1
|
Fink EL, Alcamo AM, Lovett M, Hartman M, Williams C, Garcia A, Rasmussen L, Pal R, Drury K, MackDiaz E, Ferrazzano PA, Dervan L, Appavu B, Snooks K, Stulce C, Rubin P, Pate B, Toney N, Robertson CL, Wainwright MS, Roa JD, Schober ME, Slomine BS. Post-discharge outcomes of hospitalized children diagnosed with acute SARS-CoV-2 or MIS-C. Front Pediatr 2024; 12:1340385. [PMID: 38410766 PMCID: PMC10895015 DOI: 10.3389/fped.2024.1340385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Hospitalized children diagnosed with SARS-CoV-2-related conditions are at risk for new or persistent symptoms and functional impairments. Our objective was to analyze post-hospital symptoms, healthcare utilization, and outcomes of children previously hospitalized and diagnosed with acute SARS-CoV-2 infection or Multisystem Inflammatory Syndrome in Children (MIS-C). Methods Prospective, multicenter electronic survey of parents of children <18 years of age surviving hospitalization from 12 U.S. centers between January 2020 and July 2021. The primary outcome was a parent report of child recovery status at the time of the survey (recovered vs. not recovered). Secondary outcomes included new or persistent symptoms, readmissions, and health-related quality of life. Multivariable backward stepwise logistic regression was performed for the association of patient, disease, laboratory, and treatment variables with recovered status. Results The children [n = 79; 30 (38.0%) female] with acute SARS-CoV-2 (75.7%) or MIS-C (24.3%) had a median age of 6.5 years (interquartile range 2.0-13.0) and 51 (64.6%) had a preexisting condition. Fifty children (63.3%) required critical care. One-third [23/79 (29.1%)] were not recovered at follow-up [43 (31, 54) months post-discharge]. Admission C-reactive protein levels were higher in children not recovered vs. recovered [5.7 (1.3, 25.1) vs. 1.3 (0.4, 6.3) mg/dl, p = 0.02]. At follow-up, 67% overall had new or persistent symptoms. The most common symptoms were fatigue (37%), weakness (25%), and headache (24%), all with frequencies higher in children not recovered. Forty percent had at least one return emergency visit and 24% had a hospital readmission. Recovered status was associated with better total HRQOL [87 (77, 95) vs. 77 (51, 83), p = 0.01]. In multivariable analysis, lower admission C-reactive protein [odds ratio 0.90 (95% confidence interval 0.82, 0.99)] and higher admission lymphocyte count [1.001 (1.0002, 1.002)] were associated with recovered status. Conclusions Children considered recovered by their parents following hospitalization with SARS-CoV-2-related conditions had less symptom frequency and better HRQOL than those reported as not recovered. Increased inflammation and lower lymphocyte count on hospital admission may help to identify children needing longitudinal, multidisciplinary care. Clinical Trial Registration ClinicalTrials.gov (NCT04379089).
Collapse
Affiliation(s)
- Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Alicia M. Alcamo
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Marlina Lovett
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Mary Hartman
- Division of Pediatric Critical Care Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Cydni Williams
- Department of Pediatrics, Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University, Portland, OR, United States
| | - Angela Garcia
- Division of Pediatric Physical Medicine and Rehabilitation, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Lindsey Rasmussen
- Division of Pediatric Critical Care Medicine, Lucile Packard Children’s Hospital, Stanford University, Palo Alto, CA, United States
| | - Ria Pal
- Department of Neurology, Lucile Packard Children’s Hospital, Stanford University, Palo Alto, CA, United States
| | - Kurt Drury
- Department of Pediatrics, Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University, Portland, OR, United States
- Division of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL, United States
| | - Elizabeth MackDiaz
- Division of Pediatric Critical Care Medicine, MUSC Shawn Jenkins Children’s Hospital, Charleston, SC, United States
| | - Peter A. Ferrazzano
- Department of Pediatrics, University of Wisconsin, Madison, WI, United States
| | - Leslie Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Brain Appavu
- Division of Neurology, Barrow Neurological Institute at Phoenix Children’s Hospital, College of Medicine, University of Arizona, Phoenix, AZ, United States
| | - Kellie Snooks
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Casey Stulce
- Department of Pediatrics, University of Chicago, Chicago, IL, United States
| | - Pamela Rubin
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Bianca Pate
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Nicole Toney
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Courtney L. Robertson
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children’s Center, Baltimore, MD, United States
| | - Mark S. Wainwright
- Division of Pediatric Neurology, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Juan D. Roa
- Department of Pediatrics, Universidad Nacional de Colombia and Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Michelle E. Schober
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Beth S. Slomine
- Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
2
|
Barrios EL, Mazer MB, McGonagill PW, Bergmann CB, Goodman MD, Gould RW, Rao M, Polcz VE, Davis RJ, Del Toro DE, Dirain ML, Dram A, Hale LO, Heidarian M, Kim CY, Kucaba TA, Lanz JP, McCray AE, Meszaros S, Miles S, Nelson CR, Rocha IL, Silva EE, Ungaro RF, Walton AH, Xu J, Zeumer-Spataro L, Drewry AM, Liang M, Bible LE, Loftus TJ, Turnbull IR, Efron PA, Remy KE, Brakenridge SC, Badovinac VP, Griffith TS, Moldawer LL, Hotchkiss RS, Caldwell CC. Adverse outcomes and an immunosuppressed endotype in septic patients with reduced IFN-γ ELISpot. JCI Insight 2024; 9:e175785. [PMID: 38100268 PMCID: PMC10906237 DOI: 10.1172/jci.insight.175785] [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: 09/26/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUNDSepsis remains a major clinical challenge for which successful treatment requires greater precision in identifying patients at increased risk of adverse outcomes requiring different therapeutic approaches. Predicting clinical outcomes and immunological endotyping of septic patients generally relies on using blood protein or mRNA biomarkers, or static cell phenotyping. Here, we sought to determine whether functional immune responsiveness would yield improved precision.METHODSAn ex vivo whole-blood enzyme-linked immunosorbent spot (ELISpot) assay for cellular production of interferon γ (IFN-γ) was evaluated in 107 septic and 68 nonseptic patients from 5 academic health centers using blood samples collected on days 1, 4, and 7 following ICU admission.RESULTSCompared with 46 healthy participants, unstimulated and stimulated whole-blood IFN-γ expression was either increased or unchanged, respectively, in septic and nonseptic ICU patients. However, in septic patients who did not survive 180 days, stimulated whole-blood IFN-γ expression was significantly reduced on ICU days 1, 4, and 7 (all P < 0.05), due to both significant reductions in total number of IFN-γ-producing cells and amount of IFN-γ produced per cell (all P < 0.05). Importantly, IFN-γ total expression on days 1 and 4 after admission could discriminate 180-day mortality better than absolute lymphocyte count (ALC), IL-6, and procalcitonin. Septic patients with low IFN-γ expression were older and had lower ALCs and higher soluble PD-L1 and IL-10 concentrations, consistent with an immunosuppressed endotype.CONCLUSIONSA whole-blood IFN-γ ELISpot assay can both identify septic patients at increased risk of late mortality and identify immunosuppressed septic patients.TRIAL REGISTRYN/A.FUNDINGThis prospective, observational, multicenter clinical study was directly supported by National Institute of General Medical Sciences grant R01 GM-139046, including a supplement (R01 GM-139046-03S1) from 2022 to 2024.
Collapse
Affiliation(s)
- Evan L. Barrios
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Monty B. Mazer
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Patrick W. McGonagill
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Christian B. Bergmann
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- University Hospital Ulm, Clinic for Trauma Surgery, Hand, Plastic, and Reconstructive Surgery Albert-Einstein-Allee 23, Ulm, Germany
| | - Michael D. Goodman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Robert W. Gould
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mahil Rao
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Valerie E. Polcz
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ruth J. Davis
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Drew E. Del Toro
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marvin L.S. Dirain
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alexandra Dram
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lucas O. Hale
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mohammad Heidarian
- Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Caleb Y. Kim
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Tamara A. Kucaba
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer P. Lanz
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ashley E. McCray
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sandra Meszaros
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sydney Miles
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Candace R. Nelson
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ivanna L. Rocha
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Elvia E. Silva
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ricardo F. Ungaro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew H. Walton
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julie Xu
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Leilani Zeumer-Spataro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Muxuan Liang
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Biostatistics, University of Florida College of Public Health and Health Professions and the University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tyler J. Loftus
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Isaiah R. Turnbull
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Philip A. Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kenneth E. Remy
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Scott C. Brakenridge
- Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vladimir P. Badovinac
- Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Experimental Pathology PhD Program, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Thomas S. Griffith
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Center for Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
| | - Lyle L. Moldawer
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Richard S. Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles C. Caldwell
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
3
|
Qiu X, Wang Q, Zhang Y, Zhao Q, Jiang Z, Zhou L. Prognostic Value of Neutrophils-to-Lymphocytes Ratio and Platelets-to-Lymphocytes Ratio in Sepsis Patients With Lymphopenia. Biomark Insights 2024; 19:11772719231223156. [PMID: 38186669 PMCID: PMC10768602 DOI: 10.1177/11772719231223156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Background Inflammation plays a critical role in sepsis. The integration of neutrophil-to-lymphocyte ratio (NLR) and platelets-to-lymphocytes ratio (PLR) from multiple cell types offers a novel approach to rapidly assess inflammation status. However, the predictive role of NLR and PLR in sepsis with lymphopenia remains uncertain. Objectives The purpose of this study was to explore the prognostic value of NLR and PLR in sepsis patients with lymphopenia. Design and methods In this observational retrospective study, we included 172 sepsis patients with lymphopenia and collected clinical characteristics for analysis. Through binary logistic regression analysis, we identified independent factors. Receiver-operating characteristic curves (ROC) and areas under the curves (AUC) were employed to assess the ability to predict hospital mortality risk. Results Our results showed a total hospital mortality rate of 53.49%. Multivariate analysis demonstrated that NLR (OR = 1.11, P < .001) and PLR (OR = 1.01, P = .003) were independent predictors associated with hospital mortality in sepsis patients with lymphopenia. The AUCs of NLR and PLR were 0.750 (95% CI: 0.634-0.788, P < .001) and 0.662 (95% CI: 0.580-0.743, P < .001), respectively. Notably, an optimal cut-off value of 18.93 for NLR displayed a sensitivity of 75.0% and specificity of 63.0% in discriminating hospital mortality in sepsis patients with lymphopenia, while the optimal cut-off value for PLR was 377.50, with a sensitivity of 67.5% and specificity of 64.1%. Conclusion NLR and PLR serve as independent predictors of hospital mortality in sepsis patients with lymphopenia.
Collapse
Affiliation(s)
- Xianming Qiu
- Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Institute of Respiratory Diseases, Jinan, China
| | - Quanzhen Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, China
| | - Yuke Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Institute of Respiratory Diseases, Jinan, China
| | - Qiannan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Institute of Respiratory Diseases, Jinan, China
| | - Zhiming Jiang
- Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, China
| | - Lei Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Institute of Respiratory Diseases, Jinan, China
| |
Collapse
|
4
|
Barrios EA, Mazer MB, McGonagill P, Bergmann CB, Goodman MD, Gould R, Rao M, Polcz V, Davis R, Del Toro D, Dirain M, Dram A, Hale L, Heidarian M, Kucaba TA, Lanz JP, McCray A, Meszaros S, Miles S, Nelson C, Rocha I, Silva EE, Ungaro R, Walton A, Xu J, Zeumer-Spataro L, Drewry A, Liang M, Bible LE, Loftus T, Turnbull I, Efron PA, Remy KE, Brakenridge S, Badovinac VP, Griffith TS, Moldawer LL, Hotchkiss RS, Caldwell CC. Adverse Long-Term Outcomes and an Immune Suppressed Endotype in Sepsis Patients with Reduced Interferon-γELISpot: A Multicenter, Prospective Observational Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.13.23295360. [PMID: 37745385 PMCID: PMC10516075 DOI: 10.1101/2023.09.13.23295360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Sepsis remains a major clinical challenge for which successful treatment requires greater precision in identifying patients at increased risk of adverse outcomes requiring different therapeutic approaches. Predicting clinical outcomes and immunological endotyping of septic patients has generally relied on using blood protein or mRNA biomarkers, or static cell phenotyping. Here, we sought to determine whether functional immune responsiveness would yield improved precision. METHODS An ex vivo whole blood enzyme-linked immunosorbent (ELISpot) assay for cellular production of interferon-γ (IFN-γ) was evaluated in 107 septic and 68 non-septic patients from five academic health centers using blood samples collected on days 1, 4 and 7 following ICU admission. RESULTS Compared with 46 healthy subjects, unstimulated and stimulated whole blood IFNγ expression were either increased or unchanged, respectively, in septic and nonseptic ICU patients. However, in septic patients who did not survive 180 days, stimulated whole blood IFNγ expression was significantly reduced on ICU days 1, 4 and 7 (all p<0.05), due to both significant reductions in total number of IFNγ producing cells and amount of IFNγ produced per cell (all p<0.05). Importantly, IFNγ total expression on day 1 and 4 after admission could discriminate 180-day mortality better than absolute lymphocyte count (ALC), IL-6 and procalcitonin. Septic patients with low IFNγ expression were older and had lower ALC and higher sPD-L1 and IL-10 concentrations, consistent with an immune suppressed endotype. CONCLUSIONS A whole blood IFNγ ELISpot assay can both identify septic patients at increased risk of late mortality, and identify immune-suppressed, sepsis patients.
Collapse
|