1
|
Chen G, Zhang C, Li H, Liu X. Sepsis-induced inflammatory demyelination in medullary visceral zone and cholinergic anti-inflammatory pathway: Insights from a Rat's model study. Heliyon 2024; 10:e33840. [PMID: 39027552 PMCID: PMC11255576 DOI: 10.1016/j.heliyon.2024.e33840] [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: 10/31/2023] [Revised: 06/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background Our previous studies have demonstrated that the activated Cholinergic Anti-inflammatory Pathway (CAP) effectively suppresses systemic inflammation and immunity in early sepsis. Some parameters of Heart Rate Variability (HRV) could be used to reflect the regulatory activity of CAP. However, in the early stages of severe sepsis of some patients, the inflammatory storm can still result in multiple organs dysfunction and even death, suggesting they lose CAP's modulation ability. Since CAP is part of the vagus nerve and is directly innervated by the Medullary Visceral Zone (MVZ), we can reasonably concluded that pathological changes induced by MVZ's neuroinflammation should be responsible for CAP's dysfunction in modulating systemic inflammation in early sepsis. Methods We conducted two independent septic experiments, the sepsis model rats were prepared by cecum ligation and puncture (CLP) method. In the first experiment, A total of 64 adult male Sprague-Dawley rats were included. Under the condition of sepsis and CAP's pharmacological activation or blockade, we investigated the MVZ's pathological changes, the functional state of key neurons including catecholaminergic and cholinergic neurons, key genes' expression such as Oligodendrocyte Transcription Factor 2 (Olig-2) mRNA, glial fibrillary acidic protein (GFAP) mRNA, and matrix metalloprotein (MMP) -9 mRNA, and CAP's activities reflected by HRV. The second experiment involved in 56 rats, through central anti-inflammation by feeding with 10 mg/ml minocycline sucrose solution as the only water source, or right vagus transection excepting for central anti-inflammation as a mean of the CAP's functional cancel, we confirmed that the neuroinflammation in MVZ affected systemic inflammation through CAP in sepsis. Results In the first experiment, cholinergic and catecholaminergic neurons showed significant apoptosis with reduced expressions of TH, but the expression of CHAT remained relatively unaffected in MVZ in sepsis. HRV parameters representing the tone of the vagus nerve, such as SDNN, RMSSD, HF, SD1, and SD2, did not show significant differences among the three Septic Groups, although they all decreased significantly compared to the Control Group. The expressions of GFAP mRNA and MMP-9 mRNA were up-regulated, while the expression of Olig-2 mRNA was down-regulated in the Septic Groups. Intervention of CAP had a significant effect on cholinergic and catecholaminergic neurons' apoptosis, as well as the expressions of TH/CHAT and these key genes, but had little effect on HRV in sepsis. In the second experiment, the levels of TNF-α, IL-6, in serum and MVZ were significantly increased in sepsis. Central anti-inflammatory treatment reversed these changes. However, right vagotomy abolished the central anti-inflammatory effect. Conclusions Our study uncovered that MVZ's neuroinflammation may play a crucial role in the uncontrolled systemic inflammation through inflammatory demyelination in MVZ, which disrupts CAP's modulation on the systemic inflammation in early sepsis.
Collapse
Affiliation(s)
- Gao Chen
- The Intensive Care Unite of Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, 430079, China
| | - Cheng Zhang
- Emergency Department of the First People's Hospital of Guiyang of Guizhou Province, 550002, China
| | - Hongbing Li
- Emergency Department of the First People's Hospital of Guiyang of Guizhou Province, 550002, China
| | - Xian Liu
- Geriatrics Department of the First People's Hospital of Guiyang of Guizhou Province, 550002, China
| |
Collapse
|
2
|
Dumargne H, Patural H, Charbonnieras F, Charier D, Biscarrat C, Chivot M, Argaud L, Cour M, Dargent A. Exploration of COVID-19 associated bradycardia using heart rate variability analysis in a case-control study of ARDS patients. Heart Lung 2024; 68:74-80. [PMID: 38941770 DOI: 10.1016/j.hrtlng.2024.06.014] [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: 03/13/2024] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Bradycardia and dysautonomia observed during SARS-Cov2 infection suggests involvement of the autonomic nervous system (ANS). Limited data exists on ANS dysregulation and its association with outcomes in patients with acute respiratory distress syndrome (ARDS) related to COVID-19 (C-ARDS) or other etiologies (NC-ARDS). OBJECTIVES We aimed to explore sympathovagal balance, assessed by heart rate variability (HRV), and its clinical prognostic value in C-ARDS compared with NC-ARDS. METHODS A single-center, prospective case-control study was conducted. Consecutive patients meeting ARDS criteria between 2020 and 2022 were included. HRV was assessed using 1-hour electrographic tracing during a stable, daytime period. RESULTS Twenty-four patients with C-ARDS and 19 with NC-ARDS were included. Age, sex and ARDS severity were similar between groups. The median heart rate was markedly lower in the C-ARDS group than in the NC-ARDS group (60 [53-72] versus 101 [91-112] bpm, p<.001). Most of HRV parameters were significantly increased in patients with C-ARDS. HRV correlated with heart rate only in patients with C-ARDS. A positive correlation was found between the low-to high-frequency ratio (LF/HF) and length of intensive care unit stay (r = 0.576, p<.001). CONCLUSION This study confirmed that C-ARDS was associated with marked bradycardia and severe ANS impairment, suggesting a sympathovagal imbalance with vagal overtone. Poor outcomes appeared to be more related to sympathetic rather than parasympathetic hyperactivation.
Collapse
Affiliation(s)
- Hugo Dumargne
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 69003 Lyon, France
| | - Hugues Patural
- Centre Hospitalier Universitaire de Saint Etienne, Service de réanimation pédiatrique, Saint-Etienne, France; INSERM, SAINBIOSE U1059, 42055 Saint-Etienne, France
| | - François Charbonnieras
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service de Cardiologie soins intensifs, 69004 Lyon, France
| | - David Charier
- INSERM, SAINBIOSE U1059, 42055 Saint-Etienne, France; Centre Hospitalier Universitaire de Saint Etienne, Service d'Anesthésie-Réanimation, Saint-Etienne, France
| | - Charlotte Biscarrat
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 69003 Lyon, France
| | - Matthieu Chivot
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 69003 Lyon, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 69003 Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, 69003 Lyon, France
| | - Auguste Dargent
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'Anesthésie-Réanimation Médecine Intensive-Réanimation, 69495 Pierre-Bénite, Lyon, France; APCSe VetAgro Sup UPSP 2016.A101, 69280 Marcy l'Etoile, France.
| |
Collapse
|
3
|
Arias-Colinas M, Gea A, Kwan J, Vassallo M, Allen SC, Khattab A. Cardiovascular Autonomic Dysfunction in Hospitalized Patients with a Bacterial Infection: A Longitudinal Observational Pilot Study in the UK. Biomedicines 2024; 12:1219. [PMID: 38927426 PMCID: PMC11201200 DOI: 10.3390/biomedicines12061219] [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: 05/07/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE A temporal reduction in the cardiovascular autonomic responses predisposes patients to cardiovascular instability after a viral infection and therefore increases the risk of associated complications. These findings have not been replicated in a bacterial infection. This pilot study will explore the prevalence of cardiovascular autonomic dysfunction (CAD) in hospitalized patients with a bacterial infection. METHODS A longitudinal observational pilot study was conducted. Fifty participants were included: 13 and 37 participants in the infection group and healthy group, respectively. Recruitment and data collection were carried out during a two-year period. Participants were followed up for 6 weeks: all participants' cardiovascular function was assessed at baseline (week 1) and reassessed subsequently at week 6 so that the progression of the autonomic function could be evaluated over that period of time. The collected data were thereafter analyzed using STATA/SE version 16.1 (StataCorp). The Fisher Exact test, McNemar exact test, Mann-Whitney test and Wilcoxon test were used for data analysis. RESULTS 32.4% of the participants in the healthy group were males (n = 12) and 67.6% were females (n = 25). Participants' age ranged from 33 years old to 76 years old with the majority being 40-60 years of age (62.1%) (Mean age 52.4 SD = 11.4). Heart rate variability (HRV) in response to Valsalva Maneuver, metronome breathing, standing and sustained handgrip in the infection group was lower than in the healthy group throughout the weeks. Moreover, both the HRV in response to metronome breathing and standing up showed a statistically significant difference when the mean values were compared between both groups in week 1 (p = 0.03 and p = 0.013). The prevalence of CAD was significantly higher in the infection group compared to healthy volunteers, both at the beginning of the study (p = 0.018) and at the end of follow up (p = 0.057), when all patients had been discharged. CONCLUSIONS CAD, as assessed by the HRV, is a common finding during the recovery period of a bacterial infection, even after 6 weeks post-hospital admission. This may increase the risk of complications and cardiovascular instability. It may therefore be of value to conduct a wider scale study to further evaluate this aspect so recommendations can be made for the cardiovascular autonomic assessment of patients while they are recovering from a bacterial infectious process.
Collapse
Affiliation(s)
- Monica Arias-Colinas
- Department of Preventive Medicine and Public Health, University of Navarra, 31008 Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - Alfredo Gea
- Department of Preventive Medicine and Public Health, University of Navarra, 31008 Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- Biomedical Research Network Center for Pathophysiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, 28029 Madrid, Spain
| | - Joseph Kwan
- Department of Brain Sciences, Imperial College, London W12 0NN, UK
| | - Michael Vassallo
- Department of Medicine for Older People, Royal Bournemouth Hospital, Bournemouth BH7 7DW, UK
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
| | - Stephen C. Allen
- Department of Medicine for Older People, Royal Bournemouth Hospital, Bournemouth BH7 7DW, UK
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
| | - Ahmed Khattab
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth BH8 8GP, UK
| |
Collapse
|
4
|
Albarracin Duarte JA, Chaparro Hernández J, Rojas Aceros JA, Valoyes Gélvez JE, Ascuntar J, Jaimes F. Association between early manifestations of infection or sepsis and prognosis in a high complexity hospital in the city of Medellín. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:394-402. [PMID: 38588770 DOI: 10.1016/j.redare.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/07/2023] [Indexed: 04/10/2024]
Abstract
OBJECTIVE To identify the first symptoms and signs of patients with suspected infection or sepsis and their association with the composite outcome of admission to the Intensive Care Unit (ICU) or mortality. DESIGN Prospective cohort study between June 2019 and March 2020. SETTING Hospital Universitario San Vicente Fundación, Colombia. PATIENTS Over 18 years of age with suspicion or confirmation of sepsis, which required hospitalization. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Symptoms and signs associated with infection, with their time of evolution, specified in the study. RESULTS From 1005 eligible patients, 261 were included. After multivariable adjustment with a logistic regression model, the main factors for ICU admission or mortality were heart rate (OR 1.04 with 95% CI 1.04-3.7), respiratory rate (OR 1.19 with 95% CI 1.0-1.4) and capillary refill time (OR 3.4 with 95% CI 1.9-6.1). CONCLUSIONS Heart rate, respiratory rate, and capillary refill may behave as early predictors of ICU admission and mortality in cases of sepsis.
Collapse
Affiliation(s)
| | | | | | | | - J Ascuntar
- Gerente en Sistemas de Información en Salud, GRAEPIC (Grupo Académico de Epidemiología Clínica), Universidad de Antioquia, Medellín, Colombia
| | - F Jaimes
- Médico Internista, Epidemiólogo y Doctor en Epidemiologia en Enfermedad Infecciosas, GRAEPIC (Grupo Académico de Epidemiología Clínica), Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Colombia.
| |
Collapse
|
5
|
Zhang Y, Xu W, Yang P, Zhang A. Machine learning for the prediction of sepsis-related death: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2023; 23:283. [PMID: 38082381 PMCID: PMC10712076 DOI: 10.1186/s12911-023-02383-1] [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: 08/01/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sepsis is accompanied by a considerably high risk of mortality in the short term, despite the availability of recommended mortality risk assessment tools. However, these risk assessment tools seem to have limited predictive value. With the gradual integration of machine learning into clinical practice, some researchers have attempted to employ machine learning for early mortality risk prediction in sepsis patients. Nevertheless, there is a lack of comprehensive understanding regarding the construction of predictive variables using machine learning and the value of various machine learning methods. Thus, we carried out this systematic review and meta-analysis to explore the predictive value of machine learning for sepsis-related death at different time points. METHODS PubMed, Embase, Cochrane, and Web of Science databases were searched until August 9th, 2022. The risk of bias in predictive models was assessed using the Prediction model Risk of Bias Assessment Tool (PROBAST). We also performed subgroup analysis according to time of death and type of model and summarized current predictive variables used to construct models for sepsis death prediction. RESULTS Fifty original studies were included, covering 104 models. The combined Concordance index (C-index), sensitivity, and specificity of machine learning models were 0.799, 0.81, and 0.80 in the training set, and 0.774, 0.71, and 0.68 in the validation set, respectively. Machine learning outperformed conventional clinical scoring tools and showed excellent C-index, sensitivity, and specificity in different subgroups. Random Forest (RF) and eXtreme Gradient Boosting (XGBoost) are the preferred machine learning models because they showed more favorable accuracy with similar modeling variables. This study found that lactate was the most frequent predictor but was seriously ignored by current clinical scoring tools. CONCLUSION Machine learning methods demonstrate relatively favorable accuracy in predicting the mortality risk in sepsis patients. Given the limitations in accuracy and applicability of existing prediction scoring systems, there is an opportunity to explore updates based on existing machine learning approaches. Specifically, it is essential to develop or update more suitable mortality risk assessment tools based on the specific contexts of use, such as emergency departments, general wards, and intensive care units.
Collapse
Affiliation(s)
- Yan Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Weiwei Xu
- Department of Endocrine and Metabolic Diseases, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ping Yang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - An Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| |
Collapse
|
6
|
Li S, Yang Q, Wu P, Lu Y, Yang Z, Jiang L. HEART RATE VARIABILITY PARAMETERS WERE NOT ASSOCIATED WITH 30-DAY ALL-CAUSE MORTALITY IN INTENSIVE CARE UNIT PATIENTS WITH OR WITHOUT ATRIAL FIBRILLATION: A RETROSPECTIVE STUDY OF THE MIMIC-IV DATABASE. Shock 2023; 60:24-33. [PMID: 37219462 DOI: 10.1097/shk.0000000000002149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
ABSTRACT Objective: Our study aims to evaluate the association between heart rate variability (HRV) and short- and long-term prognosis in patients admitted to intensive care unit (ICU). Methods and Results: Adult patients continuously monitored for over 24 h in ICUs from the the American Medical Information Mart for Intensive Care (MIMIC)-IV Waveform Database were recruited in our study. Twenty HRV-related variables (8 time domain, 6 frequency domain, and 6 nonlinear variables) were calculated based on RR intervals. The association between HRV and all-cause mortality was assessed. Ninety-three patients met the inclusion criteria and were classified into atrial fibrillation (AF) and sinus rhythm (SR) groups, which were further divided into 30-day survivor group and nonsurvivor\groups based on their survival status. The 30-day all-cause mortality rates in AF and SR groups were 36.3% and 14.6%, respectively. All the time domain, frequency domain, and nonlinear HRV parameters did not differ significantly between survivors and nonsurvivors with or without AF (all P > 0.05). Presence of renal failure, malignancy, and elevated blood urea nitrogen level were associated with increased 30-day all-cause mortality in SR patients, while presence of sepsis, infection, higher platelet count, and magnesium level were associated with increased 30-day all-cause mortality in AF patients. Conclusions: Heart rate variability variables were not associated with increased 30-day all-cause mortality in ICU patients with or without AF.
Collapse
Affiliation(s)
- Sheran Li
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiyu Yang
- School of Automation, Guangdong University of Technology, Guangzhou, China
| | - Peiyu Wu
- School of Automation, Guangdong University of Technology, Guangzhou, China
| | - Yujing Lu
- School of Automation, Guangdong University of Technology, Guangzhou, China
| | - Zhengfei Yang
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Longyuan Jiang
- Department of Emergency Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
7
|
Schupp T, Weidner K, Rusnak J, Jawhar S, Forner J, Dulatahu F, Brück LM, Hoffmann U, Bertsch T, Akin I, Behnes M. Norepinephrine dose, lactate or heart rate: what impacts prognosis in sepsis and septic shock? Results from a prospective, monocentric registry. Curr Med Res Opin 2023; 39:647-659. [PMID: 36951515 DOI: 10.1080/03007995.2023.2194777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVE The study comprehensively investigates the prognostic value of norepinephrine (NE) dose, lactate and heart rate in patients with sepsis and septic shock. BACKGROUND Limited data regarding the prognostic value of NE dose, lactate and heart rate in patients meeting the sepsis-3 criteria is available. METHODS Consecutive patients with sepsis and septic shock from 2019 to 2021 were included. The prognostic value of NE dose, lactate and heart rate was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, Kaplan-Meier analyses, as well as one-factorial repeated measures analysis of variance (ANOVA) and Cox proportional regression analyses. RESULTS 339 patients with sepsis or septic shock were included. With an area under the curve (AUC) of up to 0.638 and 0.685, NE dose and lactate revealed moderate prognostic accuracy for 30-day all-cause mortality, whereas heart rate was not associated with prognosis. Very high NE doses (i.e. > 1.0 mcg/kg/min) (HR = 2.938; 95% CI 1.933 - 4.464; p = .001) and lactate levels (i.e. ≥ 4 mmol/l) (HR = 2.963; 95% CI 2.095 - 4.191; p = .001) on admission were associated with highest risk of death. Finally, increasing NE doses and lactate levels from day 1 to 3 indicated increased risk of death, which was consistent after multivariable adjustment. CONCLUSION Both very high NE doses and lactate levels - but not heart rate - were associated with increased risk of 30-d all-cause mortality in patients with sepsis and septic shock.
Collapse
Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Schanas Jawhar
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Floriana Dulatahu
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Lea Marie Brück
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ursula Hoffmann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| |
Collapse
|
8
|
Schuurman AR, Sloot PMA, Wiersinga WJ, van der Poll T. Embracing complexity in sepsis. Crit Care 2023; 27:102. [PMID: 36906606 PMCID: PMC10007743 DOI: 10.1186/s13054-023-04374-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 02/19/2023] [Indexed: 03/13/2023] Open
Abstract
Sepsis involves the dynamic interplay between a pathogen, the host response, the failure of organ systems, medical interventions and a myriad of other factors. This together results in a complex, dynamic and dysregulated state that has remained ungovernable thus far. While it is generally accepted that sepsis is very complex indeed, the concepts, approaches and methods that are necessary to understand this complexity remain underappreciated. In this perspective we view sepsis through the lens of complexity theory. We describe the concepts that support viewing sepsis as a state of a highly complex, non-linear and spatio-dynamic system. We argue that methods from the field of complex systems are pivotal for a fuller understanding of sepsis, and we highlight the progress that has been made over the last decades in this respect. Still, despite these considerable advancements, methods like computational modelling and network-based analyses continue to fly under the general scientific radar. We discuss what barriers contribute to this disconnect, and what we can do to embrace complexity with regards to measurements, research approaches and clinical applications. Specifically, we advocate a focus on longitudinal, more continuous biological data collection in sepsis. Understanding the complexity of sepsis will require a huge multidisciplinary effort, in which computational approaches derived from complex systems science must be supported by, and integrated with, biological data. Such integration could finetune computational models, guide validation experiments, and identify key pathways that could be targeted to modulate the system to the benefit of the host. We offer an example for immunological predictive modelling, which may inform agile trials that could be adjusted throughout the trajectory of disease. Overall, we argue that we should expand our current mental frameworks of sepsis, and embrace nonlinear, system-based thinking in order to move the field forward.
Collapse
Affiliation(s)
- Alex R Schuurman
- Centre for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centres - Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Peter M A Sloot
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Centre for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centres - Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Centre for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centres - Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
9
|
Debnath S, Koppel R, Saadi N, Potak D, Weinberger B, Zanos TP. Prediction of intrapartum fever using continuously monitored vital signs and heart rate variability. Digit Health 2023; 9:20552076231187594. [PMID: 37448783 PMCID: PMC10336767 DOI: 10.1177/20552076231187594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives Neonatal early onset sepsis (EOS), bacterial infection during the first seven days of life, is difficult to diagnose because presenting signs are non-specific, but early diagnosis before birth can direct life-saving treatment for mother and baby. Specifically, maternal fever during labor from placental infection is the strongest predictor of EOS. Alterations in maternal heart rate variability (HRV) may precede development of intrapartum fever, enabling incipient EOS detection. The objective of this work was to build a predictive model for intrapartum fever. Methods Continuously measured temperature, heart rate, and beat-to-beat RR intervals were obtained from wireless sensors on women (n = 141) in labor; traditional manual vital signs were taken every 3-6 hours. Validated measures of HRV were calculated in moving 5-minute windows of RR intervals: standard deviation of normal-to-normal intervals (SDNN) and root mean square of successive differences (RMSSD) between normal heartbeats. Results Fever (>38.0 °C) was detected by manual or continuous measurements in 48 women. Compared to afebrile mothers, average SDNN and RMSSD in febrile mothers decreased significantly (p < 0.001) at 2 and 3 hours before fever onset, respectively. This observed HRV divergence and raw recorded vitals were applied to a logistic regression model at various time horizons, up to 4-5 hours before fever onset. Model performance increased with decreasing time horizons, and a model built using continuous vital signs as input variables consistently outperformed a model built from episodic vital signs. Conclusions HRV-based predictive models could identify mothers at risk for fever and infants at risk for EOS, guiding maternal antibiotic prophylaxis and neonatal monitoring.
Collapse
Affiliation(s)
- Shubham Debnath
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Robert Koppel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Nafeesa Saadi
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Debra Potak
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Barry Weinberger
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Queens, NY, USA
| | - Theodoros P Zanos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| |
Collapse
|
10
|
Hildenborg M, Kåhlin J, Granath F, Schening A, Granström A, Ebberyd A, Klevenvall L, Zetterberg H, Han J, Schlegel TT, Harris R, Harris HE, Eriksson LI. The Neuroimmune Response to Surgery – An Exploratory Study of Trauma-Induced Changes in Innate Immunity and Heart Rate Variability. Front Immunol 2022; 13:911744. [PMID: 35874666 PMCID: PMC9301672 DOI: 10.3389/fimmu.2022.911744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Surgery triggers a systemic inflammatory response that ultimately impacts the brain and associates with long-term cognitive impairment. Adequate regulation of this immune surge is pivotal for a successful surgical recovery. We explored the temporal immune response in a surgical cohort and its associations with neuroimmune regulatory pathways and cognition, in keeping with the growing body of evidence pointing towards the brain as a regulator of peripheral inflammation. Brain-to-immune communication acts through cellular, humoral and neural pathways. In this context, the vagal nerve and the cholinergic anti-inflammatory pathway (CAP) have been shown to modify peripheral immune cell activity in both acute and chronic inflammatory conditions. However, the relevance of neuroimmune regulatory mechanisms following a surgical trauma is not yet elucidated. Twenty-five male patients undergoing elective laparoscopic abdominal surgery were included in this observational prospective study. Serial blood samples with extensive immune characterization, assessments of heart rate variability (HRV) and cognitive tests were performed before surgery and continuing up to 6 months post-surgery. Temporal immune responses revealed biphasic reaction patterns with most pronounced changes at 5 hours after skin incision and 14 days following surgery. Estimations of cardiac vagal nerve activity through HRV recordings revealed great individual variations depending on the pre-operative HRV baseline. A principal component analysis displayed distinct differences in systemic inflammatory biomarker trajectories primarily based on pre-operative HRV, with potiential consequences for long-term surgical outcomes. In conclusion, individual pre-operative HRV generates differential response patterns that associate with distinct inflammatory trajectories following surgery. Long-term surgical outcomes need to be examined further in larger studies with mixed gender cohorts.
Collapse
Affiliation(s)
- Malin Hildenborg
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- *Correspondence: Malin Hildenborg,
| | - Jessica Kåhlin
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Granath
- Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Department for Medicine Solna, Karolinska Institutet, Stockhlom, Sweden
| | - Anna Schening
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Granström
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Anette Ebberyd
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lena Klevenvall
- Rheumatology Unit, Center for Molecular Medicine, Department for Medicine Solna, Karolinska Institutet, Stockhlom, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital of Gothenburg, Mölndal, Sweden
- Department of Molecular Neuroscience, University College London Institute of Neurology, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong SAR, China
| | - Jinming Han
- Department of Clinical Neuroscience, Karolinska Institutet, Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Todd T. Schlegel
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Nicollier-Schlegel SARL, Trélex, Switzerland
| | - Robert Harris
- Department of Clinical Neuroscience, Karolinska Institutet, Centre for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Erlandsson Harris
- Rheumatology Unit, Center for Molecular Medicine, Department for Medicine Solna, Karolinska Institutet, Stockhlom, Sweden
| | - Lars I. Eriksson
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
11
|
The Association between Inflammatory Biomarkers and Cardiovascular Autonomic Dysfunction after Bacterial Infection. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12073484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Heart rate variability (HRV) is a known measure of cardiac autonomic function. A cardiovascular autonomic dysfunction (CAD), measured as changes in HRV, is usually presented after an infectious process. The aim of the present study is to assess the association between serum inflammatory markers and CAD. For this purpose, 50 volunteers (13 of them recovering from an infection) were recruited and followed-up for 6 weeks. Their serum inflammatory biomarkers (CRP, IL1, IL4, IL6, IL10, and TNFalpha) were quantified throughout those weeks, along with their HRV resting, in response to the Valsalva maneuver, metronome breathing, standing and sustained handgrip. The correlation of within-subject changes in both HRV and inflammatory biomarkers was assessed to evaluate the concurrent changes. An inverse within-subject correlation was found between CRP and HRV in response to the Valsalva maneuver (rho (95% CI): −0.517 (−0.877 to −0.001); p = 0.032) and HRV standing (rho (95% CI): −0.490 (−0.943 to −0.036); p = 0.034). At the beginning, increased values of CRP are found along with reduced levels of HRV. Then, the CRP was reduced, accompanied by an improvement (increase) in HRV. These results suggest that CRP is a potential marker of CAD. Whether it is the cause, the consequence or a risk indicator non-causally associated is still to be determined.
Collapse
|
12
|
Nakashima R, Inagaki N, Kasaoka S. Exploration of autonomic regulation reflecting on pathophysiological change of sepsis: a prospective observational study. Acute Med Surg 2022; 9:e776. [PMID: 35949315 PMCID: PMC9353857 DOI: 10.1002/ams2.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/19/2022] [Indexed: 11/12/2022] Open
Abstract
Aim It remains unclear how autonomic regulation modulates pathophysiological changes of sepsis. This study aims to analyze and clarify those in patients with suspected sepsis. Methods In this single‐centered, prospective, observational study, adult patients who had an infection, a quick Sequential Organ Failure Assessment score of 2 or more at the emergency department, and underwent intensive care were screened. Heart rate variability (HRV) and serum adrenaline were measured immediately after arrival. The primary outcome was defined as vasopressor dependence during 48 h after arrival. Results A total of 63 patients were included. All the patients had SOFA score of 2 or more on admission. Vasopressor dependence, renal replacement therapy, and in‐hospital mortality were associated with higher adrenaline (which reflects sympathetic adrenergic system activity). Bacteremia was associated with lower high‐frequency components of HRV (parasympathetic nerve activity). The HRV parameter of sympathetic nerve activity had no significant association with the outcomes. In the multivariate logistic regression model adjusted for age and sex, vasopressor dependence remained associated with higher adrenaline (cut‐off 0.11 ng/mL, odds ratio 9.71, 95% confidence interval 2.55–37; P = 0.000874), and lower high‐frequency components with bacteremia (17.2 ms2, odds ratio 4.86, 95% confidence interval 1.36–17.4; P = 0.0152). There were no significant correlations between parameters of HRV and serum adrenaline. Conclusion Hypoperfusion, organ dysfunction, and in‐hospital mortality were associated with an increased sympathetic adrenergic activity. Bacteremia was associated with decreased parasympathetic nerve activity. The autonomic regulator may involve a multilayered and differentiated modulating process for sepsis.
Collapse
Affiliation(s)
- Ryuta Nakashima
- Graduate School of Medical Sciences Kumamoto University Kumamoto City Kumamoto Japan
- Department of Emergency and Intensive Care Medicine Oita City Medical Association's Almeida Memorial Hospital Oita City Oita Japan
- Department of Emergency Medicine Oita Prefecture Saiseikai Hita Hospital Hita City Oita Japan
| | - Nobuhiro Inagaki
- Department of Emergency and Intensive Care Medicine Oita City Medical Association's Almeida Memorial Hospital Oita City Oita Japan
| | - Shunji Kasaoka
- Disaster Medical Education and Research Center Kumamoto University Hospital Kumamoto City Kumamoto Japan
| |
Collapse
|
13
|
Liu N, Chee ML, Foo MZQ, Pong JZ, Guo D, Koh ZX, Ho AFW, Niu C, Chong SL, Ong MEH. Heart rate n-variability (HRnV) measures for prediction of mortality in sepsis patients presenting at the emergency department. PLoS One 2021; 16:e0249868. [PMID: 34460853 PMCID: PMC8405012 DOI: 10.1371/journal.pone.0249868] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
Sepsis is a potentially life-threatening condition that requires prompt recognition and treatment. Recently, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality. This paper presents using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and comparing against current mortality prediction scores. This study was a retrospective cohort study on patients presenting to the emergency department of a tertiary hospital in Singapore between September 2014 to April 2017. Patients were included if they were above 21 years old and were suspected of having sepsis by their attending physician. The primary outcome was 30-day in-hospital mortality. Stepwise multivariable logistic regression model was built to predict the outcome, and the results based on 10-fold cross-validation were presented using receiver operating curve analysis. The final predictive model comprised 21 variables, including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve of the model was 0.77 (95% confidence interval 0.70–0.84), outperforming several established clinical scores. The HRnV measures may have the potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality. Our exploration of the use of wealthy inherent information obtained from novel HRnV measures could also create a new perspective for data scientists to develop innovative approaches for ECG analysis and risk monitoring.
Collapse
Affiliation(s)
- Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- Institute of Data Science, National University of Singapore, Singapore, Singapore
- * E-mail:
| | - Marcel Lucas Chee
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Mabel Zhi Qi Foo
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Zhenwen Pong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Dagang Guo
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore
| | - Zhi Xiong Koh
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Chenglin Niu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Children’s Emergency, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
14
|
Sabir L, Ramlakhan S, Goodacre S. Comparison of qSOFA and Hospital Early Warning Scores for prognosis in suspected sepsis in emergency department patients: a systematic review. Emerg Med J 2021; 39:284-294. [PMID: 34404680 DOI: 10.1136/emermed-2020-210416] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis is a major cause of morbidity and mortality and many tools exist to facilitate early recognition. This review compares two tools: the quick Sequential Organ Failure Assessment (qSOFA) and Early Warning Scores (National/Modified Early Warning Scores (NEWS/MEWS)) for predicting intensive care unit (ICU) admission and mortality when applied in the emergency department. METHODS A literature search was conducted using Medline, CINAHL, Embase and Cochrane Library, handsearching of references and a grey literature search with no language or date restrictions. Two authors selected studies and quality assessment completed using QUADAS-2. Area under the receiver operating characteristic curve (AUROC), sensitivities and specificities were compared. RESULTS 13 studies were included, totalling 403 865 patients. All reported mortality and six reported ICU admission.The ranges for AUROC estimates varied from little better than chance to good prediction of mortality (NEWS: 0.59-0.88; qSOFA: 0.57-0.79; MEWS 0.56-0.75), however, individual papers generally reported higher AUROC values for NEWS than qSOFA. NEWS values demonstrated a tendency towards better sensitivity for ICU admission (NEWS ≥5, 46%-91%; qSOFA ≥2, 12%-53%) and mortality (NEWS ≥5, 51%-97%; qSOFA ≥2, 14%-71%) but lower specificity (ICU: NEWS ≥5, 25%-91%; qSOFA ≥2, 67%-99%; mortality: NEWS ≥5, 22%-91%; qSOFA ≥2, 58%-99%). CONCLUSION The wide range of AUROC estimates and high heterogeneity limit our conclusions. Allowing for this, the NEWS AUROC was consistently higher than qSOFA within individual papers. Both scores allow threshold setting, determined by the preferred compromise between sensitivity and specificity. At established thresholds NEWS tended to higher sensitivity while qSOFA tended to a higher specificity. PROSPERO REGISTRATION NUMBER CRD42019131414.
Collapse
Affiliation(s)
- Lisa Sabir
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Shammi Ramlakhan
- Emergency Department, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| |
Collapse
|
15
|
Beneyto-Ripoll C, Palazón-Bru A, Llópez-Espinós P, Martínez-Díaz AM, Gil-Guillén VF, de Los Ángeles Carbonell-Torregrosa M. A critical appraisal of the prognostic predictive models for patients with sepsis: Which model can be applied in clinical practice? Int J Clin Pract 2021; 75:e14044. [PMID: 33492724 DOI: 10.1111/ijcp.14044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Sepsis is associated with high mortality and predictive models can help in clinical decision-making. The objective of this study was to carry out a systematic review of these models. METHODS In 2019, we conducted a systematic review in MEDLINE and EMBASE (CDR42018111121:PROSPERO) of articles that developed predictive models for mortality in septic patients (inclusion criteria). We followed the CHARMS recommendations (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies), extracting the information from its 11 domains (Source of data, Participants, etc). We determined the risk of bias and applicability (participants, outcome, predictors and analysis) through PROBAST (Prediction model Risk Of Bias ASsessment Tool). RESULTS A total of 14 studies were included. In the CHARMS extraction, the models found showed great variability in its 11 domains. Regarding the PROBAST checklist, only one article had an unclear risk of bias as it did not indicate how missing data were handled while the others all had a high risk of bias. This was mainly due to the statistical analysis (inadequate sample size, handling of continuous predictors, missing data and selection of predictors), since 13 studies had a high risk of bias. Applicability was satisfactory in six articles. Most of the models integrate predictors from routine clinical practice. Discrimination and calibration were assessed for almost all the models, with the area under the ROC curve ranging from 0.59 to 0.955 and no lack of calibration. Only three models were externally validated and their maximum discrimination values in the derivation were from 0.712 and 0.84. One of them (Osborn) had undergone multiple validation studies. DISCUSSION Despite most of the studies showing a high risk of bias, we very cautiously recommend applying the Osborn model, as this has been externally validated various times.
Collapse
Affiliation(s)
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Alicante, Spain
| | | | | | | | - María de Los Ángeles Carbonell-Torregrosa
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Alicante, Spain
- Emergency Services, General University Hospital of Elda, Elda, Alicante, Spain
| |
Collapse
|
16
|
Chong SL, Ong GYK, Allen JC, Lee JH, Piragasam R, Koh GZX, Mahajan P, Liu N, Ong MEH. Early prediction of serious infections in febrile infants incorporating heart rate variability in an emergency department: a pilot study. Emerg Med J 2021; 38:607-612. [PMID: 33863774 DOI: 10.1136/emermed-2020-210675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early differentiation of febrile young infants with from those without serious infections (SIs) remains a diagnostic challenge. We sought to (1) compare vital signs and heart rate variability (HRV) parameters between febrile infants with versus without SIs, (2) assess the performance of HRV and vital signs with reference to current triage tools and (3) compare HRV and vital signs to HRV, vital signs and blood biomarkers, when predicting for the presence of SIs. METHODS Using a prospective observational design, we recruited patients <3 months old presenting to a tertiary paediatric ED in Singapore from December 2018 through November 2019. We obtained patient demographic characteristics, triage assessment (including the Severity Index Score (SIS)), HRV parameters (time, frequency and non-linear domains) and laboratory results. We performed multivariable logistic regression analyses to predict the presence of an SI, using area under the curve (AUC) with the corresponding 95% CI to assess predictive capability. RESULTS Among 203 infants with a mean age of 38.4 days (SD 27.6), 67 infants (33.0%) had an SI. There were significant differences in the time, frequency and non-linear domains of HRV parameters between infants with versus without SIs. In predicting SIs, gender, temperature and the HRV non-linear parameter Poincaré plot SD2 (AUC 0.78, 95% CI 0.71 to 0.84) performed better than SIS alone (AUC 0.61, 95% CI 0.53 to 0.68). Model performance improved with the addition of absolute neutrophil count and C reactive protein (AUC 0.82, 95% CI 0.76 to 0.89). CONCLUSION An exploratory prediction model incorporating HRV and biomarkers improved prediction of SIs. Further research is needed to assess if HRV can identify which young febrile infants have an SI at ED triage. TRIAL REGISTRATION NUMBER NCT04103151.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | | | - Prashant Mahajan
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nan Liu
- Centre for Quantitative Medicine and Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
| |
Collapse
|
17
|
Shiraishi A, Gando S, Abe T, Kushimoto S, Mayumi T, Fujishima S, Hagiwara A, Shiino Y, Shiraishi SI, Hifumi T, Otomo Y, Okamoto K, Sasaki J, Takuma K, Yamakawa K, Hanaki Y, Harada M, Morino K. Quick sequential organ failure assessment versus systemic inflammatory response syndrome criteria for emergency department patients with suspected infection. Sci Rep 2021; 11:5347. [PMID: 33674716 PMCID: PMC7935946 DOI: 10.1038/s41598-021-84743-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 02/17/2021] [Indexed: 12/26/2022] Open
Abstract
Previous studies have shown inconsistent prognostic accuracy for mortality with both quick sequential organ failure assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria. We aimed to validate the accuracy of qSOFA and the SIRS criteria for predicting in-hospital mortality in patients with suspected infection in the emergency department. A prospective study was conducted including participants with suspected infection who were hospitalised or died in 34 emergency departments in Japan. Prognostic accuracy of qSOFA and SIRS criteria for in-hospital mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Of the 1060 participants, 402 (37.9%) and 915 (86.3%) had qSOFA ≥ 2 and SIRS criteria ≥ 2 (given thresholds), respectively, and there were 157 (14.8%) in-hospital deaths. Greater accuracy for in-hospital mortality was shown with qSOFA than with the SIRS criteria (AUROC: 0.64 versus 0.52, difference + 0.13, 95% CI [+ 0.07, + 0.18]). Sensitivity and specificity for predicting in-hospital mortality at the given thresholds were 0.55 and 0.65 based on qSOFA and 0.88 and 0.14 based on SIRS criteria, respectively. To predict in-hospital mortality in patients visiting to the emergency department with suspected infection, qSOFA was demonstrated to be modestly more accurate than the SIRS criteria albeit insufficiently sensitive.Clinical Trial Registration: The study was pre-registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000027258).
Collapse
Affiliation(s)
- Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929, Higashicho, Kamogawa, Chiba, 296-8602, Japan.
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yoshihiro Hanaki
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Masahiro Harada
- Department of Emergency and Critical Care, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Kazuma Morino
- Medical Center for Emergency, Yamagata Prefectural Central Hospital, Yamagata, Japan
| |
Collapse
|
18
|
Seely AJE. Optimizing Our Patients' Entropy Production as Therapy? Hypotheses Originating from the Physics of Physiology. ENTROPY 2020; 22:e22101095. [PMID: 33286863 PMCID: PMC7597192 DOI: 10.3390/e22101095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 02/01/2023]
Abstract
Understanding how nature drives entropy production offers novel insights regarding patient care. Whilst energy is always preserved and energy gradients irreversibly dissipate (thus producing entropy), increasing evidence suggests that they do so in the most optimal means possible. For living complex non-equilibrium systems to create a healthy internal emergent order, they must continuously produce entropy over time. The Maximum Entropy Production Principle (MEPP) highlights nature's drive for non-equilibrium systems to augment their entropy production if possible. This physical drive is hypothesized to be responsible for the spontaneous formation of fractal structures in space (e.g., multi-scale self-similar tree-like vascular structures that optimize delivery to and clearance from an organ system) and time (e.g., complex heart and respiratory rate variability); both are ubiquitous and essential for physiology and health. Second, human entropy production, measured by heat production divided by temperature, is hypothesized to relate to both metabolism and consciousness, dissipating oxidative energy gradients and reducing information into meaning and memory, respectively. Third, both MEPP and natural selection are hypothesized to drive enhanced functioning and adaptability, selecting states with robust basilar entropy production, as well as the capacity to enhance entropy production in response to exercise, heat stress, and illness. Finally, a targeted focus on optimizing our patients' entropy production has the potential to improve health and clinical outcomes. With the implications of developing a novel understanding of health, illness, and treatment strategies, further exploration of this uncharted ground will offer value.
Collapse
Affiliation(s)
- Andrew J. E. Seely
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada;
- Ottawa Hospital Research Institute, University of Ottawa, ON K1Y 4E9, Canada
- Thoracic Surgery and Critical Care Medicine, University of Ottawa, ON K1H 8L6, Canada
| |
Collapse
|
19
|
Abstract
Adaption to changes of external environment or internal health, the body-mind connection, or autonomic nervous system must be flexible and healthy. Population health studies with wearable technology and remote monitoring will lead to paradigm shifts in how to approach the physiology of emotion. Heart rate variability as a whole health biomarker could emerge as a foundation for a process beginning with objective habits and skills of real-time modulation with focused breathing for healthier decision making and autonomic health trajectory change. Physical medicine and rehabilitation is uniquely poised to refine an autonomic rehabilitation process in an integrative manner to help individuals adapt.
Collapse
Affiliation(s)
- Raouf S Gharbo
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 109 Elizabeth Meriwether, Williamsburg, VA 23185, USA.
| |
Collapse
|
20
|
Neurotransmitter system aberrations in patients with drug addiction. J Neural Transm (Vienna) 2020; 127:1641-1650. [PMID: 32804296 DOI: 10.1007/s00702-020-02242-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 08/10/2020] [Indexed: 12/13/2022]
Abstract
Drug dependence may affect the neurotransmitter system levels in the human body. This study recruited 113 healthy control subjects, 118 heroin-dependent patients and 118 methamphetamine-dependent patients and examined the serum 5-HT, dopamine, glutamate and norepinephrine levels in the 349 volunteers. ELISA assays demonstrated that the serum 5-HT levels were significantly reduced in the drug-dependent patients, whereas the serum dopamine and glutamate levels were both significantly increased in the drug-dependent patients when compared with control subjects. In contrast, the norepinephrine levels did not exhibit a significant difference between the drug-dependent and control subjects. We also used qRT-PCR to analyze the transcriptional expression levels of 5-HT1A, 5-HT1B, dopmaine-D1 and dopamine-D2 receptors in the blood of drug-dependent patients and controls, and the results show that only 5-HT1B receptor levels were dysfunctional in the heroin abusers. In addition, our results suggest that serum 5-HT, dopamine, and glutamate levels had the potential to differ between drug abusers and controls, and combining those three potential biomarkers provided an accurate means to differentiate between the drug-dependent and control subjects. Taken together, our study reveals a differential profile of neurotransmitters in the heroin-dependent patients and methamphetamine-dependent patients, and this revelation may contribute to understanding the pathophysiology of drug addiction.
Collapse
|
21
|
Wee BYH, Lee JH, Mok YH, Chong SL. A narrative review of heart rate and variability in sepsis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:768. [PMID: 32647693 PMCID: PMC7333166 DOI: 10.21037/atm-20-148] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Clinicians face challenges in the timely diagnosis and management of pediatric sepsis. Pediatric heart rate has been incorporated into early warning systems and studied as a predictor for critical illness. We aim to review: (I) the role of heart rate in pediatric warning systems and (II) the role of heart rate variability (HRV) in adult and neonatal sepsis, with a focus on its potential applications in pediatrics. We conducted a literature search for papers published up to December 2019 on the utility of heart rate and HRV analysis in the diagnosis and management of sepsis, using four medical databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical utility of pediatric heart rate in predicting clinical deterioration is limited by the lack of consensus among warning systems, consensus-based guidelines, and evidence-based studies as to what constitutes abnormal heart rate in the pediatric age group. Current studies demonstrate that abnormal heart rate itself does not adequately discriminate children with sepsis from those without. HRV analysis provides a quick and non-invasive method of assessment and can provide more information than traditional heart rate. HRV analysis has the potential to add value in identification and prognostication of adult and neonatal sepsis. With further studies to explore its role, HRV analysis has the potential to add to current tools in the diagnosis and prognosis of pediatric sepsis.
Collapse
Affiliation(s)
- Benjamin Yi Hao Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
22
|
Johnston BW, Barrett-Jolley R, Krige A, Welters ID. Heart rate variability: Measurement and emerging use in critical care medicine. J Intensive Care Soc 2020; 21:148-157. [PMID: 32489411 PMCID: PMC7238479 DOI: 10.1177/1751143719853744] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Variation in the time interval between consecutive R wave peaks of the QRS complex has long been recognised. Measurement of this RR interval is used to derive heart rate variability. Heart rate variability is thought to reflect modulation of automaticity of the sinus node by the sympathetic and parasympathetic components of the autonomic nervous system. The clinical application of heart rate variability in determining prognosis post myocardial infarction and the risk of sudden cardiac death is well recognised. More recently, analysis of heart rate variability has found utility in predicting foetal deterioration, deterioration due to sepsis and impending multiorgan dysfunction syndrome in critically unwell adults. Moreover, reductions in heart rate variability have been associated with increased mortality in patients admitted to the intensive care unit. It is hypothesised that heart rate variability reflects and quantifies the neural regulation of organ systems such as the cardiovascular and respiratory systems. In disease states, it is thought that there is an 'uncoupling' of organ systems, leading to alterations in 'inter-organ communication' and a clinically detectable reduction in heart rate variability. Despite the increasing evidence of the utility of measuring heart rate variability, there remains debate as to the methodology that best represents clinically relevant outcomes. With continuing advances in technology, our understanding of the physiology responsible for heart rate variability evolves. In this article, we review the current understanding of the physiological basis of heart rate variability and the methods available for its measurement. Finally, we review the emerging use of heart rate variability analysis in intensive care medicine and conditions in which heart rate variability has shown promise as a potential physiomarker of disease.
Collapse
Affiliation(s)
- Brian W Johnston
- University of Liverpool and The Royal Liverpool University Hospital, Liverpool Healthcare Partners, Liverpool, UK
| | - Richard Barrett-Jolley
- University of Liverpool and The Royal Liverpool University Hospital, Liverpool Healthcare Partners, Liverpool, UK
| | - Anton Krige
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Ingeborg D Welters
- University of Liverpool and The Royal Liverpool University Hospital, Liverpool Healthcare Partners, Liverpool, UK
| |
Collapse
|
23
|
Chiew CJ, Wang H, Ong MEH, Wong TH, Koh ZX, Liu N, Feng M. Serial Heart Rate Variability Measures for Risk Prediction of Septic Patients in the Emergency Department. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2020; 2019:285-294. [PMID: 32308821 PMCID: PMC7153136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In this study, we used serial heart rate variability (HRV) measures over 2 hours to improve the prediction of 30-day in-hospital mortality among septic patients in the emergency department (ED). We presented a generalizable methodology for processing and analysing HRV time series (HRVTS) data which may be noisy and incomplete. Feature sets were created from the HRVTS data of 162 patients with suspected sepsis using aggregation-based, deltabased and regression-based series-to-point transformations, and modelled over 100 random stratified splits. An optimized feature set comprising 12 selected HRVTS features performed better than baseline feature sets which only included patient demographics, vital signs and single time-point HRV measures taken at triage. This improved risk stratification approach could be used in the ED to identify high-risk septic patients for appropriate management and disposition.
Collapse
Affiliation(s)
- Calvin J Chiew
- Preventive Medicine Residency Program, National University Health System, Singapore
| | - Han Wang
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore
| | - Marcus E H Ong
- Health Services Research Centre, Singapore Health Services, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Nan Liu
- Health Services Research Centre, Singapore Health Services, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Mengling Feng
- Saw Swee Hock School of Public Health, National University Health System, National University of Singapore, Singapore
| |
Collapse
|
24
|
Kenig A, Ilan Y. A Personalized Signature and Chronotherapy-Based Platform for Improving the Efficacy of Sepsis Treatment. Front Physiol 2019; 10:1542. [PMID: 31920730 PMCID: PMC6930923 DOI: 10.3389/fphys.2019.01542] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/05/2019] [Indexed: 12/27/2022] Open
Abstract
Sepsis remains a major therapeutic challenge and is associated with a high rate of morbidity and mortality. It is a dynamic condition in which multiple parameters change over time, rendering it difficult to overcome the various injurious responses, which worsen the prognosis in these patients. The prognosis of sepsis is associated with a disbalance of compensatory responses to infectious triggers, part of which can be deleterious. Marked inter- and intra-patient variability characterizes the mechanisms that underlie sepsis progression and determine the response to therapy. In this paper, we review some of the data on the use of chronopharmacological approaches for the treatment of patients with sepsis and discuss the role of the autonomic nervous system in the mechanisms associated with immune response and chronotherapy in these patients. We describe the implementation of an individualized platform that is based on the personalized autonomic nervous system, immune, and chronobiology-derived parameters for generating a patient-tailored therapeutic regimen. The notion of overcoming the deleterious compensatory response in a highly dynamic system in sepsis is presented to ensure an improved response to current therapies.
Collapse
Affiliation(s)
- Ariel Kenig
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yaron Ilan
- Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
25
|
Jarczok MN, Koenig J, Wittling A, Fischer JE, Thayer JF. First Evaluation of an Index of Low Vagally-Mediated Heart Rate Variability as a Marker of Health Risks in Human Adults: Proof of Concept. J Clin Med 2019; 8:jcm8111940. [PMID: 31717972 PMCID: PMC6912519 DOI: 10.3390/jcm8111940] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
Multiple studies have demonstrated low vagally-mediated heart rate variability (HRV) being associated with a range of risk factors for heart disease and stroke, including inflammation, hyperglycemia, hyperlipidemia, and hypertension. Yet, no cut point exists that indicates elevated risk. In the present study we sought to identify a cut point-value for HRV that is associated with elevated risk across a range of known risk factors. Methods: A total of 9550 working adults from 19 study sites took part in a health assessment that included measures of inflammation, hyperglycemia, hyperlipidemia, and hypertension and vagally-mediated HRV (Root mean square of successive differences between normal heartbeats (RMSSD)). Multiple age and sex adjusted logistic regressions were calculated per risk factor (normal versus clinical range), with RMSSD being entered in binary at different cut points ranging from 15–39 msec with a 2 msec increment. Results: For daytime RMSSD, values below 25 ± 4 indicated elevated risk (odds ratios (OR) 1.5–3.5 across risk factors). For nighttime RMSSD, values below 29 ± 4 indicated elevated risk (OR 1.2–2.0). Conclusion: These results provide the first evidence that a single value of RMSSD may be associated with elevated risk across a range of established cardiovascular risk factors and may present an easy to assess novel marker of cardiovascular risk.
Collapse
Affiliation(s)
- Marc N. Jarczok
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, 89081 Ulm, Germany
- Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, Heidelberg University, 68167 Mannheim, Germany;
- Correspondence:
| | - Julian Koenig
- Section for Translational Psychobiology in Child and Adolescent Psychiatry, Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, 69115 Heidelberg, Germany;
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, CH-3000 Bern, Switzerland
| | - Arne Wittling
- Center for Neuroscience Research NPO, 54296 Trier, Germany;
| | - Joachim E. Fischer
- Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, Heidelberg University, 68167 Mannheim, Germany;
| | - Julian F. Thayer
- Department of Psychological Science, The University of California, Irvine, Irvine, CA 92697-7085, USA;
| |
Collapse
|
26
|
Pong JZ, Koh ZX, Samsudin MI, Fook-Chong S, Liu N, Ong MEH. Validation of the mortality in emergency department sepsis (MEDS) score in a Singaporean cohort. Medicine (Baltimore) 2019; 98:e16962. [PMID: 31441900 PMCID: PMC6716723 DOI: 10.1097/md.0000000000016962] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The emergency department (ED) serves as the first point of hospital contact for most septic patients. Early mortality risk stratification using a quick and accurate triage tool would have great value in guiding management. The mortality in emergency department sepsis (MEDS) score was developed to risk stratify patients presenting to the ED with suspected sepsis, and its performance in the literature has been promising. We report in this study the first utilization of the MEDS score in a Singaporean cohort.In this retrospective observational cohort study, adult patients presenting to the ED with suspected sepsis and fulfilling systemic inflammatory response syndrome (SIRS) criteria were recruited. Primary outcome was 30-day in-hospital mortality (IHM) and secondary outcome was 72-hour mortality. MEDS, acute physiology and chronic health evaluation II (APACHE II), and sequential organ failure assessment (SOFA) scores were compared for prediction of primary and secondary outcomes. Receiver operating characteristic (ROC) analysis was conducted to compare predictive performance.Of the 249 patients included in the study, 46 patients (18.5%) met 30-day IHM. MEDS score achieved an area under the ROC curve (AUC) of 0.87 (95% confidence interval [CI], 0.82-0.93), outperforming the APACHE II score (0.77, 95% CI 0.69-0.85) and SOFA score (0.78, 95% CI 0.71-0.85). On secondary analysis, MEDS score was superior to both APACHE II and SOFA scores in predicting 72-hour mortality, with AUC of 0.88 (95% CI 0.82-0.95), 0.81 (95% CI 0.72-0.89), and 0.79 (95% CI 0.71-0.87), respectively. In predicting 30-day IHM, MEDS score ≥12, APACHE II score ≥23, and SOFA score ≥5 performed at sensitivities of 76.1%, 67.4%, and 76.1%, and specificities of 83.3%, 73.9%, and 65.0%, respectively.The MEDS score performed well in its ability for mortality risk stratification in a Singaporean ED cohort.
Collapse
Affiliation(s)
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital
| | | | | | - Nan Liu
- Duke-NUS Medical School, National University of Singapore
- Health Services Research Centre, Singapore Health Services
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore
- Department of Emergency Medicine, Singapore General Hospital
| |
Collapse
|
27
|
Pong JZ, Fook-Chong S, Koh ZX, Samsudin MI, Tagami T, Chiew CJ, Wong TH, Ho AFW, Ong MEH, Liu N. Combining Heart Rate Variability with Disease Severity Score Variables for Mortality Risk Stratification in Septic Patients Presenting at the Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16101725. [PMID: 31100830 PMCID: PMC6571945 DOI: 10.3390/ijerph16101725] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 12/29/2022]
Abstract
The emergency department (ED) serves as the first point of hospital contact for many septic patients, where risk-stratification would be invaluable. We devised a combination model incorporating demographic, clinical, and heart rate variability (HRV) parameters, alongside individual variables of the Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II), and Mortality in Emergency Department Sepsis (MEDS) scores for mortality risk-stratification. ED patients fulfilling systemic inflammatory response syndrome criteria were recruited. National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), quick SOFA (qSOFA), SOFA, APACHE II, and MEDS scores were calculated. For the prediction of 30-day in-hospital mortality, combination model performed with an area under the receiver operating characteristic curve of 0.91 (95% confidence interval (CI): 0.88–0.95), outperforming NEWS (0.70, 95% CI: 0.63–0.77), MEWS (0.61, 95% CI 0.53–0.69), qSOFA (0.70, 95% CI 0.63–0.77), SOFA (0.74, 95% CI: 0.67–0.80), APACHE II (0.76, 95% CI: 0.69–0.82), and MEDS scores (0.86, 95% CI: 0.81–0.90). The combination model had an optimal sensitivity and specificity of 91.4% (95% CI: 81.6–96.5%) and 77.9% (95% CI: 72.6–82.4%), respectively. A combination model incorporating clinical, HRV, and disease severity score variables showed superior predictive ability for the mortality risk-stratification of septic patients presenting at the ED.
Collapse
Affiliation(s)
- Jeremy Zhenwen Pong
- Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore.
| | - Stephanie Fook-Chong
- Health Services Research Unit, Singapore General Hospital, Singapore 169608, Singapore.
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore.
| | | | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo 206-8512, Japan.
| | - Calvin J Chiew
- Preventive Medicine Residency Program, National University Health System, Singapore 119228, Singapore.
| | - Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Singapore 169608, Singapore.
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore.
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore.
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore.
| | - Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore.
- Health Services Research Centre, Singapore Health Services, Singapore 169856, Singapore.
| |
Collapse
|
28
|
Prabhakar SM, Tagami T, Liu N, Samsudin MI, Ng JCJ, Koh ZX, Ong MEH. Combining quick sequential organ failure assessment score with heart rate variability may improve predictive ability for mortality in septic patients at the emergency department. PLoS One 2019; 14:e0213445. [PMID: 30883595 PMCID: PMC6422271 DOI: 10.1371/journal.pone.0213445] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 02/21/2019] [Indexed: 12/22/2022] Open
Abstract
Background Although the quick Sequential Organ Failure Assessment (qSOFA) score was recently introduced to identify patients with suspected infection/sepsis, it has limitations as a predictive tool for adverse outcomes. We hypothesized that combining qSOFA score with heart rate variability (HRV) variables improves predictive ability for mortality in septic patients at the emergency department (ED). Methods This was a retrospective study using the electronic medical record of a tertiary care hospital in Singapore between September 2014 and February 2017. All patients aged 21 years or older who were suspected with infection/sepsis in the ED and received electrocardiography monitoring with ZOLL X Series Monitor (ZOLL Medical Corporation, Chelmsford, MA) were included. We fitted a logistic regression model to predict the 30-day mortality using one of the HRV variables selected from one of each three domains those previously reported as strong association with mortality (i.e. standard deviation of NN [SDNN], ratio of low frequency to high frequency power [LF/HF], detrended fluctuation analysis α-2 [DFA α-2]) in addition to the qSOFA score. The predictive accuracy was assessed with other scoring systems (i.e. qSOFA alone, National Early Warning Score, and Modified Early Warning Score) using the area under the receiver operating characteristic curve. Results A total of 343 septic patients were included. Non-survivors were significantly older (survivors vs. non-survivors, 65.7 vs. 72.9, p <0.01) and had higher qSOFA (0.8 vs. 1.4, p <0.01) as compared to survivors. There were significant differences in HRV variables between survivors and non-survivors including SDNN (23.7s vs. 31.8s, p = 0.02), LF/HF (2.8 vs. 1.5, p = 0.02), DFA α-2 (1.0 vs. 0.7, P < 0.01). Our prediction model using DFA-α-2 had the highest c-statistic of 0.76 (95% CI, 0.70 to 0.82), followed by qSOFA of 0.68 (95% CI, 0.62 to 0.75), National Early Warning Score at 0.67 (95% CI, 0.61 to 0.74), and Modified Early Warning Score at 0.59 (95% CI, 0.53 to 0.67). Conclusions Adding DFA-α-2 to the qSOFA score may improve the accuracy of predicting in-hospital mortality in septic patients who present to the ED. Further multicenter prospective studies are required to confirm our results.
Collapse
Affiliation(s)
| | - Takashi Tagami
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
- * E-mail: (TT); (NL)
| | - Nan Liu
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- * E-mail: (TT); (NL)
| | | | - Janson Cheng Ji Ng
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
29
|
Chiew CJ, Liu N, Tagami T, Wong TH, Koh ZX, Ong MEH. Heart rate variability based machine learning models for risk prediction of suspected sepsis patients in the emergency department. Medicine (Baltimore) 2019; 98:e14197. [PMID: 30732136 PMCID: PMC6380871 DOI: 10.1097/md.0000000000014197] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Early identification of high-risk septic patients in the emergency department (ED) may guide appropriate management and disposition, thereby improving outcomes. We compared the performance of machine learning models against conventional risk stratification tools, namely the Quick Sequential Organ Failure Assessment (qSOFA), National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), and our previously described Singapore ED Sepsis (SEDS) model, in the prediction of 30-day in-hospital mortality (IHM) among suspected sepsis patients in the ED.Adult patients who presented to Singapore General Hospital (SGH) ED between September 2014 and April 2016, and who met ≥2 of the 4 Systemic Inflammatory Response Syndrome (SIRS) criteria were included. Patient demographics, vital signs and heart rate variability (HRV) measures obtained at triage were used as predictors. Baseline models were created using qSOFA, NEWS, MEWS, and SEDS scores. Candidate models were trained using k-nearest neighbors, random forest, adaptive boosting, gradient boosting and support vector machine. Models were evaluated on F1 score and area under the precision-recall curve (AUPRC).A total of 214 patients were included, of whom 40 (18.7%) met the outcome. Gradient boosting was the best model with a F1 score of 0.50 and AUPRC of 0.35, and performed better than all the baseline comparators (SEDS, F1 0.40, AUPRC 0.22; qSOFA, F1 0.32, AUPRC 0.21; NEWS, F1 0.38, AUPRC 0.28; MEWS, F1 0.30, AUPRC 0.25).A machine learning model can be used to improve prediction of 30-day IHM among suspected sepsis patients in the ED compared to traditional risk stratification tools.
Collapse
Affiliation(s)
- Calvin J. Chiew
- Health Services Research Unit, Division of Medicine, Singapore General Hospital
| | - Nan Liu
- Health Services Research Centre, Singapore Health Services
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Takashi Tagami
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Ting Hway Wong
- Health Services Research Unit, Division of Medicine, Singapore General Hospital
- Department of General Surgery, Singapore General Hospital
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Marcus E. H. Ong
- Health Services Research Centre, Singapore Health Services
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| |
Collapse
|