enrolling adults from both medical and trauma-surgical intensive care units (ICUs). Plasma sTREM-1 was measured in participants within 24 h of ICU admission. We analyzed associations between age (≤50 and >50 years) and sTREM-1 using linear regression. We then examined associations between sTREM-1 and both 28-day mortality and persistent organ dysfunction (defined as need for dialysis, vasopressors, or invasive mechanical ventilation) 7 days following admission using relative risk regression. RESULTS Of 231 critically ill adults, older patients (n = 122) had higher prevalence of chronic disease and sepsis on enrollment than younger patients, but acute illness severity was similar. Age over 50 was associated with 27% higher sTREM-1 concentrations (95% CI 6%-53%), adjusted for sex and Charlson comorbidity index (CCI). Two-fold higher sTREM-1 was associated with 2.42-fold higher risk for mortality (95% CI 1.57, 3.73) and 1.86-fold higher risk for persistent organ dysfunction (95% CI 1.45, 2.39), adjusted for sex, CCI, and age. CONCLUSIONS sTREM-1 was elevated among critically ill older adults, and strongly associated with both death and persistent organ dysfunction. Immune responses associated with sTREM-1 may contribute to age-related differences in ICU outcomes, warranting further study as a potential therapeutic target in older adults.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Benaroya Research Institute, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
| | - F. Linzee Mabrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - W. Conrad Liles
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
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Bline KE, Hall MW. Immune Function in Critically Ill Septic Children. Pathogens 2021; 10:1239. [PMID: 34684188 PMCID: PMC8539782 DOI: 10.3390/pathogens10101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 11/19/2022] Open
Abstract
The inflammatory response in pediatric sepsis is highly dynamic and includes both pro- and anti-inflammatory elements that involve the innate and adaptive immune systems. While the pro-inflammatory response is responsible for the initial clinical signs and symptoms of sepsis, a concurrent compensatory anti-inflammatory response often results in an occult, but highly clinically relevant, form of acquired immunodeficiency. When severe, this is termed "immunoparalysis" and is associated with increased risks for nosocomial infection, prolonged organ dysfunction, and death. This review focuses on the pathophysiology and clinical implications of both over- and under-active immune function in septic children. Host-, disease-, and treatment-specific risk factors for immunoparalysis are reviewed along with immune phenotype-specific approaches for immunomodulation in pediatric sepsis which are currently the subject of clinical trials.
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Affiliation(s)
- Katherine Elizabeth Bline
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH 43205, USA;
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Metabolic Reprogramming and Host Tolerance: A Novel Concept to Understand Sepsis-Associated AKI. J Clin Med 2021; 10:jcm10184184. [PMID: 34575294 PMCID: PMC8471000 DOI: 10.3390/jcm10184184] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 12/26/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent complication of sepsis that increases mortality and the risk of progression to chronic kidney disease. However, the mechanisms leading to sepsis-associated AKI are still poorly understood. The recognition that sepsis induces organ dysfunction in the absence of overt necrosis or apoptosis has led to the consideration that tubular epithelial cells (TEC) may deploy defense mechanisms to survive the insult. This concept dovetails well with the notion that the defense against infection does not only depend on the capacity of the immune system to limit the microbial load (known as resistance), but also on the capacity of cells and tissues to limit tissue injury (known as tolerance). In this review, we discuss the importance of TEC metabolic reprogramming as a defense strategy during sepsis, and how this cellular response is likely to operate through a tolerance mechanism. We discuss the fundamental role of specific regulatory nodes and of mitochondria in orchestrating this response, and how this opens avenues for the exploration of targeted therapeutic strategies to prevent or treat sepsis-associated AKI.
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10
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Comparing Mortality Prediction by Quick Sequential Organ Failure Assessment with Emergency Physician Judgment. Shock 2021; 54:213-217. [PMID: 31851118 DOI: 10.1097/shk.0000000000001496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
STUDY OBJECTIVE The quick sequential organ failure assessment (qSOFA) was proposed to identify infected patients at risk for mortality, an indication of sepsis, in nonintensive care unit settings. This study tests whether qSOFA improves physician prediction of mortality among infected Emergency Department (ED) patients. METHODS We performed a secondary analysis of a prospective, observational study of potentially septic ED patients, conducted between two urban, academic medical centers, from July 2016 to December 2017. We enrolled ED patients with two or more systemic inflammatory response syndrome criteria and severe sepsis qualifying organ dysfunction, systolic blood pressure <90 mm Hg, or lactate ≥ 4.0 mmol/L. Infectious etiology was adjudicated retrospectively by paired physician review. We excluded noninfected patients. Treating ED physicians submitted judgment for in-hospital mortality (0%-100%) at hospital admission, and qSOFA was calculated retrospectively using ED data. The primary outcome was in-hospital mortality within 28 days. We used logistic regression to predict mortality using physician judgment, qSOFA, and combined physician judgment and qSOFA. To assess differences between models, 95% confidence intervals for area under the curve (AUC) were derived by bootstrapping with 1,000 iterations. RESULTS Of 405 patients meeting inclusion criteria, 195 (48.1%) were determined to have infection and analyzed. Of analyzed patients, 16 (8.2%) suffered in-hospital mortality within 28 days. Analyzed patients had a mean age of 58.3 (SD 16.5) years and 78 (40%) were female. qSOFA alone (AUC 0.63; 95% CI: 0.53-0.73) was not superior to unstructured physician judgment (AUC 0.80; 0.70-0.89) when predicting 28-day in-hospital mortality with mean AUC difference 0.17 (0.07-0.28) across bootstrapped datasets. Combining qSOFA with physician judgment (AUC 0.79; 0.69-0.89) did not improve performance compared with physician judgment alone. CONCLUSION When predicting 28-day in-hospital mortality among infected ED patients, qSOFA did not outperform or improve physician judgment.
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11
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Starikova E, Mammedova J, Ozhiganova A, Lebedeva A, Malashicheva A, Semenova D, Khokhlova E, Mameli E, Caporali A, Wills J, Sokolov A. Protective Role of Mytilus edulis Hydrolysate in Lipopolysaccharide-Galactosamine Acute Liver Injury. Front Pharmacol 2021; 12:667572. [PMID: 34084140 PMCID: PMC8167060 DOI: 10.3389/fphar.2021.667572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/19/2021] [Indexed: 12/02/2022] Open
Abstract
Acute liver injury in its terminal phase trigger systemic inflammatory response syndrome with multiple organ failure. An uncontrolled inflammatory reaction is difficult to treat and contributes to high mortality. Therefore, to solve this problem a search for new therapeutic approaches remains urgent. This study aimed to explore the protective effects of M. edulis hydrolysate (N2-01) against Lipopolysaccharide-D-Galactosamine (LPS/D-GalN)-induced murine acute liver injure and the underlying mechanisms. N2-01 analysis, using Liquid Chromatography Mass Spectrometry (LCMS) metabolomic and proteomic platforms, confirmed composition, molecular-weight distribution, and high reproducibility between M. edulis hydrolysate manufactured batches. N2-01 efficiently protected mice against LPS/D-GalN-induced acute liver injury. The most prominent result (100% survival rate) was obtained by the constant subcutaneous administration of small doses of the drug. N2-01 decreased Vascular Cell Adhesion Molecule-1 (VCAM-1) expression from 4.648 ± 0.445 to 1.503 ± 0.091 Mean Fluorescence Intensity (MFI) and Interleukin-6 (IL-6) production in activated Human Umbilical Vein Endothelial Cells (HUVECs) from 7.473 ± 0.666 to 2.980 ± 0.130 ng/ml in vitro. The drug increased Nitric Oxide (NO) production by HUVECs from 27.203 ± 2.890 to 69.200 ± 4.716 MFI but significantly decreased inducible Nitric Oxide Synthase (iNOS) expression from 24.030 ± 2.776 to 15.300 ± 1.290 MFI and NO production by murine peritoneal lavage cells from 6.777 ± 0.373 µm to 2.175 ± 0.279 µm. The capability of the preparation to enhance the endothelium barrier function and to reduce vascular permeability was confirmed in Electrical Cell-substrate Impedance Sensor (ECIS) test in vitro and Miles assay in vivo. These results suggest N2-01 as a promising agent for treating a wide range of conditions associated with uncontrolled inflammation and endothelial dysfunction.
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Affiliation(s)
- Eleonora Starikova
- Laboratory of Immunoregulation, Department of Immunology, Institute of Experimental Medicine, St. Petersburg, Russian Federation
| | - Jennet Mammedova
- Laboratory of General Immunology, Department of Immunology, Institute of Experimental Medicine, St. Petersburg, Russian Federation
| | - Arina Ozhiganova
- Laboratory of Immunoregulation, Department of Immunology, Institute of Experimental Medicine, St. Petersburg, Russian Federation
| | - Aleksandra Lebedeva
- Laboratory of Immunoregulation, Department of Immunology, Institute of Experimental Medicine, St. Petersburg, Russian Federation
| | - Anna Malashicheva
- Laboratory of Molecular Cardiology, Almazov National Medical Research Centre, St. Petersburg, Russian Federation.,Laboratory of Regenerative Biomedicine, Institute of Cytology RAS, St. Petersburg, Russian Federation
| | - Daria Semenova
- Laboratory of Molecular Cardiology, Almazov National Medical Research Centre, St. Petersburg, Russian Federation.,Laboratory of Regenerative Biomedicine, Institute of Cytology RAS, St. Petersburg, Russian Federation
| | - Evgeniia Khokhlova
- Laboratory of Regenerative Biomedicine, Institute of Cytology RAS, St. Petersburg, Russian Federation
| | - Eleonora Mameli
- Laboratory of Vascular Biology, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrea Caporali
- Laboratory of Vascular Biology, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jimi Wills
- Cancer Research United Kingdom Edinburgh Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, United Kingdom
| | - Alexey Sokolov
- Laboratory of Biochemical Genetics, Department of Molecular Genetics, Institute of Experimental Medicine, St. Petersburg, Russian Federation
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12
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Sepsis plasma-derived exosomal miR-1-3p induces endothelial cell dysfunction by targeting SERP1. Clin Sci (Lond) 2021; 135:347-365. [PMID: 33416075 PMCID: PMC7843403 DOI: 10.1042/cs20200573] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 12/21/2022]
Abstract
Acute lung injury (ALI) is the leading cause of death in sepsis patients. Exosomes participate in the occurrence and development of ALI by regulating endothelial cell inflammatory response, oxidative stress and apoptosis, causing serious pulmonary vascular leakage and interstitial edema. The current study investigated the effect of exosomal miRNAs on endothelial cells during sepsis. We found a significant increase in miR-1-3p expression in cecal ligation and puncture (CLP) rats exosomes sequencing and sepsis patients' exosomes, and lipopolysaccharide (LPS)-stimulated human umbilical vein endothelial cells (HUVECs) in vitro. However, the specific biological function of miR-1-3p in ALI remains unknown. Therefore, mimics or inhibitors of miR-1-3p were transfected to modulate its expression in HUVECs. Cell proliferation, apoptosis, contraction, permeability, and membrane injury were examined via cell counting kit-8 (CCK-8), flow cytometry, phalloidin staining, Transwell assay, lactate dehydrogenase (LDH) activity, and Western blotting. The miR-1-3p target gene was predicted with miRNA-related databases and validated by luciferase reporter. Target gene expression was blocked by siRNA to explore the underlying mechanisms. The results illustrated increased miR-1-3p and decreased stress-associated endoplasmic reticulum protein 1 (SERP1) expression both in vivo and in vitro. SERP1 was a direct target gene of miR-1-3p. Up-regulated miR-1-3p inhibits cell proliferation, promotes apoptosis and cytoskeleton contraction, increases monolayer endothelial cell permeability and membrane injury by targeting SERP1, which leads to dysfunction of endothelial cells and weakens vascular barrier function involved in the development of ALI. MiR-1-3p and SERP1 may be promising therapeutic candidates for sepsis-induced lung injury.
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13
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Koch C, Edinger F, Fischer T, Brenck F, Hecker A, Katzer C, Markmann M, Sander M, Schneck E. Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients. World J Emerg Surg 2020; 15:63. [PMID: 33239088 PMCID: PMC7687806 DOI: 10.1186/s13017-020-00343-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients. METHODS Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria. RESULTS Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]). CONCLUSIONS None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.
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Affiliation(s)
- Christian Koch
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany. .,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany.
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Tobias Fischer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Florian Brenck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Christian Katzer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
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14
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Schneider JE, Romanowsky J, Schuetz P, Stojanovic I, Cheng HK, Liesenfeld O, Buturovic L, Sweeney TE. Cost Impact Model of a Novel Multi-mRNA Host Response Assay for Diagnosis and Risk Assessment of Acute Respiratory Tract Infections and Sepsis in the Emergency Department. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2020; 7:24-34. [PMID: 32685595 PMCID: PMC7299497 DOI: 10.36469/jheor.2020.12637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/20/2020] [Accepted: 03/27/2020] [Indexed: 06/02/2023]
Abstract
BACKGROUND Early identification of acute infections and sepsis remains an unmet medical need. While early detection and initiation of treatment reduces mortality, inappropriate treatment leads to adverse events and the development of antimicrobial resistance. Current diagnostic and prognostic solutions, including procalcitonin, lack required accuracy. A novel blood-based host response test, HostDx™ Sepsis by Inflammatix, Inc., assesses the likelihood of a bacterial infection, the likelihood of a viral infection, and the severity of the condition. OBJECTIVES We estimated the economic impact of adopting HostDx Sepsis testing among patients with suspected acute respiratory tract infection (ARTI) in the emergency department (ED). METHODS Our cost impact model estimated costs for adult ED patients with suspected ARTI under the standard of care versus with the adoption of HostDx Sepsis from the perspective of US payers. Included costs were those assumed to be associated with an episode of sepsis diagnosis, management, and treatment. Projected accuracies for test predictions, disease prevalence, and clinical parameters was derived from patient-level meta-analysis data of randomized trials, supplemented with published performance data for HostDx Sepsis. One-way sensitivity analysis was performed on key input parameters. RESULTS Compared to standard of care including procalcitonin, the superior test characteristics of HostDx Sepsis resulted in an average cost savings of approximately US$1974 per patient (-31.3%) exclusive of the cost of HostDx Sepsis. Reductions in hospital days (-0.80 days, -36.7%), antibiotic days (-1.49 days, -29.5%), and percent 30-day mortality (-1.67%, -13.64%) were driven by HostDx Sepsis providing fewer "noninformative" moderate risk predictions and more "certain" low- or high-risk predictions compared to standard of care, especially for patients who were not severely ill. These results were robust to changes in key parameters, including disease prevalence. CONCLUSIONS Our model shows substantial savings associated with introduction of HostDx Sepsis among patients with ARTIs in EDs. These results need confirmation in interventional trials.
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Affiliation(s)
| | | | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau,
Switzerland
- Department of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal Medicine, Kantonsspital Aarau, Aarau,
Switzerland
- Medical Faculty, University of Basel, Basel,
Switzerland
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15
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Lee W, Park EJ, Kwon OK, Kim H, Yoo Y, Kim SW, Seo YK, Kim IS, Na DH, Bae JS. Dual peptide-dendrimer conjugate inhibits acetylation of transforming growth factor β-induced protein and improves survival in sepsis. Biomaterials 2020; 246:120000. [PMID: 32247936 DOI: 10.1016/j.biomaterials.2020.120000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
Sepsis is a potentially fatal complication of infections and there are currently no effective therapeutic options for severe sepsis. In this study, we revealed the secretion mechanism of transforming growth factor β-induced protein (TGFBIp) that was recently identified as a therapeutic target for sepsis, and designed TGFBIp acetylation inhibitory peptide (TAIP) that suppresses acetylation of lysine 676 in TGFBIp. To improve bioavailability and biodegradation of the peptide, TAIP was conjugated to polyamidoamine (PAMAM) dendrimers. Additionally, the cell-penetrating peptide (CPP) was conjugated to the TAIP-modified PAMAM dendrimers for the intracellular delivery of TGFBIp. The resulting nanostructures, decorated with TAIP and CPP via poly(ethylene glycol) linkage, improved the mortality and organ damage in the septic mouse model and suppressed lipopolysaccharide-activated severe vascular inflammatory responses in endothelial cells. Thus, the dendrimer-based nanostructures for delivery of TAIP using CPP show great promise in practical applications in sepsis therapy.
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Affiliation(s)
- Wonhwa Lee
- College of Pharmacy, CMRI, Research Institute of Pharmaceutical Sciences, BK21 Plus KNU Multi-Omics Based Creative Drug Research Team, Kyungpook National University, Daegu, 41566, Republic of Korea; Aging Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, 34141, Republic of Korea.
| | - Eun Ji Park
- College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea; D&D Pharmatech, Seongnam, Gyeonggi-do, 13486, Republic of Korea.
| | - Oh Kwang Kwon
- College of Pharmacy, CMRI, Research Institute of Pharmaceutical Sciences, BK21 Plus KNU Multi-Omics Based Creative Drug Research Team, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Hyelim Kim
- College of Pharmacy, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Youngbum Yoo
- Aging Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, 34141, Republic of Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, 41944, Republic of Korea
| | - Young-Kyo Seo
- Aging Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, 34141, Republic of Korea
| | - In-San Kim
- Biomedical Research Institute, Korea Institute of Science and Technology, Seoul, 02792, Republic of Korea; KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul, 02841, Republic of Korea
| | - Dong Hee Na
- College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea.
| | - Jong-Sup Bae
- College of Pharmacy, CMRI, Research Institute of Pharmaceutical Sciences, BK21 Plus KNU Multi-Omics Based Creative Drug Research Team, Kyungpook National University, Daegu, 41566, Republic of Korea.
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16
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Libert C, Ayala A, Bauer M, Cavaillon JM, Deutschman C, Frostell C, Knapp S, Kozlov AV, Wang P, Osuchowski MF, Remick DG. Part II: Minimum Quality Threshold in Preclinical Sepsis Studies (MQTiPSS) for Types of Infections and Organ Dysfunction Endpoints. Shock 2020; 51:23-32. [PMID: 30106873 DOI: 10.1097/shk.0000000000001242] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although the clinical definitions of sepsis and recommended treatments are regularly updated, a systematic review has not been done for preclinical models. To address this deficit, a Wiggers-Bernard Conference on preclinical sepsis modeling reviewed the 260 most highly cited papers between 2003 and 2012 using sepsis models to create a series of recommendations. This Part II report provides recommendations for the types of infections and documentation of organ injury in preclinical sepsis models. Concerning the types of infections, the review showed that the cecal ligation and puncture model was used for 44% of the studies while 40% injected endotoxin. Recommendation #8 (numbered sequentially from Part I): endotoxin injection should not be considered as a model of sepsis; live bacteria or fungal strains derived from clinical isolates are more appropriate. Recommendation #9: microorganisms should replicate those typically found in human sepsis. Sepsis-3 states that sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, but the review of the papers showed limited attempts to document organ dysfunction. Recommendation #10: organ dysfunction definitions should be used in preclinical models. Recommendation #11: not all activities in an organ/system need to be abnormal to verify organ dysfunction. Recommendation #12: organ dysfunction should be measured in an objective manner using reproducible scoring systems. Recommendation #13: not all experiments must measure all parameters of organ dysfunction, but investigators should attempt to fully capture as much information as possible. These recommendations are proposed as "best practices" for animal models of sepsis.
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Affiliation(s)
- Claude Libert
- Center for Inflammation Research, VIB, Ghent, Belgium.,Ghent University, Ghent, Belgium
| | - Alfred Ayala
- Rhode Island Hospital & Alpert School of Medicine at Brown University, Providence, Rhode Island
| | | | | | - Clifford Deutschman
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York
| | - Claes Frostell
- Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | | | - Andrey V Kozlov
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
| | - Ping Wang
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Marcin F Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
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17
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A Promising Candidate: Heparin-Binding Protein Steps onto the Stage of Sepsis Prediction. J Immunol Res 2019; 2019:7515346. [PMID: 31930151 PMCID: PMC6942865 DOI: 10.1155/2019/7515346] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/06/2019] [Indexed: 12/30/2022] Open
Abstract
Sepsis is a systemic inflammatory response syndrome caused by infection. With high morbidity and mortality of this disease, there is a need to find early effective diagnosis and assessment methods to improve the prognosis of patients. Heparin-binding protein (HBP) is a granular protein derived from polynuclear neutrophils. The biosynthetic HBP in neutrophils is rapidly released under the stimulation of bacteria, resulting in increased vascular permeability and edema. It is reasonable to speculate that the HBP in plasma may serve as a novel diagnostic marker for sepsis, bacterial skin infection, acute bacterial meningitis, leptospirosis, protozoan parasites, and even some noncommunicable diseases. It implies that in the detection and diagnosis of sepsis, it will be possible to make relevant diagnosis through this new indicator in the future. In this review, we summarize the typical biological function of HBP and its latest research progress to provide theoretical basis for clinical prediction and diagnosis of sepsis.
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18
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Pedersen PB, Henriksen DP, Brabrand M, Lassen AT. Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study. BMJ Open 2019; 9:e032692. [PMID: 31666275 PMCID: PMC6830583 DOI: 10.1136/bmjopen-2019-032692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival. DESIGN This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults). SETTING Emergency department at Odense University Hospital, Denmark. PARTICIPANTS We included all adult patients who arrived from 1 April 2012 to 31 March 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality. RESULTS We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%). CONCLUSIONS The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital & Hospital of South West Jutland, Odense & Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
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19
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Shi B, Shi F, Xu K, Shi L, Tang H, Wang N, Wu Y, Gu J, Ding J, Huang Y. The prognostic performance of Sepsis-3 and SIRS criteria for patients with urolithiasis-associated sepsis transferred to ICU following surgical interventions. Exp Ther Med 2019; 18:4165-4172. [PMID: 31641388 DOI: 10.3892/etm.2019.8057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/25/2019] [Indexed: 12/20/2022] Open
Abstract
The aim of the present study was to validate the prognostic effectiveness of Sepsis-3 criteria, including sequential organ failure assessment (SOFA) and quick SOFA (qSOFA), with systemic inflammatory response syndrome (SIRS) criteria among patients with urolithiasis associated sepsis that were transferred to intensive care unit (ICU) facilities following surgical interventions. To achieve this, the records of all patients transferred to ICU following surgical interventions with urolithiasis-associated sepsis between January 2010 to July 2017 at Xin Hua Hospital Affiliated to Shanghai Jiao Tong University were retrospectively reviewed. A total of 107 patients were enrolled. The prognostic performances of SOFA, qSOFA and SIRS for predicting in-hospital mortality (sepsis-related mortality during patients' hospitalizations) or prolonged length of ICU stay (>3 days) were compared using the area under the receiver operating characteristic curve (AUROC) and Z statistic values. The results revealed that the overall in-hospital mortality rate was 8.4% and the percentage of in-hospital mortality or prolonged length of ICU stay (>3 days) was 72.0% among the 107 patients. The favorable outcome group exhibited significantly decreased white blood cell counts, and levels of C-reactive protein and procalcitonin and increased systolic blood pressure and mean arterial pressure. The AUROC of qSOFA, SIRS and SOFA were 0.615, 0.625 and 0.860, respectively. SOFA was significantly more effective at predicting adverse outcomes when compared with SIRS and qSOFA criteria. Following adjustments for patient age and comorbidities, the AUROC values of qSOFA, SIRS and SOFA were 0.713, 0.722 and 0.940. In conclusion, the results of the present study indicate that the prognostic performance of SOFA for predicting in-hospital mortality or prolonged ICU stay among patients with urolithiasis-associated sepsis following surgical interventions was significantly improved when compared with qSOFA or SIRS criteria. Based on these results it is recommended that urologists use the SOFA score for patients with urolithiasis-associated sepsis.
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Affiliation(s)
- Bowen Shi
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
| | - Fei Shi
- Department of Urology, Civil Aviation Hospital, Shanghai 200000, P.R. China
| | - Ke Xu
- Department of Urology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu, Jiangsu 215500, P.R. China
| | - Liuhui Shi
- Department of Urology, Civil Aviation Hospital, Shanghai 200000, P.R. China
| | - Haixiao Tang
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
| | - Ning Wang
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
| | - Yanyuan Wu
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
| | - Jun Gu
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
| | - Jie Ding
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
| | - Yunteng Huang
- Department of Urology, School of Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200092, P.R. China
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20
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Sarmin M, Afroze F, Sharifuzzaman, Alam T, Shaly NJ, Ahmed T, Chisti MJ. Predictor of Death in Diarrheal Children Under 5 Years of Age Having Severe Sepsis in an Urban Critical Care Ward in Bangladesh. Glob Pediatr Health 2019; 6:2333794X19862716. [PMID: 31384628 PMCID: PMC6647208 DOI: 10.1177/2333794x19862716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/23/2019] [Accepted: 06/03/2019] [Indexed: 01/20/2023] Open
Abstract
We aimed to identify clinical predictors of fatal outcome in children under 5
years of age having diarrhea and severe sepsis and treated in the Intensive Care
Unit of the Dhaka Hospital of icddr,b from October 2010 through September 2011.
Among 191 enrolled children, 70 (37%) died and were considered to be cases,
while the remaining 121 (63%) who survived constituted the controls. The cases
more often had shortness of breath (SOB), septic shock, dehydrating diarrhea
compared with the controls (for all, P < .05). After
adjusting for potential confounders using logistic regression analysis, the
likelihood of death was higher in children who had septic shock and SOB and
lower in children having dehydrating diarrhea (for all, P <
.05). Thus, SOB can trigger an early alarm for sepsis recognition; otherwise,
these children can end up with fatality from septic shock. In resource-poor
settings, early identification of these predictors can alleviate death.
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Affiliation(s)
- Monira Sarmin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Afroze
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharifuzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmina Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nusrat Jahan Shaly
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Liu Z, Triba MN, Amathieu R, Lin X, Bouchemal N, Hantz E, Le Moyec L, Savarin P. Nuclear magnetic resonance-based serum metabolomic analysis reveals different disease evolution profiles between septic shock survivors and non-survivors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:169. [PMID: 31088568 PMCID: PMC6518644 DOI: 10.1186/s13054-019-2456-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/25/2019] [Indexed: 01/02/2023]
Abstract
Background Septic shock is the most severe phase of sepsis and is associated with high rates of mortality. However, early stage prediction of septic shock outcomes remains difficult. Metabolomic techniques have emerged as a promising tool for improving prognosis. Methods Orthogonal projections to latent structures-discriminant analysis (OPLS-DA) models separating the serum metabolomes of survivors from those of non-survivors were established with samples obtained at the intensive care unit (ICU) admission (H0) and 24 h later (H24). For 51 patients with available H0 and H24 samples, multi-level modeling was performed to provide insight into different metabolic evolutions that occurred between H0 and H24 in the surviving and non-surviving patients. Relative quantification and receiver operational characteristic curves (ROC) were applied to estimate the predictability of key discriminatory metabolites for septic shock mortality. Results Metabolites that were involved in energy supply and protein breakdown were primarily responsible for differentiating survivors from non-survivors. This was not only seen in the H0 and H24 discriminatory models, but also in the H0-H24 paired models. Reanalysis of extra H0-H24 paired samples in the established multi-level model demonstrated good performance of the model for the classification of samplings. According to the ROC results, nine discriminatory metabolites defined consistently from the unpaired model and the H0-H24 time-trend change (ΔH24-H0) show good prediction of mortality. These results suggest that NMR-based metabolomic analysis is useful for a better overall assessment of septic shock patients. Conclusions Dysregulation of the metabolites identified by this study is associated with poor outcomes for septic shock. Evaluation of these compounds during the first 24 h after ICU admission in the septic shock patient may be helpful for estimating the severity of cases and for predicting outcomes. Trial registration All human serum samples were collected and stored, provided by the “center of biologic resources for liver disease”, in Jean Verdier Hospital, Bondy, France (BB-0033-00027). Electronic supplementary material The online version of this article (10.1186/s13054-019-2456-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhicheng Liu
- School of Pharmacy, Anhui Medical University, Hefei, China.,Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France
| | - Mohamed N Triba
- Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France
| | - Roland Amathieu
- Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France.,Intensive Care Unit, Diaconesse-Croix Saint-Simon Hospital, 125 rue d'Avron, 75020, Paris, France
| | - Xiangping Lin
- Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France
| | - Nadia Bouchemal
- Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France
| | - Edith Hantz
- Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France
| | - Laurence Le Moyec
- Université Paris Saclay, University Evry, UBIAE EA 7362, 91025, Evry, France
| | - Philippe Savarin
- Sorbonne Paris Cité, Laboratoire de Chimie, Structures et Propriétés de Biomateriaux et d'Agents Therapeutiques, UMR 7244, University Paris 13, F-93017, Bobigny, France.
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22
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Circulating Exosomes Isolated from Septic Mice Induce Cardiovascular Hyperpermeability Through Promoting Podosome Cluster Formation. Shock 2019. [PMID: 28650928 DOI: 10.1097/shk.0000000000000928] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Septic shock increases vascular permeability, leading to multiple organ failure including cardiac dysfunction, a major contributor to septic death. Podosome, an actin-based dynamic membrane structure, plays critical roles in extracellular matrix degradation and angiogenesis. However, whether podosome contributes to endothelial barrier dysfunction during septic shock remains unknown. In this study, we found that the endothelial hyperpermeability, stimulated by phorbol 12-myristate 13-acetate and thrombin, was accompanied by increased formation of podosome clusters at the cell periphery, indicating a positive correlation between podosome clusters and endothelial leakage. Interestingly, we observed that circulating exosomes collected from septic mice were able to stimulate podosome cluster formation in cardiac endothelial cells, together with increased permeability in vitro/in vivo and cardiac dysfunction. Mechanistically, we identified that septic exosomes contained higher levels of reactive oxygen species (ROS) than normal ones, which were effectively transported to endothelial cells (ECs). Depletion of ROS in septic exosomes significantly reduced their capacity for promoting podosome cluster formation and thereby dampened vascular leakage. Finally, we elucidated that podosome cluster-induced endothelial hyperpermeability was associated with fragmentation/depletion of zonula occludens-1 (ZO-1) at the cell periphery. Our results demonstrate that septic exosomes were enriched with high amounts of ROS, which can be transported to ECs, leading to the generation of podosome clusters in target ECs and thereby, causing ZO-1 relocation, vascular leakage, and cardiac dysfunction.
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23
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Delay of appropriate antibiotic treatment is associated with high mortality in patients with community-onset sepsis in a Swedish setting. Eur J Clin Microbiol Infect Dis 2019; 38:1223-1234. [PMID: 30911928 PMCID: PMC6570779 DOI: 10.1007/s10096-019-03529-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
Abstract
Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important. Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock. A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012–2013. The criterion “early appropriate antibiotic treatment” was defined as administration of the first dose of adequate antibiotics within 1 h, and the second dose given with less than 25% delay after the recommended dose interval. A high-risk patient was defined as a septic patient with either shock within 24 h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality. Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment. Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.
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24
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Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score? Eur J Emerg Med 2019; 25:328-334. [PMID: 28338533 PMCID: PMC6133213 DOI: 10.1097/mej.0000000000000460] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective The aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff. Patients and methods This was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records. Results We included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620). Conclusion Clinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of ‘treat first what kills first’ can be supplemented with ‘judge first and calculate later’.
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25
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Rahman N'IA, Chan CM, Zakaria MI, Jaafar MJ. Knowledge and attitude towards identification of systemic inflammatory response syndrome (SIRS) and sepsis among emergency personnel in tertiary teaching hospital. Australas Emerg Care 2018; 22:13-21. [PMID: 30998867 DOI: 10.1016/j.auec.2018.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION An emergency department (ED) is often the first point of medical contact for sepsis patient, which plays an important role in early identification and management of high-risk septic patients. The present study was aim to evaluate emergency personnel's knowledge and attitude toward identification and management of systemic inflammatory response syndrome (SIRS) and sepsis. METHODS This cross-sectional study was conducted in a tertiary teaching hospital and recruited all emergency personnel. A validated questionnaire on knowledge and attitude towards identification and management of SIRS/sepsis was distributed among 120 emergency personnel. Data were analyzed using descriptive and inferential statistics. RESULTS Overall finding founds emergency nurses and assistant medical officer appeared to have moderate knowledge in several important areas of SIRS/sepsis identification and management. Majority of the emergency personnel have neutral attitudes, as they do not give enough importance towards identification of patients with SIRS and sepsis. The present study finding found that knowledge of clinical criteria and management of SIRS/sepsis was highest among assistant medical officers (p=0.02) and bachelor's degree holders (p=0.02) with emergency experience more than 5 years (p=0.03). A trend toward an increase in knowledge of SIRS and sepsis is significantly correlated with positive attitudes. CONCLUSION The emergency personnel demonstrated a moderate knowledge and neutral attitude toward identification and management of SIRS and sepsis. Therefore, the awareness and knowledge of SIRS and sepsis should be enhanced among emergency personnel in order to improve outcome.
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Affiliation(s)
- Nurul 'Inayati Abdul Rahman
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Critical Care Nursing, Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, Malaysia.
| | - Chong Mei Chan
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Idzwan Zakaria
- Academic Unit Trauma and Emergency, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Mohd Johar Jaafar
- Department of Emergency Medicine, University of Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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26
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Frattari A, Polilli E, Primiterra V, Savini V, Ursini T, Di Iorio G, Parruti G. Analysis of peripheral blood lymphocyte subsets in critical patients at ICU admission: A preliminary investigation of their role in the prediction of sepsis during ICU stay. Int J Immunopathol Pharmacol 2018; 32:2058738418792310. [PMID: 30114952 PMCID: PMC6100127 DOI: 10.1177/2058738418792310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A better knowledge of factors predicting the development of sepsis in patients
hospitalized in intensive care unit (ICU) might help deploy more targeted
preventive and therapeutic strategies. In addition to the known clinical and
demographic predictors of septic syndromes, in this study, we investigated
whether measuring T and B lymphocyte subsets upon admission in the ICU may help
individualize the prediction of ensuing sepsis during ICU stay. Between May 2015
and December 2016, we performed a prospective cohort study evaluating peripheral
blood lymphocyte T-CD4+ (T-helper cells), T-CD8+ (cytotoxic T-cells), T-CD56 +
(natural killer cells), and T-CD19+ (B-lymphocytes), using flow cytometry on
blood samples collected 2 days after admission in the ICU. We enrolled 176
patients, 65.3% males, with mean age of 61.1 ± 15.4 years. At univariate
analyses, higher percentages of CD19 B-cells were significantly associated with
ensuing sepsis (20.5% (15.7–27.7)% vs 16.9% (11.3–22)%, P = 0.0001), whereas median interquartile range (IQR) proportions
of CD4 T-cells (41.2% (33.4–50.6)% vs 40% (35–47)%, P = 0.5), CD8 T-cells (21.1% (15.8–28.2)% vs 19.6% (14.6–25.1)%,
P = 0.2) and CD56 T-cells (1.7% (0.9–3.1)% vs
1.45% (0.7–2.3)%, P = 0.4) did not reveal any
significant association. An unexpected, highly significant inverse correlation
of CD8 T-cells and CD19 B-cells proportions, however, was observed, suggesting
that patients with lower CD19 and higher CD8 proportions might be somehow
protected from ensuing sepsis. We therefore studied the ability of the CD8/CD19
ratio to predict ensuing sepsis in our sample. In final models of multivariate
logistic regression, the following independent associations were found: previous
antibiotic exposure (odds ratio (OR): 3.8 (95% confidence interval (CI):
1.35–10.87), P = 0.01), isolation of at least one
multi-drug resistant organism at any time during ICU stay (OR: 8.4 (95% CI:
3.47–20.6), P < 0.0001), decreasing age (OR:
0.9 (95% CI: 0.93–0.99), P = 0.02) and a CD8/CD19
ratio >2.2 (OR: 10.3 (95% CI: 1.91–55.36), P = 0.007). Our data provide preliminary evidence that immune
characterization of critically ill patients on ICU admission may help
personalize the prediction of ensuing sepsis during their ICU stay. Further
polycentric evaluation of the true potential of this new tool is warranted.
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Affiliation(s)
| | - Ennio Polilli
- 2 Unit of Clinical Pathology, Pescara General Hospital, Pescara, Italy
| | | | - Vincenzo Savini
- 3 Unit of Clinical Microbiology, Pescara General Hospital, Pescara, Italy
| | - Tamara Ursini
- 4 Unit of Infectious Diseases, Pescara General Hospital, Pescara, Italy
| | | | - Giustino Parruti
- 4 Unit of Infectious Diseases, Pescara General Hospital, Pescara, Italy
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Ipek E, Yolcu M, Yildirim E, Altinkaynak K, Ozbek Sebin S, Kalkan K, Gulcu O, Ermis E, Ozturk M. A Novel Marker of Inflammation: Azurocidin in Patients with ST Segment Elevation Myocardial Infarction. Int J Mol Sci 2018; 19:ijms19123797. [PMID: 30501029 PMCID: PMC6321077 DOI: 10.3390/ijms19123797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 11/23/2018] [Accepted: 11/26/2018] [Indexed: 12/22/2022] Open
Abstract
(1) To investigate the role of azurocidin, an antimicrobial protein, in patients with ST segment elevation myocardial infarction (STEMI). (2) This single-center prospective observational study included patients with STEMI and healthy age- and sex-matched control subjects. Baseline demographic, clinical and biochemical data were compared between the two groups. Azurocidin levels at baseline were determined using an enzyme-linked immunosorbent assay. Multivariate linear regression analysis with enter method was used to test the association between azurocidin and independent variables, such as the thrombolysis in myocardial infarction (TIMI) score, synergy between percutaneous coronary intervention with TAXUS and cardiac surgery score, global registry of acute coronary events score, Killip class, C-reactive protein (CRP), and creatinine kinase-myocardial band (CK-MB). (3) A total of 76 patients with STEMI and 30 healthy control subjects were enrolled in the study. Mean ± SD azurocidin levels were significantly higher in patients compared with healthy controls (18.07 ± 13.99 versus 10.09 ± 5.29 ng/mL, respectively). In a receiver-operating characteristic curve analysis, an azurocidin cut-off level of >11.46 ng/mL had 74% sensitivity and 58% specificity in predicting myocardial infarction. Azurocidin levels had a positive correlation with TIMI score (r = 0.651). In multivariate linear regression analysis, the TIMI score was an independent predictor of the azurocidin level. (4) Azurocidin is an infection marker that may be important in patients with STEMI.
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Affiliation(s)
- Emrah Ipek
- Department of Cardiology, Istanbul Cerrahi Hospital, 34365 Istanbul, Turkey.
| | - Mustafa Yolcu
- Department of Cardiology, Medicana International Hospital, Yeniyuzyil University, 34365 Istanbul, Turkey.
| | - Erkan Yildirim
- Department of Cardiology, Biruni University, 34365 Istanbul, Turkey.
| | - Konca Altinkaynak
- Department of Clinical Biochemistry, University of Health Sciences, Erzurum Training and Research Hospital, 25100 Erzurum, Turkey.
| | - Saime Ozbek Sebin
- Department of Physiology, Ataturk University School of Medicine, 25100 Erzurum, Turkey.
| | - Kamuran Kalkan
- Department of Cardiology, University of Health Sciences, Erzurum Training and Research Hospital, 25100 Erzurum, Turkey.
| | - Oktay Gulcu
- Department of Cardiology, University of Health Sciences, Erzurum Training and Research Hospital, 25100 Erzurum, Turkey.
| | - Emrah Ermis
- Department of Cardiology, Biruni University, 34365 Istanbul, Turkey.
| | - Mustafa Ozturk
- Department of Cardiology, University of Health Sciences, Erzurum Training and Research Hospital, 25100 Erzurum, Turkey.
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Boushra MN, Miller SN, Koyfman A, Long B. Consideration of Occult Infection and Sepsis Mimics in the Sick Patient Without an Apparent Infectious Source. J Emerg Med 2018; 56:36-45. [PMID: 30396751 DOI: 10.1016/j.jemermed.2018.09.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/01/2018] [Accepted: 09/20/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evaluation and treatment of the acutely ill patient is typically complicated by multiple comorbidities and incomplete medical histories. This is exemplified by patients with sepsis, whose care is complicated by variable presentations, shifting definitions, and a variety of potential sources. Many practitioners fail to consider and recognize less-common sources of infection in a timely manner. Additionally, multiple noninfectious conditions can present with the fever and tachycardia typical of the septic patient. The errors of anchoring and premature closure may lead to delay in, or failure of, diagnosis of these conditions. OBJECTIVE This review addresses the evaluation of the acutely ill-appearing patient without an apparent source, focusing on occult sources of infection and conditions that mimic sepsis. DISCUSSION Musculoskeletal, cardiac, neuraxial, and abdominal sources of sepsis should be considered in the acutely ill patient. Indwelling devices should be carefully examined for signs of infection. Consideration for sepsis mimics, such as neuroleptic malignant syndrome, malignant hyperthermia, medication toxicity, and thyroid storm, in patients who fail to respond to standard therapies for sepsis, may lead the physician to potentially reversible life-threatening diagnoses and management. CONCLUSION In the seemingly septic patient who does not respond to antimicrobials and fluids, the differential should be broadened to include acutely life-threatening conditions that can mimic sepsis. A review of the patient's medical history, medications, and recent exposures can assist in identifying the source of the patient's elevated body temperature and tachycardia. Consideration of potential sources and other mimics of sepsis is needed in the emergency department.
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Affiliation(s)
- Marina N Boushra
- Department of Emergency Medicine, Vidant Medical Center, Greenville, North Carolina
| | - Susan N Miller
- Department of Emergency Medicine, Vidant Medical Center, Greenville, North Carolina
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Pedersen PB, Hrobjartsson A, Nielsen DL, Henriksen DP, Brabrand M, Lassen AT. Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review. PLoS One 2018; 13:e0206610. [PMID: 30383864 PMCID: PMC6211733 DOI: 10.1371/journal.pone.0206610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023] Open
Abstract
Introduction Patients in an emergency department are diverse. Some are more seriously ill than others and some even arrive in multi-organ failure. Knowledge of the prevalence of organ failure and its prognosis in unselected patients is important from a diagnostic, hospital planning, and from a quality evaluation point of view, but is not reported systematically. Objectives To analyse the prevalence and prognosis of new onset organ failure in unselected acute patients at arrival to hospital. Methods A systematic review of studies of prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital. We searched PubMed, Cochrane Library, Embase and Cinahl, and read references in included studies. Two authors decided independently on study eligibility and extracted data. Results were summarised qualitatively. Results Four studies were included with a total of 678,960 patients. The number of different organ failures reported in the studies ranged from one to six, and the settings were emergency departments and wards. The definitions of organ failure varied between studies. The prevalence of organ failure was 7%, 14%, 14%, and 23%, and in-hospital mortality was 5%, 11% and 15% respectively. The relative risk of in-hospital mortality for patients with organ failure compared to patients without organ failure varied from 2.58 to 8.65. Numbers of organ failures per 1,000 visits varied from 71 to 256. Conclusion The results of this review indicate that clinicians have good reasons to be alert when a patient arrives to the emergency department; as a state of organ failure seems both frequent and highly severe. However, most studies identified were performed in patients after a diagnosis was established, and only very few studies were performed in unselected patients. Systematic review registration number PROSPERO: CRD42017060871.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- * E-mail:
| | - Asbjørn Hrobjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark & Odense University Hospital, Odense, Denmark
| | | | - Daniel Pilsgaard Henriksen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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30
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The Emperor Has No Clothes? Searching for Dysregulation in Sepsis. J Clin Med 2018; 7:jcm7090247. [PMID: 30158480 PMCID: PMC6162833 DOI: 10.3390/jcm7090247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/14/2018] [Accepted: 08/25/2018] [Indexed: 12/31/2022] Open
Abstract
The core conception of sepsis—that it is a dysregulated state—is a powerful and durable idea that has inspired decades of research. But is it true that the body’s response to sepsis is dysregulated? To answer that question, this review surveyed the history of trials of experimental sepsis treatments targeting the host response. Sepsis survival is not improved by blocking one or many immune pathways. Similarly, sepsis is resistant to treatment by normalizing one or many physiologic parameters simultaneously. The vast majority of interventions are either ineffective or harmful. With this track record of failure, it is time to consider the alternative hypothesis—regulation instead of dysregulation—and the possibility that sepsis traits are often functional, and that some physiologic alterations in sepsis do more good than harm, while others are neutral. This review discusses the implications of this perspective for the future of sepsis research.
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Baig MA, Sheikh S, Hussain E, Bakhtawar S, Subhan Khan M, Mujtaba S, Waheed S. Comparison of qSOFA and SOFA score for predicting mortality in severe sepsis and septic shock patients in the emergency department of a low middle income country. Turk J Emerg Med 2018; 18:148-151. [PMID: 30533557 PMCID: PMC6261097 DOI: 10.1016/j.tjem.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/30/2018] [Accepted: 08/13/2018] [Indexed: 01/27/2023] Open
Abstract
Objective We aimed to determine a comparison between the Quick Sequential Organ Failure Assessment (qSOFA) score and existing Sequential Organ Failure Assessment (SOFA) score when applied to severe sepsis & septic shock patients in the Emergency Department (ED) for prediction of in-hospital mortality in the setting of a tertiary care hospital ED in a low-middle income country. Method We conducted a prospective observational cohort study on 760 subjects. The qSOFA, SOFA score and in-hospital mortality were assessed by area under the receiver operating curve (AUROC). We calculated sensitivity and specificity for each score for outcomes at cut-offs of 0.92 and 0.63 for qSOFA and SOFA in Severe Sepsis respectively and 0.89 and 0.63 for qSOFA and SOFA in Septic shock respectively. Results In patients with severe sepsis, the AUROC of qSOFA for predicting mortality in subjects was 0.92 (95% CI; 0.89–0.94) with 96% sensitivity and 87% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 71% sensitivity and 57% specificity. In patients with septic shock, the AUROC of qSOFA for predicting mortality in subjects was 0.89 (95% CI; 0.85–0.92) with 92% sensitivity and 85% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 70% sensitivity and 59% specificity. Conclusion Our study concludes that qSOFA score is an effective tool at predicting in hospital mortality in comparison to SOFA score when applied to severe sepsis and septic shock patients in the setting of a tertiary care hospital ED of a low-middle income country however, further studies are needed before application for this purpose.
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Affiliation(s)
- Muhammad Akbar Baig
- Department of Emergency Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
- Corresponding author. Department of Emergency Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800. Pakistan.
| | - Sadaf Sheikh
- Department of Emergency Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Erfaan Hussain
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Samina Bakhtawar
- People's Primary Healthcare Initiative (PPHI)- Sindh, C-27/1, Block-2, Umer Sharif Park, Block-2 Clifton, Karachi, Pakistan
| | - Muhammad Subhan Khan
- Department of Emergency Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Syed Mujtaba
- Department of Emergency Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Shahan Waheed
- Department of Emergency Medicine, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
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Intermediate-term and long-term mortality among acute medical patients hospitalized with community-acquired sepsis: a population-based study. Eur J Emerg Med 2018; 24:404-410. [PMID: 26919223 DOI: 10.1097/mej.0000000000000379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Admission with severe sepsis is associated with an increased short-term mortality, but it is unestablished whether sepsis severity has an impact on intermediate-term and long-term mortality following admission to an acute medical admission unit. PATIENTS AND METHODS This was a population-based study of all adults admitted to an acute medical admission unit, Odense University Hospital, Denmark, from September 2010 to August 2011, identified by symptoms and clinical findings. We categorized the mortality periods into intermediate-term (31-180 days) and long-term (181-365, 366-730, and 731-1096 days). Mortality hazard ratios (HRs), comparing patients admitted with sepsis with those of a well-defined background population, were estimated using multivariable Cox regression. HRs were presented with 95% confidence intervals. RESULTS In total, 621 (36.3%) presented with sepsis, 1071 (62.5%) presented with severe sepsis, and 21 (1.2%) presented with septic shock. Thirty-day all-cause mortality for patients with sepsis, severe sepsis, and septic shock was 6.1, 18.8, and 38.1%, respectively. The adjusted HR among patients with sepsis of any severity within the time periods 31-180, 181-365, 366-720, and 721-1096 days was 7.1 (6.0-8.5), 2.8 (2.3-3.5), 2.1 (1.8-2.6), and 2.2 (1.7-2.9), respectively. Long-term mortality was unrelated to sepsis severity [721-1096 days: sepsis HR: 2.2 (1.5-3.2), severe sepsis HR: 2.1 (1.5-3.0)]. CONCLUSION Patients admitted with community-acquired sepsis showed high intermediate-term mortality, increasing with sepsis severity. Long-term mortality was increased two-fold compared with sepsis-free individuals, but might be explained by unmeasured confounding. Further, long-term mortality was unrelated to sepsis severity.
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Lafon T, Vallejo C, Organista A, Baisse A, Zmiri C, Coroller L, Morel G, Daix T, François B, Vignon P. Validation du score qSOFA au Service d’Accueil des Urgences : étude prospective monocentrique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction : Le sepsis est défini comme une défaillance d’organes secondaire à une infection pouvant entraîner le décès du patient. Le score quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) a récemment été proposé pour dépister la présence d’une défaillance d’organes chez les patients suspects d’infection. L’objectif de cette étude est de valider l’utilisation du score qSOFA au service d’accueil des urgences (SAU) pour prédire la mortalité et le recours à l’hospitalisation en réanimation.
Méthodes : Étude prospective monocentrique au SAU sur 6 mois. Les données démographiques, la source infectieuse, le score qSOFA, le score SOFA et les valeurs biologiques étaient collectés. Les dossiers étaient relus par un comité d’adjudication indépendant pour valider le diagnostic de sepsis en utilisant la définition Sepsis-3. La mortalité à 28 jours était colligée.
Résultats : Parmi les 476 patients suspects d’infection, 374 avaient leur diagnostic confirmé (204 hommes, âge moyen : 65 ± 20 ans). Le score qSOFA était positif chez 77 patients (21%). La mortalité était supérieure pour les patients avec un score qSOFA ≥ 2 (47% vs 4% : p < 0,01). Pour prédire la mortalité à 28 jours, le score qSOFA avait une sensibilité de 74% (IC 95% : 59 - 85%) et une spécificité de 87% (IC 95% : 83 - 91%). L’aire sous la courbe ROC du score qSOFA pour prédire la mortalité à 28 jours était de 0,80 (IC 95% : 0,76 - 0,84).
Conclusion : Cette étude confirme que le score qSOFA recueilli au SAU semble être fiable pour prédire la mortalité à 28 jours.
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Mosevoll KA, Skrede S, Markussen DL, Fanebust HR, Flaatten HK, Aßmus J, Reikvam H, Bruserud Ø. Inflammatory Mediator Profiles Differ in Sepsis Patients With and Without Bacteremia. Front Immunol 2018; 9:691. [PMID: 29681903 PMCID: PMC5897503 DOI: 10.3389/fimmu.2018.00691] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/20/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic levels of cytokines are altered during infection and sepsis. This prospective observational study aimed to investigate whether plasma levels of multiple inflammatory mediators differed between sepsis patients with and those without bacteremia during the initial phase of hospitalization. A total of 80 sepsis patients with proven bacterial infection and no immunosuppression were included in the study. Plasma samples were collected within 24 h of hospitalization, and Luminex® analysis was performed on 35 mediators: 16 cytokines, six growth factors, four adhesion molecules, and nine matrix metalloproteases (MMPs)/tissue inhibitors of metalloproteinases (TIMPs). Forty-two patients (52.5%) and 38 (47.5%) patients showed positive and negative blood cultures, respectively. There were significant differences in plasma levels of six soluble mediators between the two “bacteremia” and “non-bacteremia” groups, using Mann–Whitney U test (p < 0.0014): tumor necrosis factor alpha (TNFα), CCL4, E-selectin, vascular cell adhesion molecule-1 (VCAM-1), intracellular adhesion molecule-1 (ICAM-1), and TIMP-1. Ten soluble mediators also significantly differed in plasma levels between the two groups, with p-values ranging between 0.05 and 0.0014: interleukin (IL)-1ra, IL-10, CCL2, CCL5, CXCL8, CXCL11, hepatocyte growth factor, MMP-8, TIMP-2, and TIMP-4. VCAM-1 showed the most robust results using univariate and multivariate logistic regression. Using unsupervised hierarchical clustering, we found that TNFα, CCL4, E-selectin, VCAM-1, ICAM-1, and TIMP-1 could be used to discriminate between patients with and those without bacteremia. Patients with bacteremia were mainly clustered in two separate groups (two upper clusters, 41/42, 98%), with higher levels of the mediators. One (2%) patient with bacteremia was clustered in the lower cluster, which compromised most of the patients without bacteremia (23/38, 61%) (χ2 test, p < 0.0001). Our study showed that analysis of the plasma inflammatory mediator profile could represent a potential strategy for early identification of patients with bacteremia.
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Affiliation(s)
- Knut Anders Mosevoll
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Jörg Aßmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Number of organ dysfunctions predicts mortality in emergency department patients with suspected infection: a multicenter validation study. Eur J Emerg Med 2018; 24:176-182. [PMID: 26313315 DOI: 10.1097/mej.0000000000000317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to validate the association between number of organ dysfunctions and mortality in emergency department (ED) patients with suspected infection. METHODS This study was conducted at two medical care center EDs. The internal validation set was a prospective cohort study conducted in Boston, USA. The external validation set was a retrospective case-control study conducted in Aarhus, Denmark. The study included adult patients (>18 years) with clinically suspected infection. Laboratory results and clinical data were used to assess organ dysfunctions. Inhospital mortality was the outcome measure. Multivariate logistic regression was used to determine the independent mortality odds for number and types of organ dysfunctions. RESULTS We enrolled 4952 (internal) and 483 (external) patients. The mortality rate significantly increased with increasing number of organ dysfunctions: internal validation: 0 organ dysfunctions: 0.5% mortality, 1: 3.6%, 2: 9.5%, 3: 17%, and 4 or more: 37%; external validation: 2.2, 6.7, 17, 41, and 57% mortality (both P<0.001 for trend). Age-adjusted and comorbidity-adjusted number of organ dysfunctions remained an independent predictor. The effect of specific types of organ dysfunction on mortality was most pronounced for hematologic [odds ratio (OR) 3.3 (95% confidence interval (CI) 2.0-5.4)], metabolic [OR 3.3 (95% CI 2.4-4.6); internal validation], and cardiovascular dysfunctions [OR 14 (95% CI 3.7-50); external validation]. CONCLUSION The number of organ dysfunctions predicts sepsis mortality.
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PKCα-LSD1-NF-κB-Signaling Cascade Is Crucial for Epigenetic Control of the Inflammatory Response. Mol Cell 2018; 69:398-411.e6. [PMID: 29395062 DOI: 10.1016/j.molcel.2018.01.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/15/2017] [Accepted: 12/29/2017] [Indexed: 01/05/2023]
Abstract
The inflammatory response mediated by nuclear factor κB (NF-κB) signaling is essential for host defense against pathogens. Although the regulatory mechanism of NF-κB signaling has been well studied, the molecular basis for epigenetic regulation of the inflammatory response is poorly understood. Here we identify a new signaling axis of PKCα-LSD1-NF-κB, which is critical for activation and amplification of the inflammatory response. In response to excessive inflammatory stimuli, PKCα translocates to the nucleus and phosphorylates LSD1. LSD1 phosphorylation is required for p65 binding and facilitates p65 demethylation, leading to enhanced stability. In vivo genetic analysis using Lsd1SA/SA mice with ablation of LSD1 phosphorylation and chemical approaches in wild-type mice with inhibition of PKCα or LSD1 activity show attenuated sepsis-induced inflammatory lung injury and mortality. Together, we demonstrate that the PKCα-LSD1-NF-κB signaling cascade is crucial for epigenetic control of the inflammatory response, and targeting this signaling could be a powerful therapeutic strategy for systemic inflammatory diseases, including sepsis.
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Serial Daily Organ Failure Assessment Beyond ICU Day 5 Does Not Independently Add Precision to ICU Risk-of-Death Prediction. Crit Care Med 2017; 45:2014-2022. [PMID: 28906286 DOI: 10.1097/ccm.0000000000002708] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To identify circumstances in which repeated measures of organ failure would improve mortality prediction in ICU patients. DESIGN Retrospective cohort study, with external validation in a deidentified ICU database. SETTING Eleven ICUs in three university hospitals within an academic healthcare system in 2014. PATIENTS Adults (18 yr old or older) who satisfied the following criteria: 1) two of four systemic inflammatory response syndrome criteria plus an ordered blood culture, all within 24 hours of hospital admission; and 2) ICU admission for at least 2 calendar days, within 72 hours of emergency department presentation. INTERVENTION NoneMEASUREMENTS AND MAIN RESULTS:: Data were collected until death, ICU discharge, or the seventh ICU day, whichever came first. The highest Sequential Organ Failure Assessment score from the ICU admission day (ICU day 1) was included in a multivariable model controlling for other covariates. The worst Sequential Organ Failure Assessment scores from the first 7 days after ICU admission were incrementally added and retained if they obtained statistical significance (p < 0.05). The cohort was divided into seven subcohorts to facilitate statistical comparison using the integrated discriminatory index. Of the 1,290 derivation cohort patients, 83 patients (6.4%) died in the ICU, compared with 949 of the 8,441 patients (11.2%) in the validation cohort. Incremental addition of Sequential Organ Failure Assessment data up to ICU day 5 improved the integrated discriminatory index in the validation cohort. Adding ICU day 6 or 7 Sequential Organ Failure Assessment data did not further improve model performance. CONCLUSIONS Serial organ failure data improve prediction of ICU mortality, but a point exists after which further data no longer improve ICU mortality prediction of early sepsis.
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Occhionorelli S, Zese M, Cultrera R, Lacavalla D, Albanese M, Vasquez G. Open Abdomen Management and Candida Infections: A Very Likely Link. Gastroenterol Res Pract 2017; 2017:5187620. [PMID: 29362562 PMCID: PMC5738572 DOI: 10.1155/2017/5187620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Laparostomy can be applied in trauma, abdominal sepsis, intra-abdominal hypertension, or compartment syndrome. Systemic infections, especially if complicated by Candida, are associated with a high risk of mortality. METHODS This is a single-centre retrospective case series of 47 cases admitted to our Department, which required laparostomy procedure; we analyzed the type of surgery, temporary abdominal closure, duration of open abdomen, complications, SOFA score, mortality with Candida infections, and empirical or targeted antifungal therapy. RESULTS We found that patients with Candida infection were related with a statistically significant difference (p < 0.05) with a complication after OA closure, total complications, time elapsed after OA application, time spent on the first surgical OA application, type of temporary abdominal closure that is used, and duration of the open abdomen. The use of empirical and targeted antifungal therapy is related to the duration of open abdomen too. CONCLUSIONS Management of the OA is often burdened by sepsis or septic shock, especially when complicated by Candida infection. Candida score is a validated tool to identify patients who can be treated empirically, but every situation must be considered on an individual basis.
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Affiliation(s)
- Savino Occhionorelli
- Department of Morphology, Surgery and Experimental Medicine-University of Ferrara and Sant'Anna University Hospital of Ferrara, Ferrara, Italy
| | - Monica Zese
- Department of Morphology, Surgery and Experimental Medicine-University of Ferrara and Sant'Anna University Hospital of Ferrara, Ferrara, Italy
| | - Rosario Cultrera
- Department of Medical Sciences, Centre for International Cooperation and Development, Infectious Diseases Unit-University of Ferrara and Sant'Anna University Hospital of Ferrara, Ferrara, Italy
| | - Domenico Lacavalla
- Department of Morphology, Surgery and Experimental Medicine-University of Ferrara and Sant'Anna University Hospital of Ferrara, Ferrara, Italy
| | - Marco Albanese
- Department of Morphology, Surgery and Experimental Medicine-University of Ferrara and Sant'Anna University Hospital of Ferrara, Ferrara, Italy
| | - Giorgio Vasquez
- Department of Surgery, Emergency Surgery Service, Sant'Anna University Hospital, Ferrara, Italy
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Antwi AO, Obiri DD, Osafo N, Forkuo AD, Essel LB. Stigmasterol inhibits lipopolysaccharide-induced innate immune responses in murine models. Int Immunopharmacol 2017; 53:105-113. [DOI: 10.1016/j.intimp.2017.10.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/09/2017] [Accepted: 10/16/2017] [Indexed: 01/23/2023]
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Pedersen PB, Hrobjartsson A, Nielsen DL, Henriksen DP, Brabrand M, Lassen AT. Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: protocol for a systematic review. Syst Rev 2017; 6:227. [PMID: 29141664 PMCID: PMC5688673 DOI: 10.1186/s13643-017-0622-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/07/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acutely ill patients are a heterogeneous group, and some of these suffer from organ failure. As the prognosis of organ failure improves with early treatment, it is important to identify these patients as early as possible. Most studies on organ failure have been performed in intensive care settings, or on selected groups of patients, where a high prevalence and mortality have been reported. Before patients arrive to the intensive care unit, or the general ward, most of them have passed through the emergency department (ED), where diagnosis and treatment has been initiated. The prevalence and prognosis of acutely ill patients, with organ failure, at arrival have been studied in some selected groups, but methods and results differ. This systematic review aims to identify, summarize, and analyze studies of prevalence and prognosis of new onset organ failure in acutely ill undifferentiated patients, at arrival to hospital. The result of the review will assist physicians working in an ED, when assessing patients' risk of organ failure and their associated prognosis. METHODS The information sources used are electronic databases, PubMed, Cochrane Library, EMBASE, and CINAHL; references in included studies and review articles; and authors' personal files. One author will perform the title and abstract screening and exclude obviously ineligible studies. By an independent full-text screening, two authors will decide on the eligibility for the remaining studies. Eligible studies will include an unselected group of acutely ill adult patients at arrival to hospital, with one or more organ failures (respiratory, renal, cerebral, circulatory, hepatic, or coagulation failure). Included studies will have assessed the prevalence or prognosis, defined as mortality or ICU transfer, of new onset organ failure. From included studies, bibliographical and study description data, patient characteristics, and data related to prevalence of organ failure and prognosis will be extracted. We will assess risk of bias in included studies using the Quality in Prognosis Studies tool for prognostic studies and the Newcastle-Ottawa Scale for observational studies. We expect heterogeneity and to conduct a qualitative synthesis of the results. If, however, heterogeneity is low, we will conduct a random effects meta-analysis stratified by basic study design. DISCUSSION This review will summarize and analyze studies of prevalence and prognosis of acutely ill patients, with organ failure at arrival to hospital, assist ED physicians assessing the risk of organ failure in unselected patients, and guide recommendations for further research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017060871.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark and Odense University Hospital, DK-5000, Odense C, Denmark.
| | - Asbjorn Hrobjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark and Odense University Hospital, DK-5000, Odense C, Denmark
| | - Daniel Lykke Nielsen
- Department of Emergency Medicine, Odense University Hospital, DK-5000, Odense C, Denmark
| | - Daniel Pilsgaard Henriksen
- Department of Emergency Medicine and Department of Respiratory Medicine, Odense University Hospital, DK-5000, Odense C, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, DK-5000, Odense C, Denmark.,Hospital of South West Jutland, DK-6700, Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark and Odense University Hospital, DK-5000, Odense C, Denmark
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Kim M, Watase T, Jablonowski KD, Gatewood MO, Henning DJ. A Sepsis-related Diagnosis Impacts Interventions and Predicts Outcomes for Emergency Patients with Severe Sepsis. West J Emerg Med 2017; 18:1098-1107. [PMID: 29085543 PMCID: PMC5654880 DOI: 10.5811/westjem.2017.7.34770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/28/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022] Open
Abstract
Introduction Many patients meeting criteria for severe sepsis are not given a sepsis-related diagnosis by emergency physicians (EP). This study 1) compares emergency department (ED) interventions and in-hospital outcomes among patients with severe sepsis, based on the presence or absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hour sepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsis-related diagnosis. Methods We performed a retrospective cohort study using patients meeting criteria for severe sepsis at two urban, academic tertiary care centers from March 2015 through May 2015. We included all ED patients with the following: 1) the 1992 Consensus definition of severe sepsis, including two or more systemic inflammatory response syndrome criteria and evidence of organ dysfunction; or 2) physician diagnosis of severe sepsis or septic shock. We excluded patients transferred to or from another hospital and those <18 years old. Patients with an EP-assigned sepsis diagnosis created the “Physician Diagnosis” group; the remaining patients composed the “Consensus Criteria” group. The primary outcome was in-hospital mortality. Secondary outcomes included completed elements of the current three-hour sepsis bundle; non-elective intubation; vasopressor administration; intensive care unit (ICU) admission from the ED; and transfer to the ICU in < 24 hours. We compared proportions of each outcome between groups using the chi-square test, and we also performed a stratified analysis using chi square to assess the association between failure to complete the three-hour bundle and adverse outcomes in each group. Results Of 418 patients identified with severe sepsis we excluded 54, leaving 364 patients for analysis: 121 “Physician Diagnosis” and 243 “Consensus Criteria.” The “Physician Diagnosis” group had a higher in-hospital mortality (12.4% vs 3.3%, P < 0.01) and compliance with the three-hour sepsis bundle (52.1% vs 20.2%, P < 0.01) compared with the “Consensus Criteria” group. An incomplete three-hour sepsis bundle was not associated with a higher incidence of death, intubation, vasopressor use, ICU admission or transfer to the ICU in <24 hours in patients without a sepsis diagnosis. Conclusion “Physician Diagnosis” patients more frequently received sepsis-specific interventions and had a higher incidence of mortality. “Consensus Criteria” patients had infrequent adverse outcomes regardless of three-hour bundle compliance. EPs’ sepsis diagnoses reflect risk-stratification beyond the severe sepsis criteria.
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Affiliation(s)
- Mitchell Kim
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Taketo Watase
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Karl D Jablonowski
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Medley O Gatewood
- University of Washington, Division of Emergency Medicine, Seattle, Washington
| | - Daniel J Henning
- University of Washington, Division of Emergency Medicine, Seattle, Washington
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Shankar-Hari M, Harrison D, Rubenfeld G, Rowan K. Epidemiology of sepsis and septic shock in critical care units: comparison between sepsis-2 and sepsis-3 populations using a national critical care database. Br J Anaesth 2017; 119:626-636. [DOI: 10.1093/bja/aex234] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 12/22/2022] Open
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Taniguchi LU, Pires EMC, Vieira JM, Azevedo LCPD. Systemic inflammatory response syndrome criteria and the prediction of hospital mortality in critically ill patients: a retrospective cohort study. Rev Bras Ter Intensiva 2017; 29:317-324. [PMID: 28977100 PMCID: PMC5632974 DOI: 10.5935/0103-507x.20170047] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 04/18/2017] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE This study intended to determine whether the systemic inflammatory response syndrome criteria can predict hospital mortality in a Brazilian cohort of critically ill patients. METHODS We performed a retrospective cohort study at a private tertiary hospital in São Paulo (SP), Brazil. We extracted information from the adult intensive care unit database (Sistema EpimedTM). We compared the SAPS 3 and the systemic inflammatory response syndrome model as dichotomous (≥ 2 criteria: systemic inflammatory response syndrome -positive versus 0 - 1 criterion: systemic inflammatory response syndrome -negative) and ordinal variables from 0 to 4 (according to the number of systemic inflammatory response syndrome criteria met) in the prediction of hospital mortality at intensive care unit admission. Model discrimination was compared using the area under the receiver operating characteristics (AUROC) curve. RESULTS From January to December 2012, we studied 932 patients (60.4% were systemic inflammatory response syndrome -positive). systemic inflammatory response syndrome -positive patients were more critically ill than systemic inflammatory response syndrome -negative patients and had higher hospital mortality (16.9% versus 8.1%, p < 0.001). In the adjusted analysis, being systemic inflammatory response syndrome -positive independently increased the risk of death by 82% (odds ratio 1.82; 95% confidence interval [CI] 1.12 - 2.96, p = 0.016). However, the AUROC curve for the SAPS 3 model was higher (0.81, 95%CI 0.78 - 0.85) compared to the systemic inflammatory response syndrome model with the systemic inflammatory response syndrome criteria as a dichotomous variable (0.60, 95%CI 0.55 - 0.65) and as an ordinal variable (0.62, 95%CI 0.57 - 0.68; p < 0.001) for hospital mortality. CONCLUSION Although systemic inflammatory response syndrome is associated with hospital mortality, the systemic inflammatory response syndrome criteria show low accuracy in the prediction of mortality compared with the SAPS 3.
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Affiliation(s)
- Leandro Utino Taniguchi
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - José Mauro Vieira
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Luciano Cesar Pontes de Azevedo
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Clinical predictors of early death from sepsis. J Crit Care 2017; 42:30-34. [PMID: 28668774 DOI: 10.1016/j.jcrc.2017.06.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 06/09/2017] [Accepted: 06/22/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients with severe sepsis who experience rapid, early deterioration and death are of particular concern. Our objective was to identify predictors of early death in Emergency Department (ED) patients with severe sepsis. METHODS Secondary analysis of two prospective studies of adult ED patients with severe sepsis. The primary outcome was early death, defined as death within 24h of triage. RESULTS Out of 410 severe sepsis admissions, 20 patients experienced early death. These patients demonstrated significantly higher initial lactate (7.3 versus 3.3mmol/L, p<0.001) and modified SOFA (mSOFA) scores (10 vs 6, p<0.001), were less likely to normalize their lactate (p<0.001), had lower initial pH (p<0.001), and more frequently had early positive blood cultures (p=0.021). Multivariable logistic regression identified initial serum lactate level (OR 1.19, 95% CI 1.06-1.35) and mSOFA score (OR 1.17, 95% CI 1.00-1.36) as independent predictors of early death. A repeat lactate≥5mmol/L had a sensitivity of 55% and specificity of 89% for early death. There were no significant treatment differences between groups. CONCLUSION Initial serum lactate and mSOFA score were independent predictors of mortality within 24h of ED admission in patients with severe sepsis.
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Novel Function of Isoamylamine Improves Survival in Endotoxemic Mice by Ameliorating Coagulopathy and Attenuating MMP-9 Expression Through p-ERK/p-p38 Signaling at Early Stage. Shock 2017; 47:772-779. [DOI: 10.1097/shk.0000000000000786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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GYM score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection. Eur J Emerg Med 2017; 24:183-188. [DOI: 10.1097/mej.0000000000000321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Fisher J, Linder A. Heparin-binding protein: a key player in the pathophysiology of organ dysfunction in sepsis. J Intern Med 2017; 281:562-574. [PMID: 28370601 DOI: 10.1111/joim.12604] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Infectious diseases remain a major health problem, and sepsis and other severe infectious diseases are common causes of morbidity and mortality. There is a need for clinical and laboratory tools to identify patients with severe infections early and to distinguish between bacterial and nonbacterial conditions. Heparin-binding protein (HBP), also known as azurocidin or cationic antimicrobial protein of 37 KDa, is a promising biomarker to distinguish between patients with these conditions. It is biologically plausible that HBP is an early and predictive biomarker because it is prefabricated and rapidly mobilized from migrating neutrophils in response to bacterial infections. HBP induces vascular leakage and oedema formation and has a pro-inflammatory effect on a variety of white blood cells and epithelial cells. The dysregulation of vascular barrier function and cellular inflammatory responses can then lead to organ dysfunction. Indeed, it has been shown that patients with sepsis express elevated levels of HBP in plasma several hours before they develop hypotension or organ dysfunction. HBP has a major role in the pathophysiology of severe bacterial infections and thus represents a potential diagnostic marker and a target for the treatment of sepsis.
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Affiliation(s)
- J Fisher
- Division of Infection Medicine, Department of Clinical Sciences, University of Lund, Lund, Sweden
| | - A Linder
- Division of Infection Medicine, Department of Clinical Sciences, University of Lund, Lund, Sweden
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Schuetz P, Birkhahn R, Sherwin R, Jones AE, Singer A, Kline JA, Runyon MS, Self WH, Courtney DM, Nowak RM, Gaieski DF, Ebmeyer S, Johannes S, Wiemer JC, Schwabe A, Shapiro NI. Serial Procalcitonin Predicts Mortality in Severe Sepsis Patients: Results From the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) Study. Crit Care Med 2017; 45:781-789. [PMID: 28257335 PMCID: PMC5389588 DOI: 10.1097/ccm.0000000000002321] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To prospectively validate that the inability to decrease procalcitonin levels by more than 80% between baseline and day 4 is associated with increased 28-day all-cause mortality in a large sepsis patient population recruited across the United States. DESIGN Blinded, prospective multicenter observational clinical trial following an Food and Drug Administration-approved protocol. SETTING Thirteen U.S.-based emergency departments and ICUs. PATIENTS Consecutive patients meeting criteria for severe sepsis or septic shock who were admitted to the ICU from the emergency department, other wards, or directly from out of hospital were included. INTERVENTIONS Procalcitonin was measured daily over the first 5 days. MEASUREMENTS AND MAIN RESULTS The primary analysis of interest was the relationship between a procalcitonin decrease of more than 80% from baseline to day 4 and 28-day mortality using Cox proportional hazards regression. Among 858 enrolled patients, 646 patients were alive and in the hospital on day 4 and included in the main intention-to-diagnose analysis. The 28-day all-cause mortality was two-fold higher when procalcitonin did not show a decrease of more than 80% from baseline to day 4 (20% vs 10%; p = 0.001). This was confirmed as an independent predictor in Cox regression analysis (hazard ratio, 1.97 [95% CI, 1.18-3.30; p < 0.009]) after adjusting for demographics, Acute Physiology and Chronic Health Evaluation II, ICU residence on day 4, sepsis syndrome severity, antibiotic administration time, and other relevant confounders. CONCLUSIONS Results of this large, prospective multicenter U.S. study indicate that inability to decrease procalcitonin by more than 80% is a significant independent predictor of mortality and may aid in sepsis care.
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Affiliation(s)
- Philipp Schuetz
- 1Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland; and Medical Faculty, University of Basel, Switzerland. 2Department of Emergency Medicine, New York Methodist Hospital, New York, NY. 3Emergency Departments, Sinai Grace Hospital and Detroit Receiving Hospital, Detroit, MI. 4Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS. 5Department of Emergency Medicine, Stony Brook University, Stony Brook, NY. 6Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. 7Department of Emergency Medicine, Vanderbilt University, Nashville, TN. 8Department of Emergency Medicine, Northwestern University, Chicago, IL. 9Department of Emergency Medicine, Henry Ford Health System, Detroit, MI. 10Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA. 11Global Medical Affairs, B·R·A·H·M·S GmbH, Hennigsdorf, Germany. 12Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Affiliation(s)
- Peter C Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raghu R Seethala
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Imoigele P Aisiku
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Morr M, Lukasz A, Rübig E, Pavenstädt H, Kümpers P. Sepsis recognition in the emergency department - impact on quality of care and outcome? BMC Emerg Med 2017; 17:11. [PMID: 28330460 PMCID: PMC5363055 DOI: 10.1186/s12873-017-0122-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/10/2017] [Indexed: 12/02/2022] Open
Abstract
Background Appropriate and timely recognition of sepsis is a prerequisite for starting goal-directed therapy bundles. We analyzed the appropriateness of sepsis recognition and documentation with regard to adequacy of therapy and outcome in an internal medicine emergency department (ED). Methods This study included 487 consecutive patients ≥18 years of age who presented to a university hospital ED during a 4-week period. Clinical, laboratory, and follow-up data were acquired independently from documentation by ED physicians. The study team independently rated quality of sepsis classification (American College of Chest Physicians/Society of Critical Care Medicine definitions), diagnostic workup, and guideline-adherent therapy in the ED. Results Of 487 included patients, 110 presented because of infection. Of those, 54 patients matched sepsis criteria, including 20 with organ damage and thus severe sepsis, as rated by the study team. Sepsis was not recognized in 32 of these 54 cases (59%). Multivariate binary logistic regression analysis revealed that higher systolic blood pressure (p <0.05), the ability to stand (p <0.01) and a low number of documented vital signs in the ED discharge letter (p < 0.05) were independent predictors of missed sepsis. Surprisingly, adequate detection of the septic focus (81 vs. 93%, p = 0.17), appropriate fluid administration (86 vs. 87%, p = 0.39), and guideline-adherent antibiotic regimen (95 vs. 100%, p = 0.42) did not differ between cases of recognized and unrecognized sepsis, respectively. Non-recognition affected neither death-censored length of hospital stay (median 7.63 d vs. 7.13 d, p = 0.42) nor a combined endpoint of death or ICU admission to (9 vs. 12%, p = 0.55). Conclusions Non-recognition of sepsis in ED patients with serious infections who formally meet organizational sepsis definitions seems to have no deleterious impact on initial therapy adequacy. Electronic supplementary material The online version of this article (doi:10.1186/s12873-017-0122-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marius Morr
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany
| | - Alexander Lukasz
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany
| | - Eva Rübig
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany
| | - Philipp Kümpers
- Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany.
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