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Frank HE, Evans L, Phillips G, Dellinger RP, Goldstein J, Harmon L, Portelli D, Sarani N, Schorr C, Terry KM, Townsend SR, Levy MM. Assessment of implementation methods in sepsis: study protocol for a cluster-randomized hybrid type 2 trial. Trials 2023; 24:620. [PMID: 37773067 PMCID: PMC10543317 DOI: 10.1186/s13063-023-07644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Sepsis is the leading cause of intensive care unit (ICU) admission and ICU death. In recognition of the burden of sepsis, the Surviving Sepsis Campaign (SSC) and the Institute for Healthcare Improvement developed sepsis "bundles" (goals to accomplish over a specific time period) to facilitate SSC guideline implementation in clinical practice. Using the SSC 3-h bundle as a base, the Centers for Medicare and Medicaid Services developed a 3-h sepsis bundle that has become the national standard for early management of sepsis. Emerging observational data, from an analysis conducted for the AIMS grant application, suggest there may be additional mortality benefit from even earlier implementation of the 3-h bundle, i.e., the 1-h bundle. METHOD The primary aims of this randomized controlled trial are to: (1) examine the effect on clinical outcomes of Emergency Department initiation of the elements of the 3-h bundle within the traditional 3 h versus initiating within 1 h of sepsis recognition and (2) examine the extent to which a rigorous implementation strategy will improve implementation and compliance with both the 1-h bundle and the 3-h bundle. This study will be entirely conducted in the Emergency Department at 18 sites. A secondary aim is to identify clinical sepsis phenotypes and their impact on treatment outcomes. DISCUSSION This cluster-randomized trial, employing implementation science methodology, is timely and important to the field. The hybrid effectiveness-implementation design is likely to have an impact on clinical practice in sepsis management by providing a rigorous evaluation of the 1- and 3-h bundles. FUNDING NHLBI R01HL162954. TRIAL REGISTRATION ClinicalTrials.gov NCT05491941. Registered on August 8, 2022.
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Affiliation(s)
- Hannah E Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Gary Phillips
- Biostatistical Consultant, Center for Biostatistics, The Ohio State University, Retired From, Columbus, OH, USA
| | - RPhillip Dellinger
- Critical Care Division, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jessyca Goldstein
- Division of Pulmonary, Critical Care and Sleep Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lori Harmon
- Society of Critical Care Medicine, Mount Prospect, IL, USA
| | - David Portelli
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Nima Sarani
- Department of Emergency Medicine, University of Kansas Health System, Kansas City, KS, USA
| | - Christa Schorr
- Cooper Research Institute, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Ahlberg CD, Wallam S, Tirba LA, Itumba SN, Gorman L, Galiatsatos P. Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review. J Crit Care 2023; 77:154324. [PMID: 37159971 DOI: 10.1016/j.jcrc.2023.154324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/11/2023]
Abstract
RATIONALE Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis. METHODS A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review. RESULTS There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology. CONCLUSIONS The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.
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Affiliation(s)
- Caitlyn D Ahlberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Sara Wallam
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Lemya A Tirba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Stephanie N Itumba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Linda Gorman
- Harrison Medical Library, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Nathanson BH, Higgins TL, Stefan M, Lagu T, Lindenauer PK, Steingrub JS. An analysis of homeless patients in the United States requiring ICU admission. J Crit Care 2019; 49:118-123. [DOI: 10.1016/j.jcrc.2018.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/03/2018] [Accepted: 10/28/2018] [Indexed: 11/27/2022]
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Nathanson BH, Raghunathan K. Response. Am J Crit Care 2018; 27:443. [PMID: 30385533 DOI: 10.4037/ajcc2018759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Walkey AJ, Shieh MS, Liu VX, Lindenauer PK. Mortality Measures to Profile Hospital Performance for Patients With Septic Shock. Crit Care Med 2018; 46:1247-1254. [PMID: 29727371 PMCID: PMC6045435 DOI: 10.1097/ccm.0000000000003184] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions. DESIGN Retrospective cohort study. SETTING U.S. acute care hospitals. PATIENTS Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used hierarchical logistic regression models to determine hospital risk-standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk-standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4-33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2-38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16-70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30-0.58]). CONCLUSIONS Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure.
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Affiliation(s)
- Allan J. Walkey
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Center for Implementation and Improvement Sciences, Boston University School of Medicine
| | - Meng-Shiou Shieh
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield MA, and Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
| | | | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield MA, and Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
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Affiliation(s)
- Allan J Walkey
- Division of Pulmonary and Critical Care Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA.
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med 2016; 193:259-72. [PMID: 26414292 DOI: 10.1164/rccm.201504-0781oc] [Citation(s) in RCA: 2046] [Impact Index Per Article: 255.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Reducing the global burden of sepsis, a recognized global health challenge, requires comprehensive data on the incidence and mortality on a global scale. OBJECTIVES To estimate the worldwide incidence and mortality of sepsis and identify knowledge gaps based on available evidence from observational studies. METHODS We systematically searched 15 international citation databases for population-level estimates of sepsis incidence rates and fatality in adult populations using consensus criteria and published in the last 36 years. MEASUREMENTS AND MAIN RESULTS The search yielded 1,553 reports from 1979 to 2015, of which 45 met our criteria. A total of 27 studies from seven high-income countries provided data for metaanalysis. For these countries, the population incidence rate was 288 (95% confidence interval [CI], 215-386; τ = 0.55) for hospital-treated sepsis cases and 148 (95% CI, 98-226; τ = 0.99) for hospital-treated severe sepsis cases per 100,000 person-years. Restricted to the last decade, the incidence rate was 437 (95% CI, 334-571; τ = 0.38) for sepsis and 270 (95% CI, 176-412; τ = 0.60) for severe sepsis cases per 100,000 person-years. Hospital mortality was 17% for sepsis and 26% for severe sepsis during this period. There were no population-level sepsis incidence estimates from lower-income countries, which limits the prediction of global cases and deaths. However, a tentative extrapolation from high-income country data suggests global estimates of 31.5 million sepsis and 19.4 million severe sepsis cases, with potentially 5.3 million deaths annually. CONCLUSIONS Population-level epidemiologic data for sepsis are scarce and nonexistent for low- and middle-income countries. Our analyses underline the urgent need to implement global strategies to measure sepsis morbidity and mortality, particularly in low- and middle-income countries.
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Affiliation(s)
- Carolin Fleischmann
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - André Scherag
- 3 Clinical Epidemiology, Integrated Research and Treatment Center, Center for Sepsis Control and Care, and
| | - Neill K J Adhikari
- 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Christiane S Hartog
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - Thomas Tsaganos
- 5 4th Department of Internal Medicine, University of Athens, Medical School, Athens, Greece; and
| | - Peter Schlattmann
- 6 Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Derek C Angus
- 7 Critical Care Medicine Division, Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Konrad Reinhart
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
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Annane D, Buisson CB, Cariou A, Martin C, Misset B, Renault A, Lehmann B, Millul V, Maxime V, Bellissant E. Design and conduct of the activated protein C and corticosteroids for human septic shock (APROCCHSS) trial. Ann Intensive Care 2016; 6:43. [PMID: 27154719 PMCID: PMC4859323 DOI: 10.1186/s13613-016-0147-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/22/2016] [Indexed: 01/10/2023] Open
Abstract
Background We aimed at assessing the benefit-to-risk ratio of activated protein C (drotrecogin-alfa activated, DAA) and corticosteroids, given alone or in combination, in patients with septic shock. Methods We implemented an investigator-led, publicly funded, multicenter, randomized according to a 2 × 2 factorial design, placebo-controlled, double-blind trial in four parallel groups in which adults with persistent septic shock and no contraindication to DAA were assigned to either DAA alone (24 mg/kg/h for 96 h), or hydrocortisone (50 mg intravenous bolus q6 for 7 days) and fludrocortisone (50 µg once daily through the nasogastric tube for 7 days) alone, or their respective combinations, or their respective placebos. Primary endpoint was 90-day mortality rate. Follow-up duration was 6 months. Statistical analysis was planned to be performed in intent-to-treat once after all participants completed 180-day follow-up and according to the 2 × 2 factorial design. Results The first patient was recruited in September 2008. The trial was suspended on October 25, 2011, owing to the withdrawal from the market of DAA. At this time, 411 patients had been enrolled. On May 17, 2012, the continuation of the trial on two parallel groups was approved by all legal authorities with the aim of investigating the benefit-to-risk ratio of corticosteroids. On June 30, 2014, the trial was suspended again by the study sponsor upon request of the independent data and safety monitoring board. Recruitment restarted on October 7, 2014, after any safety concern was ruled out. Finally, the trial was completed on June 23, 2015, with the recruitment of 1241 patients. Conclusions This report details the design, statistical plan and conduct of a randomized controlled trial of hydrocortisone and fludrocortisone in septic shock. Trial registration The trial was registered at ClinicalTrials.gov under NCT00625209
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Affiliation(s)
- Djillali Annane
- General ICU, Service de Réanimation, Hôpital Raymond Poincaré, Laboratory of Infection and Inflammation, U1173, AP-HP, University of Versailles SQY and INSERM, 104 Boulevard Raymond Poincaré, 92380, Garches, France.
| | | | - Alain Cariou
- Service de Réanimation Médicale, Hôpital Cochin, AP-HP, Paris, France
| | - Claude Martin
- Service d'Anesthésie Réanimation, Hôpital Nord, AP-HM, Marseille, France
| | - Benoit Misset
- Service de Médecine Intensive et Réanimation, Hôpital Saint-Joseph, AP-HP, Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Alain Renault
- Service de Pharmacologie, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université de Rennes 1, Rennes, France
| | | | - Valérie Millul
- Délégation à la Recherche Clinique, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Virginie Maxime
- General ICU, Service de Réanimation, Hôpital Raymond Poincaré, Laboratory of Infection and Inflammation, U1173, AP-HP, University of Versailles SQY and INSERM, 104 Boulevard Raymond Poincaré, 92380, Garches, France
| | - Eric Bellissant
- Service de Pharmacologie, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université de Rennes 1, Rennes, France
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Flavonoids of Polygonum hydropiper L. attenuates lipopolysaccharide-induced inflammatory injury via suppressing phosphorylation in MAPKs pathways. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 16:25. [PMID: 26801102 PMCID: PMC4724128 DOI: 10.1186/s12906-016-1001-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/12/2016] [Indexed: 11/30/2022]
Abstract
Background Polygonum hydropiper L. is widely used as a traditional remedy for the treatment of dysentery, gastroenteritis. It has been used to relieve swelling and pain, dispel wind and remove dampness, eliminate abundant phlegm and inflammatory for a long time. Previous study showed that antioxidants especially flavonoids pretreatment alleviated sepsis-induced injury in vitro and in vivo. In the present study, the possible anti-inflammatory effect of flavonoids from normal butanol fraction of Polygonum hydropiper L. extract (FNP) against inflammation induced by lipopolysaccharide (LPS) was evaluated in vivo and in vitro. Methods The content of total flavonoid of FNP was determined by the aluminum colorimetric method. The content of rutin, quercetin and quercitrin was determined by HPLC method. Mice received FNP orally 3 days before an intra-peritoneal (i.p.) injection of lipopolysaccharide (LPS). Total superoxidase dismutase (T-SOD), total antioxidant capacity (T-AOC), glutathione peroxidase (GSH-PX), glutathione (GSH), myeloperoxidase (MPO) and malondialdehyde (MDA) levels were measured. Tumor necrosis factor-α levels in serum and tissue was measured. mRNA expressions of pro-inflammatory cytokines in lung were assessed by Real-Time PCR. Histopathological changes were evaluated in lung, ileum and colon. We also investigated FNP on reactive oxygen species (ROS), nitric oxide (NO) and pro-inflammatory cytokines (TNF-α, IL-1β, IL-6 and IL-8) production, inducible nitric oxide synthase (iNOS), Cyclooxygenase-2 (COX-2) protein expression, phosphorylation of MAPKs and AMPK in LPS-stimulated RAW264.7 cells. Results FNP increased the levels of T-SOD, T-AOC, GSH-PX and GSH, decreased the levels of TNF-α, MPO and MDA, attenuate the histopathological lesion in LPS-stimulated mice. FNP inhibited production of inflammatory cytokines, ROS and NO, protein expressions of iNOS and COX-2, phosphorylation of ERK, JNK and c-JUN in MAPKs, promoted phosphorylation of AMPKα suppressed by LPS. Conclusion These results suggested in vivo anti-inflammatory activities of FNP might contributed to its enhancement in antioxidant capacity, its inhibitory effects may be mediated by inhibiting the phosphorylation of JNK, ERK and c-JUN in MAPKs signaling pathways.
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Thomas BS, Jafarzadeh SR, Warren DK, McCormick S, Fraser VJ, Marschall J. Temporal trends in the systemic inflammatory response syndrome, sepsis, and medical coding of sepsis. BMC Anesthesiol 2015; 15:169. [PMID: 26597871 PMCID: PMC4657245 DOI: 10.1186/s12871-015-0148-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 11/11/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Recent reports using administrative claims data suggest the incidence of community- and hospital-onset sepsis is increasing. Whether this reflects changing epidemiology, more effective diagnostic methods, or changes in physician documentation and medical coding practices is unclear. METHODS We performed a temporal-trend study from 2008 to 2012 using administrative claims data and patient-level clinical data of adult patients admitted to Barnes-Jewish Hospital in St. Louis, Missouri. Temporal-trend and annual percent change were estimated using regression models with autoregressive integrated moving average errors. RESULTS We analyzed 62,261 inpatient admissions during the 5-year study period. 'Any SIRS' (i.e., SIRS on a single calendar day during the hospitalization) and 'multi-day SIRS' (i.e., SIRS on 3 or more calendar days), which both use patient-level data, and medical coding for sepsis (i.e., ICD-9-CM discharge diagnosis codes 995.91, 995.92, or 785.52) were present in 35.3 %, 17.3 %, and 3.3 % of admissions, respectively. The incidence of admissions coded for sepsis increased 9.7 % (95 % CI: 6.1, 13.4) per year, while the patient data-defined events of 'any SIRS' decreased by 1.8 % (95 % CI: -3.2, -0.5) and 'multi-day SIRS' did not change significantly over the study period. Clinically-defined sepsis (defined as SIRS plus bacteremia) and severe sepsis (defined as SIRS plus hypotension and bacteremia) decreased at statistically significant rates of 5.7 % (95 % CI: -9.0, -2.4) and 8.6 % (95 % CI: -4.4, -12.6) annually. All-cause mortality, SIRS mortality, and SIRS and clinically-defined sepsis case fatality did not change significantly during the study period. Sepsis mortality, based on ICD-9-CM codes, however, increased by 8.8 % (95 % CI: 1.9, 16.2) annually. CONCLUSIONS The incidence of sepsis, defined by ICD-9-CM codes, and sepsis mortality increased steadily without a concomitant increase in SIRS or clinically-defined sepsis. Our results highlight the need to develop strategies to integrate clinical patient-level data with administrative data to draw more accurate conclusions about the epidemiology of sepsis.
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Affiliation(s)
- Benjamin S Thomas
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St. Louis, MO, 63110, USA. .,Department of Medicine, John A. Burns School of Medicine, 651 Ilalo Street, Honolulu, 96813, HI, USA.
| | - S Reza Jafarzadeh
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St. Louis, MO, 63110, USA.
| | - David K Warren
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St. Louis, MO, 63110, USA.
| | - Sandra McCormick
- Center for Clinical Excellence, BJC HealthCare, 4901 Forest Park Avenue, St. Louis, 63108, MO, USA.
| | - Victoria J Fraser
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St. Louis, MO, 63110, USA.
| | - Jonas Marschall
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St. Louis, MO, 63110, USA. .,Department of Infectious Diseases, Bern University Hospital and University of Bern, Friedbühlstrasse 51, CH-3010, Bern, Switzerland.
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Oud L. Contemporary Trends of Reported Sepsis Among Maternal Decedents in Texas: A Population-Based Study. Infect Dis Ther 2015; 4:321-35. [PMID: 26334239 PMCID: PMC4575290 DOI: 10.1007/s40121-015-0086-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 12/13/2022] Open
Abstract
Introduction Recent studies indicate that death certificate-based single-cause-of-death diagnoses can substantially underestimate the contribution of sepsis to mortality in the general population and among maternal decedents. There are no population-based data in the United States on the patterns of the contribution of sepsis to pregnancy-associated deaths. Methods We studied the Texas Inpatient Public Use Data File to identify pregnancy-associated hospitalizations with reported hospital death during 2001–2010. We then examined the annual reporting of sepsis, and that of other reported most common causes of maternal death, including hemorrhage, embolism, preeclampsia/eclampsia, cardiovascular conditions, cardiomyopathy, cerebrovascular accidents, and anesthesia complications. The annual rate of sepsis among decedents, its trend over time, and changes of its annual rank among other examined potential causes of maternal death were assessed. Results There were 557 pregnancy-associated hospital deaths during study period. Sepsis was reported in 131 (23.5%) decedents. Sepsis has been increasingly reported among decedents, rising by 9.1%/year (P = 0.0025). The rank of sepsis, as compared to the other examined potential causes of maternal death rose from the 5th in 2001 to 1st since 2008. At the end of the last decade, sepsis has been reported in 28.1% of pregnancy-associated deaths. More than one potential cause of maternal death was reported in 39% of decedents. Conclusion Sepsis has become the most commonly reported potential cause of death among maternal decedents in the present cohort, noted in over 1 in 4 fatal hospitalizations by the end of the last decade. Although causality cannot be inferred from administrative data, given its known contribution to maternal death, it is likely that sepsis plays an increasing role in fatal maternal hospital outcomes. The prevalent co-reporting of multiple potential causes of maternal death in the present cohort underscores the complexity of determining the sources of evolving rise of maternal mortality. Electronic supplementary material The online version of this article (doi:10.1007/s40121-015-0086-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, USA.
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12
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Stefan MS, Shieh MS, Pekow PS, Hill N, Rothberg MB, Lindenauer PK. Trends in mechanical ventilation among patients hospitalized with acute exacerbations of COPD in the United States, 2001 to 2011. Chest 2015; 147:959-968. [PMID: 25375230 DOI: 10.1378/chest.14-1216] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The use of noninvasive ventilation (NIV) in acute exacerbation of COPD has increased over time. However, little is known about patient factors influencing its use in routine clinical practice. METHODS This was a retrospective cohort study of 723,560 hospitalizations for exacerbation of COPD at 475 hospitals between 2001 and 2011. The primary study outcome was the initial form of ventilation (NIV or invasive mechanical ventilation [IMV]). Hierarchical generalized linear models were used to examine the trends in ventilation and patient characteristics associated with receipt of NIV. RESULTS After adjusting for patient and hospital characteristics, initial NIV increased by 15.1% yearly (from 5.9% to 14.8%), and initial IMV declined by 3.2% yearly (from 8.7% to 5.9%); annual exposure to any form of mechanical ventilation increased by 4.4% (from 14.1% to 20.3%). Among case subjects treated with ventilation, those aged ≥ 85 years had a 22% higher odds of receiving NIV compared with those aged < 65 years, while blacks (OR, 0.86) and Hispanics (OR, 0.91) were less likely to be treated with NIV than were whites. Cases with a high burden of comorbidities and those with concomitant pneumonia had high rates of NIV failure and were more likely to receive initial IMV. Use of NIV increased at a faster rate among the admissions of the oldest patients relative to the youngest. CONCLUSIONS The use of NIV for COPD exacerbations has increased steadily, whereas IMV use has declined. Several patient factors, including age, race, and comorbidities, influenced the receipt of NIV. Further research is needed to identify the factors driving these patterns.
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Affiliation(s)
- Mihaela S Stefan
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of General Internal Medicine, Baystate Medical Center, Springfield, MA; Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA.
| | - Meng-Shiou Shieh
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
| | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Department of Biostatistics, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, MA
| | - Nicholas Hill
- Division of Pulmonary and Critical Care Medicine, Boston, MA
| | - Michael B Rothberg
- Department of Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of General Internal Medicine, Baystate Medical Center, Springfield, MA; Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA
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Mancini N, Burioni R, Clementi M. Microbiological diagnosis of sepsis: the confounding effects of a "gold standard". Methods Mol Biol 2015; 1237:1-4. [PMID: 25319774 DOI: 10.1007/978-1-4939-1776-1_1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The need of rapid and sensitive diagnostic techniques for sepsis is every day more compelling. Its morbidity and mortality loads are dramatically high, with one quarter of patients eventually dying. Several diagnostic progresses have been made in the last years using both molecular- and nonmolecular-based approaches, and they have to be broadly shared in the scientific community also under the technical point of view. The initial chapters of this book give a thorough overlook of the state of the art in the actual diagnosis of sepsis. The other chapters provide a broad range of protocols describing both already used and futuristic tools, covering both microbiological and nonmicrobiological aspects. The potential role of each described protocol is evidenced by a brief introduction on the specific topic of each chapter. A final chapter describing algorithms potentially useful in stratifying the risk of sepsis in each single patient and suggesting the future perspectives in the diagnosis of sepsis closes the book.
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Affiliation(s)
- Nicasio Mancini
- Laboratory of Microbiology and Virology, University Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy,
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Yamane D, Huancahuari N, Hou P, Schuur J. Disparities in acute sepsis care: a systematic review. Crit Care 2015. [PMCID: PMC4471407 DOI: 10.1186/cc14102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Mancini N, Sambri V, Corti C, Ghidoli N, Tolomelli G, Paolucci M, Clerici D, Carletti S, Greco R, Tassara M, Pizzorno B, Zaniolo O, Povero M, Pradelli L, Burioni R, Stanzani M, Landini MP, Ciceri F, Clementi M. Cost-effectiveness of blood culture and a multiplex real-time PCR in hematological patients with suspected sepsis: an observational propensity score-matched study. Expert Rev Mol Diagn 2014; 14:623-32. [DOI: 10.1586/14737159.2014.916212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Walkey AJ, Wiener RS. Hospital case volume and outcomes among patients hospitalized with severe sepsis. Am J Respir Crit Care Med 2014; 189:548-55. [PMID: 24400669 DOI: 10.1164/rccm.201311-1967oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
RATIONALE Processes of care are potential determinants of outcomes in patients with severe sepsis. Whether hospitals with more experience caring for patients with severe sepsis also have improved outcomes is unclear. OBJECTIVES To determine associations between hospital severe sepsis caseload and outcomes. METHODS We analyzed data from U.S. academic hospitals provided through University HealthSystem Consortium. We used University HealthSystem Consortium's sepsis mortality model (c-statistic, 0.826) for risk adjustment. Validated International Classification of Disease, 9th Edition, Clinical Modification algorithms were used to identify hospital severe sepsis case volume. Associations between risk-adjusted severe sepsis case volume and mortality, length of stay, and costs were analyzed using spline regression and analysis of covariance. MEASUREMENTS AND MAIN RESULTS We identified 56,997 patients with severe sepsis admitted to 124 U.S. academic hospitals during 2011. Hospitals admitted 460 ± 216 patients with severe sepsis, with median length of stay 12.5 days (interquartile range, 11.1-14.2), median direct costs $26,304 (interquartile range, $21,900-$32,090), and average hospital mortality 25.6 ± 5.3%. Higher severe sepsis case volume was associated with lower unadjusted severe sepsis mortality (R2 = 0.10, P = 0.01) and risk-adjusted severe sepsis mortality (R2 = 0.21, P < 0.001). After further adjustment for geographic region, number of beds, and long-term acute care referrals, hospitals in the highest severe sepsis case volume quartile had an absolute 7% (95% confidence interval, 2.4-11.6%) lower hospital mortality than hospitals in the lowest quartile. We did not identify associations between case volume and resource use. CONCLUSIONS Academic hospitals with higher severe sepsis case volume have lower severe sepsis hospital mortality without higher costs.
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Affiliation(s)
- Allan J Walkey
- 1 The Pulmonary Center, Boston University School of Medicine and Division of Pulmonary, Allergy, and Critical Care Medicine, Boston Medical Center, Boston, Massachusetts
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Leu JIJ, Murphy ME, George DL. The p53 Codon 72 Polymorphism Modifies the Cellular Response to Inflammatory Challenge in the Liver. ACTA ACUST UNITED AC 2013; 2. [PMID: 23991369 DOI: 10.4172/2167-0889.1000117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The p53 protein is a critical stress-response mediator and signal coordinator in cellular metabolism and environmental exposure to deleterious agents. In human populations, the p53 gene contains a common single nucleotide polymorphism (SNP) affecting codon 72 that determines whether a proline (P72) or an arginine (R72) is present at this amino acid position of the polypeptide. Previous studies carried out using human populations, mouse models, and cell culture analyses have provided evidence that this amino acid difference can alter p53 functional activities, and potentially also can affect clinical presentation of disease. The clinical presentation associated with many forms of liver disease is variable, but few of the responsible underlying genetic factors or molecular pathways have been identified. The aim of the present study was to investigate whether the p53 codon 72 polymorphism influences the cellular response to hepatic stresses. A humanized p53 knock-in (Hupki) mouse model was used to address this issue. Mice expressing either the P72 or R72 normal variation of p53 were given an acute-, intermittent- or a chronic challenge, associated with exposure to lipopolysaccharide, D-galactosamine, or a high-fat diet. The results reveal that the livers of the P72 and R72 mice exhibit notable differences in inflammatory and apoptotic response to these distinct forms of stress. Interestingly the influence of this polymorphism on the response to stress is context dependent, with P72 showing increased response to liver toxins (lipopolysaccharide and D-galactosamine), but R72 showing increased response to metabolic stress (high fat diet). When taken together, these data point to the p53 codon 72 polymorphism as an important molecular mediator of events contributing to hepatic inflammation and metabolic homeostasis.
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Affiliation(s)
- Julia I-Ju Leu
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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