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Liang P, Zhu M, Sun X, Wang L, Li B, Ming S, Younis M, Yang J, Wu Y, Huang X. LncRNA-mRNA co-expression analysis reveals aquaporin-9-promoted neutrophil extracellular trap formation and inflammatory activation in sepsis. Int Immunopharmacol 2024; 140:112916. [PMID: 39133961 DOI: 10.1016/j.intimp.2024.112916] [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: 06/03/2024] [Revised: 07/29/2024] [Accepted: 08/06/2024] [Indexed: 09/01/2024]
Abstract
Sepsis is a life-threatening condition caused by an excessive inflammatory response to an infection. However, the precise regulatory mechanism of sepsis remains unclear. Using a strand-specific RNA-sequencing, we identified 115 hub differentially expressed long noncoding RNAs (lncRNAs) and 443 mRNAs in septic patients, primarily participated in crucial pathways including neutrophil extracellular trap (NET) formation and toll-like receptor signaling. Notably, NETs related gene aquaporin-9 (AQP9) and its associated lncRNAs exhibited significant upregulation in septic neutrophils. Functional experiments revealed AQP9 interacts with its lncRNAs to augment the formation of neutrophil NETs. In murine sepsis models, AQP9 inhibition with phloretin reduced proinflammatory cytokine production and lung damage. These findings provide crucial insights into the regulatory role of AQP9 in sepsis, unraveling its interaction with associated lncRNAs in transmitting downstream signals, holding promise in informing the development of novel therapeutic strategies aimed at ameliorating the debilitating effects of sepsis.
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Affiliation(s)
- Pingping Liang
- Center for Infection and Immunity and Guangdong Provincial Engineering Research Center of Molecular Imaging, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China; Guangdong-Hong Kong-Macao University Joint Laboratory of Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China; Key Laboratory of Traditional Chinese Medicine for the Prevention and Treatment of Infectious Diseases, Traditional Chinese Medicine Bureau of Guangdong Province, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Manman Zhu
- Department of Clinical Laboratory, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong 519000, China
| | - Xingzi Sun
- Center for Infection and Immunity and Guangdong Provincial Engineering Research Center of Molecular Imaging, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Li Wang
- Department of Obstetrics and Gynecology, Perinatal Medical Center, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Bin Li
- MOE Key Laboratory of Gene Function and Regulation, State Key Laboratory of Biocontrol, School of Life Sciences, Sun Yat-sen University, Guangzhou, Guangdong 510275, China
| | - Siqi Ming
- Center for Infection and Immunity and Guangdong Provincial Engineering Research Center of Molecular Imaging, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Muhammad Younis
- Center for Infection and Immunity and Guangdong Provincial Engineering Research Center of Molecular Imaging, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Jianhua Yang
- MOE Key Laboratory of Gene Function and Regulation, State Key Laboratory of Biocontrol, School of Life Sciences, Sun Yat-sen University, Guangzhou, Guangdong 510275, China
| | - Yongjian Wu
- Center for Infection and Immunity and Guangdong Provincial Engineering Research Center of Molecular Imaging, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China; Guangdong-Hong Kong-Macao University Joint Laboratory of Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China; Key Laboratory of Traditional Chinese Medicine for the Prevention and Treatment of Infectious Diseases, Traditional Chinese Medicine Bureau of Guangdong Province, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China.
| | - Xi Huang
- Center for Infection and Immunity and Guangdong Provincial Engineering Research Center of Molecular Imaging, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China; Guangdong-Hong Kong-Macao University Joint Laboratory of Interventional Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China; Key Laboratory of Traditional Chinese Medicine for the Prevention and Treatment of Infectious Diseases, Traditional Chinese Medicine Bureau of Guangdong Province, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China.
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Torres-Fernandez D, Dalsuco J, Bramugy J, Bassat Q, Varo R. Innovative strategies for the surveillance, prevention, and management of pediatric infections applied to low-income settings. Expert Rev Anti Infect Ther 2024; 22:413-422. [PMID: 38739471 DOI: 10.1080/14787210.2024.2354839] [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: 06/09/2023] [Accepted: 05/09/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Infectious diseases still cause a significant burden of morbidity and mortality among children in low- and middle-income countries (LMICs). There are ample opportunities for innovation in surveillance, prevention, and management, with the ultimate goal of improving survival. AREAS COVERED This review discusses the current status in the use and development of innovative strategies for pediatric infectious diseases in LMICs by focusing on surveillance, diagnosis, prevention, and management. Topics covered are: Minimally Invasive Tissue Sampling as a technique to accurately ascertain the cause of death; Genetic Surveillance to trace the pathogen genomic diversity and emergence of resistance; Artificial Intelligence as a multidisciplinary tool; Portable noninvasive imaging methods; and Prognostic Biomarkers to triage and risk stratify pediatric patients. EXPERT OPINION To overcome the specific hurdles in child health for LMICs, some innovative strategies appear at the forefront of research. If the development of these next-generation tools remains focused on accessibility, sustainability and capacity building, reshaping epidemiological surveillance, diagnosis, and treatment in LMICs, can become a reality and result in a significant public health impact. Their integration with existing healthcare infrastructures may revolutionize disease detection and surveillance, and improve child health and survival.
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Affiliation(s)
- David Torres-Fernandez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Jessica Dalsuco
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ICREA, Pg. Lluís Companys, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
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Fidanza M, Hibbert J, Acton E, Harbeson D, Schoeman E, Skut P, Woodman T, Eynaud A, Hartnell L, Brook B, Cai B, Lo M, Falsafi R, Hancock REW, Chiume-Kayuni M, Lufesi N, Popescu CR, Lavoie PM, Strunk T, Currie AJ, Kollmann TR, Amenyogbe N, Lee AH. Angiogenesis-associated pathways play critical roles in neonatal sepsis outcomes. Sci Rep 2024; 14:11444. [PMID: 38769383 PMCID: PMC11106288 DOI: 10.1038/s41598-024-62195-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 05/14/2024] [Indexed: 05/22/2024] Open
Abstract
Neonatal sepsis is a major cause of childhood mortality. Limited diagnostic tools and mechanistic insights have hampered our abilities to develop prophylactic or therapeutic interventions. Biomarkers in human neonatal sepsis have been repeatedly identified as associated with dysregulation of angiopoietin signaling and altered arachidonic acid metabolism. We here provide the mechanistic evidence in support of the relevance for these observations. Angiopoetin-1 (Ang-1), which promotes vascular integrity, was decreased in blood plasma of human and murine septic newborns. In preclinical models, administration of Ang-1 provided prophylactic protection from septic death. Arachidonic acid metabolism appears to be functionally connected to Ang-1 via reactive oxygen species (ROS) with a direct role of nitric oxide (NO). Strengthening this intersection via oral administration of arachidonic acid and/or the NO donor L-arginine provided prophylactic as well as therapeutic protection from septic death while also increasing plasma Ang-1 levels among septic newborns. Our data highlight that targeting angiogenesis-associated pathways with interventions that increase Ang-1 activity directly or indirectly through ROS/eNOS provide promising avenues to prevent and/or treat severe neonatal sepsis.
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Affiliation(s)
| | - Julie Hibbert
- Westfarmers Center of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA, Australia
- Medical, Molecular and Forensic Sciences, Murdoch University, Perth, WA, Australia
| | - Erica Acton
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, Canada
| | - Danny Harbeson
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | | | - Tabitha Woodman
- Medical, Molecular and Forensic Sciences, Murdoch University, Perth, WA, Australia
| | | | - Lucy Hartnell
- Telethon Kids Institute, Perth, WA, Australia
- Medical, Molecular and Forensic Sciences, Murdoch University, Perth, WA, Australia
| | - Byron Brook
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
- Precision Vaccines Program, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Bing Cai
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Mandy Lo
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Reza Falsafi
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, Canada
| | - Robert E W Hancock
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, Canada
| | - Msandeni Chiume-Kayuni
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
- Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Curative and Medical Rehabilitation, Ministry of Health, Lilongwe, Malawi
| | - Constantin R Popescu
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, Université Laval, Québec, QC, Canada
| | - Pascal M Lavoie
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, Canada
| | - Tobias Strunk
- Telethon Kids Institute, Perth, WA, Australia
- Westfarmers Center of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Perth, WA, Australia
| | - Andrew J Currie
- Medical, Molecular and Forensic Sciences, Murdoch University, Perth, WA, Australia.
| | - Tobias R Kollmann
- Telethon Kids Institute, Perth, WA, Australia.
- Department of Microbiology & Immunology, Dalhousie University, Halifax, Canada.
| | - Nelly Amenyogbe
- Telethon Kids Institute, Perth, WA, Australia.
- Department of Microbiology & Immunology, Dalhousie University, Halifax, Canada.
| | - Amy H Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, Canada.
- British Columbia Children's Hospital Research Institute, Vancouver, Canada.
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Mufumba I, Kazinga C, Namazzi R, Opoka RO, Batte A, Bond C, John CC, Conroy AL. sTREM-1: A Biomarker of Mortality in Severe Malaria Impacted by Acute Kidney Injury. J Infect Dis 2024; 229:936-946. [PMID: 38078677 PMCID: PMC11011168 DOI: 10.1093/infdis/jiad561] [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: 05/31/2023] [Accepted: 12/07/2023] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Malaria is an important cause of mortality in African children. Identification of biomarkers to identify children at risk of mortality has the potential to improve outcomes. METHODS We evaluated 11 biomarkers of host response in 592 children with severe malaria. The primary outcome was biomarker performance for predicting mortality. Biomarkers were evaluated using receiver operating characteristic (ROC) curve analysis comparing the area under the ROC curve (AUROC). RESULTS Mortality was 7.3% among children in the study with 72% of deaths occurring within 24 hours of admission. Among the candidate biomarkers, soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) had the highest AUROC (0.78 [95% confidence interval, .70-.86]), outperforming several other biomarkers including C-reactive protein and procalcitonin. sTREM-1 was the top-performing biomarker across prespecified subgroups (malaria definition, site, sex, nutritional status, age). Using established cutoffs, we evaluated mortality across sTREM-1 risk zones. Among children with acute kidney injury, 39.9% of children with a critical-risk sTREM-1 result had an indication for dialysis. When evaluated relative to a disease severity score, sTREM-1 improved mortality prediction (difference in AUROC, P = .016). CONCLUSIONS sTREM-1 is a promising biomarker to guide rational allocation of clinical resources and should be integrated into clinical decision support algorithms, particularly when acute kidney injury is suspected.
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Affiliation(s)
- Ivan Mufumba
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Ruth Namazzi
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
- Department of Pediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robert O Opoka
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
- Department of Pediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Anthony Batte
- CHILD Laboratory, Global Health Uganda, Kampala, Uganda
- Child Health and Development Center, Makerere University College of Health Sciences, Kampala, Uganda
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine
- Center for Global Health, Indiana University, Indianapolis
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine
- Center for Global Health, Indiana University, Indianapolis
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Baro B, Bassat Q. sTREM-1 to Risk-Stratify Patients With Malaria: A Functional Crystal Ball to Improve Outcomes and Save Lives. J Infect Dis 2024; 229:923-925. [PMID: 38078563 DOI: 10.1093/infdis/jiad565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 04/13/2024] Open
Affiliation(s)
- Bàrbara Baro
- ISGlobal, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Quique Bassat
- ISGlobal, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona
- CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
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Marin MJ, van Wijk XMR, Chambliss AB. Advances in sepsis biomarkers. Adv Clin Chem 2024; 119:117-166. [PMID: 38514209 DOI: 10.1016/bs.acc.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] [Indexed: 03/23/2024]
Abstract
Sepsis, a dysregulated host immune response to an infectious agent, significantly increases morbidity and mortality for hospitalized patients worldwide. This chapter reviews (1) the basic principles of infectious diseases, pathophysiology and current definition of sepsis, (2) established sepsis biomarkers such lactate, procalcitonin and C-reactive protein, (3) novel, newly regulatory-cleared/approved biomarkers, such as assays that evaluate white blood cell properties and immune response molecules, and (4) emerging biomarkers and biomarker panels to highlight future directions and opportunities in the diagnosis and management of sepsis.
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Affiliation(s)
- Maximo J Marin
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Allison B Chambliss
- Department of Pathology & Laboratory Medicine, University of California Los Angeles, Los Angeles, California, USA
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7
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Varo R, Crowley VM, Mucasse H, Sitoe A, Bramugy J, Serghides L, Weckman AM, Erice C, Bila R, Vitorino P, Mucasse C, Valente M, Ajanovic S, Balanza N, Zhong K, Derpsch Y, Gladstone M, Mayor A, Bassat Q, Kain KC. Adjunctive rosiglitazone treatment for severe pediatric malaria: A randomized placebo-controlled trial in Mozambican children. Int J Infect Dis 2024; 139:34-40. [PMID: 38013152 DOI: 10.1016/j.ijid.2023.11.031] [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: 08/03/2023] [Revised: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVES We tested the hypothesis that adjunctive rosiglitazone treatment would reduce levels of circulating angiopoietin-2 (Angpt-2) and improve outcomes of Mozambican children with severe malaria. METHODS A randomized, double-blind, placebo-controlled trial of rosiglitazone vs placebo as adjunctive treatment to artesunate in children with severe malaria was conducted. A 0.045 mg/kg/dose of rosiglitazone or matching placebo were administered, in addition to standard of malaria care, twice a day for 4 days. The primary endpoint was the rate of decline of Angpt-2 over 96 hours. Secondary outcomes included the longitudinal dynamics of angiopoietin-1 (Angpt-1) and the Angpt-2/Angpt-1 ratio over 96 hours, parasite clearance kinetics, clinical outcomes, and safety metrics. RESULTS Overall, 180 children were enrolled; 91 were assigned to rosiglitazone and 89 to placebo. Children who received rosiglitazone had a steeper rate of decline of Angpt-2 over the first 96 hours of hospitalization compared to children who received placebo; however, the trend was not significant (P = 0.28). A similar non-significant trend was observed for Angpt-1 (P = 0.65) and the Angpt-2/Angpt-1 ratio (P = 0.34). All other secondary and safety outcomes were similar between groups (P >0.05). CONCLUSION Adjunctive rosiglitazone at this dosage was safe and well tolerated but did not significantly affect the longitudinal kinetics of circulating Angpt-2.
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Affiliation(s)
- Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Humberto Mucasse
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Canada; Department of Immunology and Institute of Medical Sciences University of Toronto, Toronto, Canada
| | - Andrea M Weckman
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Clara Erice
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Rubao Bila
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Pio Vitorino
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Campos Mucasse
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Marta Valente
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Sara Ajanovic
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Núria Balanza
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Kathleen Zhong
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Yiovanna Derpsch
- Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom; School of Psychology, University of East Anglia, Norwich, United Kingdom
| | - Melissa Gladstone
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Alfredo Mayor
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Department of Physiologic Sciences, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique; Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Medicine, University of Toronto, Toronto, Canada
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Medicine, University of Toronto, Toronto, Canada; ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain; Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada; Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada; Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, Canada
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8
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Munhoz D, Collet C, Mizukami T, Yong A, Leone AM, Eftekhari A, Ko B, da Costa BR, Berry C, Collison D, Perera D, Christiansen EH, Rivero F, Zimmermann FM, Ando H, Matsuo H, Nakayama M, Escaned J, Sonck J, Sakai K, Adjedj J, Desta L, van Nunen LX, West NEJ, Fournier S, Storozhenko T, Amano T, Engstrøm T, Johnson T, Shinke T, Biscaglia S, Fearon WF, Ali Z, De Bruyne B, Johnson NP. Rationale and design of the pullback pressure gradient (PPG) global registry. Am Heart J 2023; 265:170-179. [PMID: 37611857 DOI: 10.1016/j.ahj.2023.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/20/2023] [Accepted: 07/08/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Diffuse disease has been identified as one of the main reasons leading to low post-PCI fractional flow reserve (FFR) and residual angina after PCI. Coronary pressure pullbacks allow for the evaluation of hemodynamic coronary artery disease (CAD) patterns. The pullback pressure gradient (PPG) is a novel metric that quantifies the distribution and magnitude of pressure losses along the coronary artery in a focal-to-diffuse continuum. AIM The primary objective is to determine the predictive capacity of the PPG for post-PCI FFR. METHODS This prospective, large-scale, controlled, investigator-initiated, multicenter study is enrolling patients with at least 1 lesion in a major epicardial vessel with a distal FFR ≤ 0.80 intended to be treated by PCI. The study will include 982 subjects. A standardized physiological assessment will be performed pre-PCI, including the online calculation of PPG from FFR pullbacks performed manually. PPG quantifies the CAD pattern by combining several parameters from the FFR pullback curve. Post-PCI physiology will be recorded using a standardized protocol with FFR pullbacks. We hypothesize that PPG will predict optimal PCI results (post-PCI FFR ≥ 0.88) with an area under the ROC curve (AUC) ≥ 0.80. Secondary objectives include patient-reported and clinical outcomes in patients with focal vs. diffuse CAD defined by the PPG. Clinical follow-up will be collected for up to 36 months, and an independent clinical event committee will adjudicate events. RESULTS Recruitment is ongoing and is expected to be completed in the second half of 2023. CONCLUSION This international, large-scale, prospective study with pre-specified powered hypotheses will determine the ability of the preprocedural PPG index to predict optimal revascularization assessed by post-PCI FFR. In addition, it will evaluate the impact of PPG on treatment decisions and the predictive performance of PPG for angina relief and clinical outcomes.
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Affiliation(s)
- Daniel Munhoz
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Takuya Mizukami
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo, Japan
| | - Andy Yong
- Concord Repatriation General Hospital, University of Sydney, New South Wales, Australia
| | - Antonio Maria Leone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University School of Medicine, Rome, Italy; Center of Excellence in Cardiovascular Diagnostics and Therapeutic, Ospedale Fabenefratelli Isola Tiberina Gemelli Isola, Rome, Italy
| | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Brian Ko
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia
| | - Bruno R da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, England; Clinical Epidemiology and Health Care Research, Institute of Health Policy and Management Evaluation (IHPME), University of Toronto, Toronto, Ontorio, Canada
| | - Colin Berry
- School Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Damien Collison
- School Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, St Thomas' Hospital Campus, King's College London, London, UK
| | | | - Fernando Rivero
- Cardiac Department, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan
| | | | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Koshiro Sakai
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Medicine, Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Julien Adjedj
- Department of Cardiology, Arnault Tzanck Institute Saint Laurent du Var, France
| | - Liyew Desta
- Department of Cardiology, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Lokien X van Nunen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Stephane Fournier
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Tatyana Storozhenko
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Prevention and Treatment of Emergency Conditions, L.T. Malaya Therapy National Institute NAMSU, Kharkiv, Ukraine
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Thomas Engstrøm
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Johnson
- University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Toshiro Shinke
- Department of Medicine, Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy
| | - William F Fearon
- Division of Cardiovascular Medicine and Stanford Cardiovascular Institute, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, CA
| | - Ziad Ali
- St Francis Hospital and Heart Center, Roslyn, NY
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX.
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9
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Liu W, Tao Q, Xiao J, Du Y, Pan T, Wang Y, Zhong X. Low lymphocyte to high-density lipoprotein ratio predicts mortality in sepsis patients. Front Immunol 2023; 14:1279291. [PMID: 37901205 PMCID: PMC10601636 DOI: 10.3389/fimmu.2023.1279291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Background The lymphocyte-to-high-density lipoprotein (HDL) ratio (LHR) is associated with both inflammation and immunity, and may have the potential to predict the prognosis of sepsis. Our study aimed to evaluate the relationship between LHR and sepsis-related mortality. Methods We collected data from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.2) database by targeting patients who met the Sepsis-3 criteria and recorded the absolute values of lymphocytes and HDL after admission. We then used restricted cubic splines based on logistic regression to simulate the relationship between the LHR and 90-day mortality. Subsequently, the hazardous threshold was derived based on the mortality curve, and further evaluations were performed using different methods and data sources for hazardous threshold. Results We ultimately included 1027 eligible patients from the MIMIC-IV database and described the nonlinear relationship between LHR and 90-day mortality. Based on the curve, an LHR of ≤ 0.6 indicated harmful threshold, and the odds ratio for mortality was 1.74 (P=0.001). The outperforming hazard was particularly marked in patients with chronic lung disease and remained consistent after adjusting for baseline data and validating multiple data sources. Conclusions The LHR has prognostic value in patients with sepsis, and an LHR ≤ 0.6 is a deleterious load that increases mortality.
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Affiliation(s)
- Wanjun Liu
- Department of Infectious Diseases, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Qian Tao
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jun Xiao
- School of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
| | - Yijun Du
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Tianrong Pan
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yue Wang
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xing Zhong
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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10
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Weckman AM, McDonald CR, Ngai M, Richard-Greenblatt M, Leligdowicz A, Conroy AL, Kain KC, Namasopo S, Hawkes MT. Inflammatory profiles in febrile children with moderate and severe malnutrition presenting at-hospital in Uganda are associated with increased mortality. EBioMedicine 2023; 94:104721. [PMID: 37467665 PMCID: PMC10373657 DOI: 10.1016/j.ebiom.2023.104721] [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: 03/15/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Children in Africa carry a disproportionate burden of malnutrition and infectious disease. Together, malnutrition and infection are major contributors to global child mortality; however, their collective impact on immune activation are not well described. METHODS This was a secondary analysis of a prospective cohort study of children hospitalized with acute febrile illness at a single centre in Uganda. We investigated the association between malnutrition (determined using the mid-upper arm circumference, MUAC), immune activation (as measured by inflammatory markers IL-6, IL-8, CXCL10, CHI3L1, sTNFR1, Cystatin C, granzyme B, and sTREM-1), and mortality. FINDINGS Of the 1850 children eligible for this secondary analysis, 71 (3.8%) and 145 (11.7%) presented with severe acute malnutrition (SAM, MUAC <115 mm) and moderate malnutrition (MUAC 115 to < 125 mm), respectively. SAM was associated with increased concentrations of CHI3L1, sTNFR1, Cystatin C, and sTREM-1, and decreased concentrations of CXCL10 and granzyme B, even after controlling for age, sex, and disease severity at presentation. There were 77 deaths (4.2%). SAM was associated with a 9.2-fold (95% CI 4.8-46), 17-fold (95% CI 3.9-74), and 13-fold (95% CI 3.5-52) increased odds of death in children with pneumonia, malaria, and diarrheal illness, respectively. Mediation analysis implicated sTREM-1 and CHI3L1 in the effect of SAM on mortality, suggesting that enhanced activation of these inflammatory pathways is associated with the increased mortality in undernourished children with pneumonia and malaria. INTERPRETATION Collectively, these data highlight systemic inflammation as a common pathway associated with malnutrition and infection that could be targeted to mitigate the burden of acute febrile illness in LMICs. FUNDING This work was supported in part by the Canadian Institutes of Health Research, and by kind donations from The Tesari Foundation and Kim Kertland. The funders had no role in design, analysis, or reporting of these studies.
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Affiliation(s)
- Andrea M Weckman
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Chloe R McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Melissa Richard-Greenblatt
- Public Health Ontario, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Aleksandra Leligdowicz
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University and Robarts Research Institute, Western University, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Kevin C Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada; Toronto General Hospital Research Institute, University Health Network, Canada; Department of Medicine, University of Toronto, Canada; Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada; Toronto General Research Institute, Toronto General Hospital, Toronto, Canada
| | - Sophie Namasopo
- Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada; School of Public Health, University of Alberta, Edmonton, AB, Canada; Distinguished Researcher, Stollery Science Lab, University of Alberta, Edmonton, AB, Canada; Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda; Women and Children's Research Institute, University of Alberta, Edmonton, AB, Canada.
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11
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Mitran C, Opoka RO, Conroy AL, Namasopo S, Kain KC, Hawkes MT. Pediatric Malaria with Respiratory Distress: Prognostic Significance of Point-of-Care Lactate. Microorganisms 2023; 11:microorganisms11040923. [PMID: 37110346 PMCID: PMC10145304 DOI: 10.3390/microorganisms11040923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Respiratory distress (RD) in pediatric malaria portends a grave prognosis. Lactic acidosis is a biomarker of severe disease. We investigated whether lactate, measured at admission using a handheld device among children hospitalized with malaria and RD, was predictive of subsequent mortality. We performed a pooled analysis of Ugandan children under five years of age hospitalized with malaria and RD from three past studies. In total, 1324 children with malaria and RD (median age 1.4 years, 46% female) from 21 health facilities were included. Median lactate level at admission was 4.6 mmol/L (IQR 2.6–8.5) and 586 patients (44%) had hyperlactatemia (lactate > 5 mmol/L). The mortality was 84/1324 (6.3%). In a mixed-effects Cox proportional hazard model adjusting for age, sex, clinical severity score (fixed effects), study, and site (random effects), hyperlactatemia was associated with a 3-fold increased hazard of death (aHR 3.0, 95%CI 1.8–5.3, p < 0.0001). Delayed capillary refill time (τ = 0.14, p < 0.0001), hypotension (τ = −0.10, p = 0.00049), anemia (τ = −0.25, p < 0.0001), low tissue oxygen delivery (τ = −0.19, p < 0.0001), high parasite density (τ = 0.10, p < 0.0001), and acute kidney injury (p = 0.00047) were associated with higher lactate levels. In children with malaria and RD, bedside lactate may be a useful triage tool, predictive of mortality.
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Affiliation(s)
- Catherine Mitran
- Faculty of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala P.O. Box 7062, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sophie Namasopo
- Department of Paediatrics, Kabale District Hospital, Kabale P.O. Box 1102, Uganda
| | - Kevin C. Kain
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, ON M5G 1L7, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Michael T. Hawkes
- Department of Paediatrics, Faculty of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
- Department of Medical Microbiology and Immunology, Faculty of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
- School of Public Health, University of Alberta, Edmonton, AB T6G 1C9, Canada
- Stollery Science Lab, Edmonton, AB T6G 1C9, Canada
- Women and Children’s Health Research Institute, Edmonton, AB T6G 1C9, Canada
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12
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Barber G, Tanic J, Leligdowicz A. Circulating protein and lipid markers of early sepsis diagnosis and prognosis: a scoping review. Curr Opin Lipidol 2023; 34:70-81. [PMID: 36861948 DOI: 10.1097/mol.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW Sepsis is the extreme response to infection associated with high mortality, yet reliable biomarkers for its identification and stratification are lacking. RECENT FINDINGS Our scoping review of studies published from January 2017 to September 2022 that investigated circulating protein and lipid markers to inform non-COVID-19 sepsis diagnosis and prognosis identified interleukin (IL)-6, IL-8, heparin-binding protein (HBP), and angiopoietin-2 as having the most evidence. Biomarkers can be grouped according to sepsis pathobiology to inform biological data interpretation and four such physiologic processes include: immune regulation, endothelial injury and coagulopathy, cellular injury, and organ injury. Relative to proteins, the pleiotropic effects of lipid species' render their categorization more difficult. Circulating lipids are relatively less well studied in sepsis, however, low high-density lipoprotein (HDL) is associated with poor outcome. SUMMARY There is a lack of robust, large, and multicenter studies to support the routine use of circulating proteins and lipids for sepsis diagnosis or prognosis. Future studies will benefit from standardizing cohort design as well as analytical and reporting strategies. Incorporating biomarker dynamic changes and clinical data in statistical modeling may improve specificity for sepsis diagnosis and prognosis. To guide future clinical decisions at the bedside, point-of-care circulating biomarker quantification is needed.
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Affiliation(s)
- Gemma Barber
- Schulich School of Medicine and Dentistry
- Robarts Research Insitute
| | | | - Aleksandra Leligdowicz
- Schulich School of Medicine and Dentistry
- Robarts Research Insitute
- Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
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13
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Balanza N, Erice C, Ngai M, McDonald CR, Weckman AM, Wright J, Richard-Greenblatt M, Varo R, López-Varela E, Sitoe A, Vitorino P, Bramugy J, Lanaspa M, Acácio S, Madrid L, Baro B, Kain KC, Bassat Q. Prognostic accuracy of biomarkers of immune and endothelial activation in Mozambican children hospitalized with pneumonia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001553. [PMID: 36963048 PMCID: PMC10021812 DOI: 10.1371/journal.pgph.0001553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/24/2023] [Indexed: 02/25/2023]
Abstract
Pneumonia is a leading cause of child mortality. However, currently we lack simple, objective, and accurate risk-stratification tools for pediatric pneumonia. Here we test the hypothesis that measuring biomarkers of immune and endothelial activation in children with pneumonia may facilitate the identification of those at risk of death. We recruited children <10 years old fulfilling WHO criteria for pneumonia and admitted to the Manhiça District Hospital (Mozambique) from 2010 to 2014. We measured plasma levels of IL-6, IL-8, Angpt-2, sTREM-1, sFlt-1, sTNFR1, PCT, and CRP at admission, and assessed their prognostic accuracy for in-hospital, 28-day, and 90-day mortality. Healthy community controls, within same age strata and location, were also assessed. All biomarkers were significantly elevated in 472 pneumonia cases versus 80 controls (p<0.001). IL-8, sFlt-1, and sTREM-1 were associated with in-hospital mortality (p<0.001) and showed the best discrimination with AUROCs of 0.877 (95% CI: 0.782 to 0.972), 0.832 (95% CI: 0.729 to 0.935) and 0.822 (95% CI: 0.735 to 0.908), respectively. Their performance was superior to CRP, PCT, oxygen saturation, and clinical severity scores. IL-8, sFlt-1, and sTREM-1 remained good predictors of 28-day and 90-day mortality. These findings suggest that measuring IL-8, sFlt-1, or sTREM-1 at hospital presentation can guide risk-stratification of children with pneumonia, which could enable prioritized care to improve survival and resource allocation.
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Affiliation(s)
- Núria Balanza
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Michelle Ngai
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chloe R. McDonald
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M. Weckman
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julie Wright
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Richard-Greenblatt
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Rosauro Varo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Elisa López-Varela
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Pio Vitorino
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Miguel Lanaspa
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Sozinho Acácio
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Lola Madrid
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bàrbara Baro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Kevin C. Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ICREA, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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14
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Muppidi P, Wright E, Wassmer SC, Gupta H. Diagnosis of cerebral malaria: Tools to reduce Plasmodium falciparum associated mortality. Front Cell Infect Microbiol 2023; 13:1090013. [PMID: 36844403 PMCID: PMC9947298 DOI: 10.3389/fcimb.2023.1090013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Cerebral malaria (CM) is a major cause of mortality in Plasmodium falciparum (Pf) infection and is associated with the sequestration of parasitised erythrocytes in the microvasculature of the host's vital organs. Prompt diagnosis and treatment are key to a positive outcome in CM. However, current diagnostic tools remain inadequate to assess the degree of brain dysfunction associated with CM before the window for effective treatment closes. Several host and parasite factor-based biomarkers have been suggested as rapid diagnostic tools with potential for early CM diagnosis, however, no specific biomarker signature has been validated. Here, we provide an updated review on promising CM biomarker candidates and evaluate their applicability as point-of-care tools in malaria-endemic areas.
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Affiliation(s)
- Pranavi Muppidi
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily Wright
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samuel C. Wassmer
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Himanshu Gupta
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, Mathura, UP, India
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15
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Stefanova V, Ngai M, Weckman AM, Wright JK, Zhong K, Richard-Greenblatt M, McDonald CR, Conroy AL, Namasopo S, Opoka RO, Hawkes M, Kain KC. Soluble Urokinase-Type Plasminogen Activator Receptor as a Prognostic Marker of Ugandan Children at Risk of Severe and Fatal Malaria. Clin Infect Dis 2023; 76:e1079-e1086. [PMID: 35675322 DOI: 10.1093/cid/ciac457] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/19/2022] [Accepted: 06/02/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current malaria diagnostic tests do not reliably identify children at risk of severe and fatal infection. Host immune and endothelial activation contribute to malaria pathogenesis. Soluble urokinase-type plasminogen activator receptor (suPAR) is a marker of these pathways. We hypothesized that measuring suPAR at presentation could risk-stratify children with malaria. METHODS Plasma suPAR levels were determined in consecutive febrile children with malaria at presentation to hospital in Jinja, Uganda. We evaluated the accuracy of suPAR in predicting in-hospital mortality, and whether suPAR could improve a validated clinical scoring system (Lambaréné Organ Dysfunction Score [LODS]). RESULTS Of the 1226 children with malaria, 39 (3.2%) died. suPAR concentrations at presentation were significantly higher in children who went on to die than in those who survived (P < .0001). suPAR levels were associated with disease severity (LODS: 0 vs 1, P = .001; 1 vs 2, P < .001; 2 vs 3, 0 vs 2, 1 vs 3, and 0 vs 3, P < .0001). suPAR concentrations were excellent predictors of in-hospital mortality (area under the receiver operating characteristic curve [AUROC], 0.92 [95% confidence interval {CI}, .91-.94]). The prognostic accuracy of LODS (AUROC, 0.93 [95% CI, .91-.94]) was improved when suPAR was added (AUROC, 0.97 [95% CI, .96-.98]; P < .0001). CONCLUSIONS Measuring suPAR at presentation can identify children at risk of severe and fatal malaria. Adding suPAR to clinical scores could improve the recognition and triage of children at risk of death. suPAR can be detected with a point-of-care test and can now be evaluated in prospective trials.
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Affiliation(s)
- Veselina Stefanova
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M Weckman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Julie K Wright
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen Zhong
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Ontario, Canada
| | - Melissa Richard-Greenblatt
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Chloe R McDonald
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | | | - Sophie Namasopo
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | | | | | - Kevin C Kain
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Ontario, Canada
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16
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Liles WC. MICROVASCULAR ENDOTHELIAL ACTIVATION/DYSFUNCTION AND DYSREGULATION OF THE ANGIOPOIETIN-TIE2 SYSTEM IN THE PATHOGENESIS OF LIFE-THREATENING INFECTIONS. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2023; 133:234-246. [PMID: 37701588 PMCID: PMC10493726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Microvascular endothelial activation/dysfunction has emerged as an important mechanistic pathophysiological process in the development of morbidity and mortality in life-threatening infections. The angiopoietin-Tie2 system plays an integral role in the regulation of microvascular endothelial integrity. Angiopoietin-1 (Ang-1), produced by platelets and pericytes, is the cognate agonistic ligand for Tie2, promoting endothelial quiescence and inhibiting microvascular leak. Angiopoietin-2 (Ang-2), released from activated endothelial cells in Weibel-Palade bodies, competes with Ang-1 for binding to Tie-2, thereby promoting endothelial activation/dysfunction and microvascular leak. In healthy homeostasis, levels of Ang-1 far exceed Ang-2 in circulating serum/plasma. In diseases associated with systemic inflammation, Ang-1 falls and Ang-2 rises (i.e., Ang-1/2 dysregulation). Our research has shown that Ang-1/2 dysregulation is a prominent feature in a number of life-threatening infections and critical illnesses, including sepsis, cerebral malaria, COVID-19, streptococcal toxic shock syndrome (STSS), hemolytic-uremic syndrome (HUS), dengue, and CAR T-cell-associated neurotoxicity. Further work has implicated Ang-1/2 dysregulation in the development of end-organ injury, including acute lung injury/ARDS, acute kidney injury (AKI), and blood-brain-barrier (BBB) breakdown. Current studies are focused in three areas: (a) translation of Ang-1 and -2 as clinically informative prognostic and "theranostic" biomarkers in critically ill individuals; (b) incorporation of Ang-1/2 assays in a point of care device for clinical triage decision making; and (c) development of an engineered Ang-1 super agonist nanoparticle as a novel pathogen-agnostic therapeutic to prevent and/or mitigate end-organ dysfunction in individuals with life-threatening infections and critical illnesses associated with systemic inflammation.
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17
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Biomarkers of Intestinal Injury and Dysfunction: Adding New Possibilities to Current Methods for Risk Stratification of Children with Malaria Disease. mBio 2022; 13:e0222222. [PMID: 36314796 PMCID: PMC9765273 DOI: 10.1128/mbio.02222-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Malaria remains, in 2022, a major cause of pediatric preventable mortality, with its major burden disproportionately circumscribed to sub-Saharan African countries. Although only ~1 to 2% of malaria cases can be considered severe and potentially life threatening, it is often challenging to identify them so as to prioritize adequate health care and resources. In a recent investigation, M. L. Sarangam, R. Namazzi, D. Datta, C. Bond, et al. (mBio 13:e01325-22, 2022, https://journals.asm.org/doi/10.1128/mbio.01325-22) studied intestinal barrier dysfunction and injury in Ugandan children hospitalized with severe malaria and in healthy community controls. By measuring circulating levels of four different and complementary biomarkers of gut barrier dysfunction and microbial translocation, they demonstrated that intestinal injury is common in pediatric severe malaria (18% of all cases) and is associated with increased mortality, acute kidney injury, acidosis, and endothelial activation. This commentary discusses the prognostic implications of these results, knowledge gaps that remain to be filled, and how findings could be potentially translated into effective interventions to improve outcomes in children with malaria.
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18
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Jullien S, Richard-Greenblatt M, Ngai M, Lhadon T, Sharma R, Dema K, Kain KC, Bassat Q. Performance of host-response biomarkers to risk-stratify children with pneumonia in Bhutan. J Infect 2022; 85:634-643. [PMID: 36243198 DOI: 10.1016/j.jinf.2022.10.010] [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: 01/31/2022] [Revised: 09/27/2022] [Accepted: 10/06/2022] [Indexed: 11/30/2022]
Abstract
Pneumonia is the leading cause of post-neonatal death amongst children under five years of age; however, there is no simple triage tool to identify children at risk of progressing to severe and fatal disease. Such a tool could assist for early referral and prioritization of care to improve outcomes and enhance allocation of scarce resources. We compared the performance of inflammatory and endothelial activation markers in addition to clinical signs or scoring scales to risk-stratify children hospitalized with pneumonia at the national referral hospital of Bhutan with the goal of predicting clinical outcome. Of 118 children, 31 evolved to a poor prognosis, defined as either mortality, admission in the paediatric intensive care unit, requirement of chest drainage or requirement of more than five days of oxygen therapy. Soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) was the best performing biomarker and performed better than clinical parameters. sTREM-1 levels upon admission had good predictive accuracy to identify children with pneumonia at risk of poor prognosis. Our findings confirm that immune and endothelial activation markers could be proactively used at first encounter as risk-stratification and clinical decision-making tools in children with pneumonia; however, further external validation is needed.
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Affiliation(s)
- Sophie Jullien
- Institut de Salut Global de Barcelona (ISGlobal), Universitat de Barcelona (UB), Barcelona, Spain; Departament de Medicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain; Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.
| | - Melissa Richard-Greenblatt
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Ngai
- Sandra-Rotman Centre for Global Health, Toronto General Hospital Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Tenzin Lhadon
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan; Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB), Thimphu, Bhutan
| | - Ragunath Sharma
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Kumbu Dema
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Kevin C Kain
- Sandra-Rotman Centre for Global Health, Toronto General Hospital Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada; Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Quique Bassat
- Institut de Salut Global de Barcelona (ISGlobal), Universitat de Barcelona (UB), Barcelona, Spain; ICREA, Pg. Lluís Companys 23, 08010 Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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19
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Ngai M, Hawkes MT, Erice C, Weckman AM, Wright J, Stefanova V, Opoka RO, Namasopo S, Conroy AL, Kain KC. Intestinal Injury in Ugandan Children Hospitalized With Malaria. J Infect Dis 2022; 226:2010-2020. [PMID: 35942812 DOI: 10.1093/infdis/jiac340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/07/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe malaria is associated with multiple organ dysfunction syndrome (MODS), which may involve the gastrointestinal tract. METHODS In a prospective cohort study in Uganda, we measured markers of intestinal injury (intestinal fatty-acid binding protein [I-FABP] and zonula occludens-1 [ZO-1]) and microbial translocation (lipopolysaccharide binding protein [LBP] and soluble complement of differentiation 14 [sCD14]) among children admitted with malaria. We examined their association with biomarkers of inflammation, endothelial activation, clinical signs of hypoperfusion, organ injury, and mortality. RESULTS We enrolled 523 children (median age 1.5 years, 46% female, 7.5% mortality). Intestinal FABP was above the normal range (≥400 pg/mL) in 415 of 523 patients (79%). Intestinal FABP correlated with ZO-1 (ρ = 0.11, P = .014), sCD14 (ρ = 0.12, P = .0046) as well as markers of inflammation and endothelial activation. Higher I-FABP levels were associated with lower systolic blood pressure (ρ = -0.14, P = .0015), delayed capillary refill time (ρ = 0.17, P = .00011), higher lactate level (ρ = 0.40, P < .0001), increasing stage of acute kidney injury (ρ = 0.20, P = .0034), and coma (P < .0001). Admission I-FABP levels ≥5.6 ng/mL were associated with a 7.4-fold higher relative risk of in-hospital death (95% confidence interval, 1.4-11, P = .0016). CONCLUSIONS Intestinal injury occurs commonly in children hospitalized with malaria and is associated with microbial translocation, systemic inflammation, tissue hypoperfusion, MODS, and fatal outcome.
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Affiliation(s)
- Michelle Ngai
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael T Hawkes
- Department of Paediatrics, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Department of Medical Microbiology and Immunology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Clara Erice
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea M Weckman
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julie Wright
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Veselina Stefanova
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kampala, Uganda
| | - Sophie Namasopo
- Department of Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda.,Department of Paediatrics, Kabale District Hospital, Kabale, Uganda
| | - Andrea L Conroy
- Ryan White Center for Paediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Department of Medicine, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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20
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Bi D, Lin J, Luo X, Lin L, Tang X, Luo X, Lu Y, Huang X. Biochemical characteristics of patients with imported malaria. Front Cell Infect Microbiol 2022; 12:1008430. [DOI: 10.3389/fcimb.2022.1008430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/13/2022] [Indexed: 11/11/2022] Open
Abstract
ObjectivesThis study aimed to investigate the clinical and biochemical profiles of patients with imported malaria infection between 1 January 2011 and 30 April 2022 and admitted to the Fourth People’s Hospital of Nanning.MethodsThis cohort study enrolled 170 patients with conformed imported malaria infection. The clinical and biochemical profiles of these participants were analyzed with malaria parasite clearance, and signs and symptoms related to malaria disappearance were defined as the primary outcome. A multivariable logistic regression model was used to evaluate the odds ratios (ORs) with 95% confidence intervals (CIs) for cerebral malaria. The Cox model was used to estimate the hazard ratios (HRs) with 95% CIs for parasite clearance.ResultsAdenosine deaminase and parasitemia were found to be independent risk factors for severe malaria in patients with imported malaria (OR = 1.0088, 95% CI: 1.0010–1.0167, p = 0.0272 and OR = 2.0700, 95% CI: 1.2584–3.4050, p = 0.0042, respectively). A 0.5–standard deviation (SD) increase of variation for urea (HR = 0.6714, 95% CI: 0.4911–0.9180), a 0.5-SD increase of variation for creatinine (HR = 0.4566, 95% CI: 0.2762–0.7548), a 0.25-SD increase of variation for albumin (HR = 0.4947, 95% CI: 0.3197–0.7653), a 0.25-SD increase of variation for hydroxybutyrate dehydrogenase (HR = 0.6129, 95% CI: 0.3995–0.9402), and a 1.0-SD increase of variation for ferritin (HR = 0.5887, 95% CI: 0.3799–0.9125) were associated with a higher risk for increased parasite clearance duration than a low-level change.ConclusionsAspartate aminotransferase, urea, creatinine, albumin, hydroxybutyrate dehydrogenase, and ferritin are useful biochemical indicators in routine clinical practice to evaluate prognosis for imported malaria.
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21
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McDonald CR, Leligdowicz A, Conroy AL, Weckman AM, Richard-Greenblatt M, Ngai M, Erice C, Zhong K, Namasopo S, Opoka RO, Hawkes MT, Kain KC. Immune and endothelial activation markers and risk stratification of childhood pneumonia in Uganda: A secondary analysis of a prospective cohort study. PLoS Med 2022; 19:e1004057. [PMID: 35830474 PMCID: PMC9328519 DOI: 10.1371/journal.pmed.1004057] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/27/2022] [Accepted: 06/23/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the global burden of pneumonia, reliable triage tools to identify children in low-resource settings at risk of severe and fatal respiratory tract infection are lacking. This study assessed the ability of circulating host markers of immune and endothelial activation quantified at presentation, relative to currently used clinical measures of disease severity, to identify children with pneumonia who are at risk of death. METHODS AND FINDINGS We conducted a secondary analysis of a prospective cohort study of children aged 2 to 59 months presenting to the Jinja Regional Hospital in Jinja, Uganda between February 2012 and August 2013, who met the Integrated Management of Childhood Illness (IMCI) diagnostic criteria for pneumonia. Circulating plasma markers of immune (IL-6, IL-8, CXCL-10/IP-10, CHI3L1, sTNFR1, and sTREM-1) and endothelial (sVCAM-1, sICAM-1, Angpt-1, Angpt-2, and sFlt-1) activation measured at hospital presentation were compared to lactate, respiratory rate, oxygen saturation, procalcitonin (PCT), and C-reactive protein (CRP) with a primary outcome of predicting 48-hour mortality. Of 805 children with IMCI pneumonia, 616 had severe pneumonia. Compared to 10 other immune and endothelial activation markers, sTREM-1 levels at presentation had the best predictive accuracy in identifying 48-hour mortality for children with pneumonia (AUROC 0.885, 95% CI 0.841 to 0.928; p = 0.03 to p < 0.001) and severe pneumonia (AUROC 0.870, 95% CI 0.824 to 0.916; p = 0.04 to p < 0.001). sTREM-1 was more strongly associated with 48-hour mortality than lactate (AUROC 0.745, 95% CI 0.664 to 0.826; p < 0.001), respiratory rate (AUROC 0.615, 95% CI 0.528 to 0.702; p < 0.001), oxygen saturation (AUROC 0.685, 95% CI 0.594 to 0.776; p = 0.002), PCT (AUROC 0.650, 95% CI 0.566 to 0.734; p < 0.001), and CRP (AUROC 0.562, 95% CI 0.472 to 0.653; p < 0.001) in cases of pneumonia and severe pneumonia. The main limitation of this study was the unavailability of radiographic imaging. CONCLUSIONS In this cohort of Ugandan children, sTREM-1 measured at hospital presentation was a significantly better indicator of 48-hour mortality risk than other common approaches to risk stratify children with pneumonia. Measuring sTREM-1 at clinical presentation may improve the early triage, management, and outcome of children with pneumonia at risk of death. TRIAL REGISTRATION The trial was registered at clinicaltrial.gov (NCT04726826).
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Affiliation(s)
- Chloe R. McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Aleksandra Leligdowicz
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Department of Medicine, Division of Critical Care Medicine, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Andrea L. Conroy
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, Indiana, United States of America
| | - Andrea M. Weckman
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Melissa Richard-Greenblatt
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Public Health Ontario Laboratory, Toronto, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Clara Erice
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Kathleen Zhong
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Sophie Namasopo
- Department of Paediatrics, Kabale Regional Referral Hospital, Kabale, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, Kawempe, Kampala, Uganda
| | - Michael T. Hawkes
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Kevin C. Kain
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
- * E-mail:
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22
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Conroy AL, Hawkes MT, Leligdowicz A, Mufumba I, Starr MC, Zhong K, Namasopo S, John CC, Opoka RO, Kain KC. Blackwater fever and acute kidney injury in children hospitalized with an acute febrile illness: pathophysiology and prognostic significance. BMC Med 2022; 20:221. [PMID: 35773743 PMCID: PMC9248152 DOI: 10.1186/s12916-022-02410-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/17/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) and blackwater fever (BWF) are related but distinct renal complications of acute febrile illness in East Africa. The pathogenesis and prognostic significance of BWF and AKI are not well understood. METHODS A prospective observational cohort study was conducted to evaluate the association between BWF and AKI in children hospitalized with an acute febrile illness. Secondary objectives were to examine the association of AKI and BWF with (i) host response biomarkers and (ii) mortality. AKI was defined using the Kidney Disease: Improving Global Outcomes criteria and BWF was based on parental report of tea-colored urine. Host markers of immune and endothelial activation were quantified on admission plasma samples. The relationships between BWF and AKI and clinical and biologic factors were evaluated using multivariable regression. RESULTS We evaluated BWF and AKI in 999 children with acute febrile illness (mean age 1.7 years (standard deviation 1.06), 55.7% male). At enrollment, 8.2% of children had a history of BWF, 49.5% had AKI, and 11.1% had severe AKI. A history of BWF was independently associated with 2.18-fold increased odds of AKI (95% CI 1.15 to 4.16). When examining host response, severe AKI was associated with increased immune and endothelial activation (increased CHI3L1, sTNFR1, sTREM-1, IL-8, Angpt-2, sFlt-1) while BWF was predominantly associated with endothelial activation (increased Angpt-2 and sFlt-1, decreased Angpt-1). The presence of severe AKI, not BWF, was associated with increased risk of in-hospital death (RR, 2.17 95% CI 1.01 to 4.64) adjusting for age, sex, and disease severity. CONCLUSIONS BWF is associated with severe AKI in children hospitalized with a severe febrile illness. Increased awareness of AKI in the setting of BWF, and improved access to AKI diagnostics, is needed to reduce disease progression and in-hospital mortality in this high-risk group of children through early implementation of kidney-protective measures.
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Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA.
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, 3-593 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, T6G1C9, Canada
| | - Aleksandra Leligdowicz
- Division of Critical Care Medicine, Robarts Research Institute, University of Western Ontario, 1511 Richmond St, London, ON, N6A 3K7, Canada
| | | | - Michelle C Starr
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Kathleen Zhong
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, M5G1L7, Canada
| | | | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Robert O Opoka
- Global Health Uganda, Kampala, Uganda.,Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, M5G1L7, Canada
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23
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Pathophysiology of Acute Kidney Injury in Malaria and Non-Malarial Febrile Illness: A Prospective Cohort Study. Pathogens 2022; 11:pathogens11040436. [PMID: 35456111 PMCID: PMC9031196 DOI: 10.3390/pathogens11040436] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 01/06/2023] Open
Abstract
Acute kidney injury (AKI) is a life-threatening complication. Malaria and sepsis are leading causes of AKI in low-and-middle-income countries, but its etiology and pathogenesis are poorly understood. A prospective observational cohort study was conducted to evaluate pathways of immune and endothelial activation in children hospitalized with an acute febrile illness in Uganda. The relationship between clinical outcome and AKI, defined using the Kidney Disease: Improving Global Outcomes criteria, was investigated. The study included 967 participants (mean age 1.67 years, 44.7% female) with 687 (71.0%) positive for malaria by rapid diagnostic test and 280 (29.1%) children had a non-malarial febrile illness (NMFI). The frequency of AKI was higher in children with NMFI compared to malaria (AKI, 55.0% vs. 46.7%, p = 0.02). However, the frequency of severe AKI (stage 2 or 3 AKI) was comparable (12.1% vs. 10.5%, p = 0.45). Circulating markers of both immune and endothelial activation were associated with severe AKI. Children who had malaria and AKI had increased mortality (no AKI, 0.8% vs. AKI, 4.1%, p = 0.005), while there was no difference in mortality among children with NMFI (no AKI, 4.0% vs. AKI, 4.6%, p = 0.81). AKI is a common complication in children hospitalized with acute infections. Immune and endothelial activation appear to play central roles in the pathogenesis of AKI.
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