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Terhalle L, Arntz L, Hoffmann F, Arnold I, Hafner L, Picking-Pitasch L, Zuppinger J, Delport Lehnen K, Leuppi J, Somasundaram R, Nickel CH, Bingisser R. Nonspecific stress biomarkers for mortality prediction in older emergency department patients presenting with falls: a prospective multicenter observational study. Intern Emerg Med 2024:10.1007/s11739-024-03693-6. [PMID: 38960969 DOI: 10.1007/s11739-024-03693-6] [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] [Received: 01/17/2024] [Accepted: 06/21/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Older patients presenting to the emergency department (ED) after falling are increasingly prevalent. Falls are associated with functional decline and death. Biomarkers predicting short-term mortality might facilitate decisions regarding resource allocation and disposition. D-dimer levels are used to rule out thromboembolic disease, while copeptin and adrenomedullin (MR-proADM) may be used as measures of the patient`s stress level. These nonspecific biomarkers were selected as potential predictors for mortality. METHODS Prospective, international, multicenter, cross-sectional observation was performed in two tertiary and two regional hospitals in Germany and Switzerland. Patients aged 65 years or older presenting to the ED after a fall were enrolled. Demographic data, Activities of Daily Living (ADL), and D-dimers were collected upon presentation. Copeptin and MR-proADM levels were determined from frozen samples. Primary outcome was 30-day mortality; and secondary outcomes were mortality at 90, 180, and 365 days. RESULTS Five hundred and seventy-two patients were included. Median age was 83 [IQR 78, 89] years, 236 (67.7%) were female. Mortality overall was 3.1% (30 d), 5.4% (90 d), 7.5% (180 d), and 13.8% (365 d), respectively. Non-survivors were older, had a lower ADL index and higher levels of all three biomarkers. Elevated levels of MR-proADM and D-dimer were associated with higher risk of mortality. MR-proADM and D-dimer showed high sensitivity and low negative likelihood ratio regarding short-term mortality, whereas copeptin did not. CONCLUSION D-dimer and MR-proADM levels might be useful as prognostic markers in older patients presenting to the ED after a fall, by identifying patients at low risk of short-term mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02244983.
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Affiliation(s)
- Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Laura Arntz
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Hoffmann
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
- Emergency Department, Cantonal Hospital Basel-Landschaft, Liestal, Switzerland
| | - Karen Delport Lehnen
- Emergency Department, Cantonal Hospital Basel-Landschaft Campus Bruderholz, Binningen, Switzerland
| | - Jörg Leuppi
- Medical Faculty, University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Emergency Department, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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2
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Zhang W, Zhou H, Cen M, Ouyang W, Chen J, Xia L, Lin X, Liu J, He T, Xu F. N-myc and STAT interactor is a novel biomarker of severity in community-acquired pneumonia: a prospective study. Respir Res 2022; 23:253. [PMID: 36123652 PMCID: PMC9483521 DOI: 10.1186/s12931-022-02139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives To tested the ability of N-myc and STAT interactor (NMI) levels in patients with community-acquired pneumonia (CAP) to predict the severity of the disease. Methods Prospective observational analysis of patients with CAP was performed. The NMI levels in serum of 394 CAP patients on admission were measured by immunoassay. Thirty-day mortality and intensive care unit (ICU) admission were set as clinical outcomes. The predicting value of NMI for clinical outcomes was determined by receiver operating characteristic curve and logistic regression analysis. The internal validity was assessed using cross-validation with bootstrap resampling. Results NMI was an independent risk factor for both 30-day mortality and admission to ICU for CAP patients. The area under curve (AUC) of NMI to predict mortality was 0.91 (95% CI: 0.86–0.96), and that to predict ICU admission was 0.92 (95% CI: 0.88–0.97), significantly higher than that of other biomarkers including procalcitonin and C-reactive protein. The proportion of clinical outcomes notably rose as NMI levels elevated (P < 0.001). The AUCs of the new score systems including NMI (N-PSI and N-CURB65 score) to predict outcomes were significantly higher than the original score systems. Conclusions NMI is a novel biomarker for predicting CAP severity superior to former biomarkers in 30-day mortality and ICU admission. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02139-x.
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Affiliation(s)
- Wanying Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Hui Zhou
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Mengyuan Cen
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Wei Ouyang
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Jie Chen
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Lexin Xia
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Xiuhui Lin
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Jinliang Liu
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Teng He
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China
| | - Feng Xu
- Department of Infectious Diseases, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou, 310009, China.
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Laínez Martínez S, González Del Castillo J. Usefulness of monocyte distribution width (MDW) as a sepsis biomarker. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35 Suppl 1:2-5. [PMID: 35488816 PMCID: PMC9106205 DOI: 10.37201/req/s01.01.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Sepsis is one of the main causes of mortality in the emergency department (ED), due to the fact that signs and symptoms are common to other acute diseases, and this can result in delayed detection. This diagnostic complexity has a huge impact on an entity in which early recognition determined treatment, as wells as enhance the patient’s prognosis. Therefore, it is crucial to improve early identification. Different analytical tools arise from this approach, such as biomarkers: procalcitonin, C-reactive protein or MR-proadrenomedullin. In this review we will focus on a newer biomarker, the monocyte distribution width. The main objectives are to evaluate the usefulness of monocyte distribution width (MDW) in sepsis identification in ED, its limitations, and to compare it with other biomarkers.
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Affiliation(s)
| | - J González Del Castillo
- Juan González del Castillo, Servicio de Urgencias. Hospital Clínico San Carlos. Calle Profesor Martín-Lagos s/n, 28040 Madrid. Spain.
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4
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Wei J, Sun J, Zeng J, Ji E, Xu J, Tang C, Huo H, Zhang Y, Li H, Yang H. Precise Investigation of the Efficacy of Multicomponent Drugs Against Pneumonia Infected With Influenza Virus. Front Pharmacol 2021; 12:604009. [PMID: 34867309 PMCID: PMC8636456 DOI: 10.3389/fphar.2021.604009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/01/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Viral pneumonia is one of the most serious respiratory diseases, and multicomponent traditional Chinese medicines have been applied in the management of infected patients. As a representative TCM, HouYanQing (HYQ) oral liquid shows antiviral activity. However, the unclear mechanisms, as well as the ambiguous clinical effects, limit widespread application of this treatment. Therefore, in this study, a proteomics-based approach was utilized to precisely investigate its efficacy. Methods: Based on the efficacy evaluation of HYQ in a mouse model of pneumonia caused by influenza A virus (H1N1) and the subsequent proteomics analysis, specific signatures regulated by HYQ treatment of viral pneumonia were identified. Results: Experimental verifications indicate that HYQ may show distinctive effects in viral pneumonia patients, such as elevated galectin-3-binding protein and glutathione peroxidase 3 levels. Conclusion: This study provides a precise investigation of the efficacy of a multicomponent drug against viral pneumonia and offers a promising alternative for personalized management of viral pneumonia.
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Affiliation(s)
- Junying Wei
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianhui Sun
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jiawei Zeng
- Department of Clinical Laboratory, Mianyang Central Hospital, Mianyang, China
| | - Enhui Ji
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jing Xu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chunyu Tang
- Research Center of Anti-infection Chinese Medicine Engineering Technology, Yongzhou, China
| | - Hairu Huo
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yi Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hongmei Li
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hongjun Yang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
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5
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The Infections Causing Acute Respiratory Failure in Elderly Patients. VENTILATORY SUPPORT AND OXYGEN THERAPY IN ELDER, PALLIATIVE AND END-OF-LIFE CARE PATIENTS 2020. [PMCID: PMC7122443 DOI: 10.1007/978-3-030-26664-6_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The immune system of older individuals declines with advancing age (“immunosenescence”) increasing susceptibility to infection, as well as to an increased risk of a worse outcome. Severe community-acquired pneumonia and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are causes of acute respiratory failure (ARF) in elderly patients. Non-invasive mechanical ventilation (NIV) is effective in the treatment of patients with ARF, above all in case of AECOPD.
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de Carvalho FT, Rabello Filho R, Bulgarelli L, Serpa Neto A, Deliberato RO. Procalcitonin as a Diagnostic, Therapeutic, and Prognostic Tool: a Critical Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0178-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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7
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Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Schroeder S, Nobre V, Annane D, Reinhart K, Damas P, Nijsten M, Shajiei A, deLange DW, Deliberato RO, Oliveira CF, Shehabi Y, van Oers JAH, Beishuizen A, Girbes ARJ, de Jong E, Mueller B, Schuetz P. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018; 22:191. [PMID: 30111341 PMCID: PMC6092799 DOI: 10.1186/s13054-018-2125-7] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 07/10/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection. METHODS For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the "procalcitonin-guided" group) or the current standard of care (the "controls"). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay. RESULTS Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001). CONCLUSION Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.
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Affiliation(s)
- Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Marc A. Meier
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, AP-HP, Paris, France
| | - Charles E. Luyt
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, AP-HP, Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Florence Tubach
- Département d’Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Stefan Schroeder
- Department of Anesthesiology and Intensive Care Medicine, Krankenhaus Dueren, Dueren, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, Garches, France
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Liege, Belgium
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | - Arezoo Shajiei
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | | | - Rodrigo O. Deliberato
- Laboratory for Critical Care Research, Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Carolina F. Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Australia
- Faculty of Medicine Nursing and Health Sciences, School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | | | | | | | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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8
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Mylotte JM. Will Maintenance of Oral Hygiene in Nursing Home Residents Prevent Pneumonia? J Am Geriatr Soc 2017; 66:590-594. [DOI: 10.1111/jgs.15190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Joseph M. Mylotte
- Department of Medicine; Division of Infectious Diseases; School of Medicine and Biomedical Sciences; State University of New York at Buffalo; Buffalo New York
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9
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Athlin S, Lidman C, Lundqvist A, Naucler P, Nilsson AC, Spindler C, Strålin K, Hedlund J. Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017. Infect Dis (Lond) 2017; 50:247-272. [PMID: 29119848 DOI: 10.1080/23744235.2017.1399316] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.
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Affiliation(s)
- Simon Athlin
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b Faculty of Medicin and Health , Örebro University , Örebro , Sweden
| | - Christer Lidman
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anders Lundqvist
- e Department of Infectious Diseases , Södra Älvsborgs Hospital , Borås , Sweden
| | - Pontus Naucler
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anna C Nilsson
- f Infectious Disease Research Unit, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Carl Spindler
- d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Kristoffer Strålin
- b Faculty of Medicin and Health , Örebro University , Örebro , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,g Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Hedlund
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
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10
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Odermatt J, Meili M, Hersberger L, Bolliger R, Christ-Crain M, Briel M, Bucher HC, Mueller B, Schuetz P. Pro-Adrenomedullin predicts 10-year all-cause mortality in community-dwelling patients: a prospective cohort study. BMC Cardiovasc Disord 2017; 17:178. [PMID: 28676115 PMCID: PMC5496393 DOI: 10.1186/s12872-017-0605-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 06/22/2017] [Indexed: 01/20/2023] Open
Abstract
Background Several studies found mid-regional pro-adrenomedullin (ProADM), the prohormone of the cardiovascular protein adrenomedullin, to be strongly associated with short-term mortality, mostly in the inpatient setting. We evaluated associations of ProADM levels with 10-year mortality in community-dwelling primary care patients with respiratory tract infections. Methods This is a post-hoc analysis using clinical and biomarker data of 134 primary care patients with respiratory tract infections. ProADM was measured on admission and after 7 days in batch-analysis. 10-year follow-up data was collected by GP, patient and relative tracing through phone interviews. We calculated Cox regression models and area under the receiver operating characteristics curves to assess associations of ProADM with 10-year all-cause mortality. Results During the 10-year follow-up 6% of included patients died. Median baseline ProADM blood levels (nmol/l) were significantly higher in non-survivors compared to survivors (0.5, IQR 0.4–1.3; vs. 0.2, IQR 0.1–0.5; p = 0.02) and showed a significant association with 10-year all-cause mortality in an age-adjusted cox regression model (HR: 2.5, 95%-CI: 1.0–6.1, p = 0.04). ProADM levels on day 7 showed similar results. Conclusions This posthoc analysis found an association of elevated ProADM blood levels and 10-year all-cause mortality in a primary care cohort with respiratory tract infections. Due to the methodological limitations including incomplete data regarding follow-up information and biomarker measurement, this study warrants validation in future larger studies. Trial registration Current Controlled Trials, SRCTN73182671
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Affiliation(s)
- Jonas Odermatt
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Marc Meili
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Lara Hersberger
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Rebekka Bolliger
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Basel-Stadt, Switzerland.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Heiner C Bucher
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Basel-Stadt, Switzerland
| | - Beat Mueller
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland
| | - Philipp Schuetz
- Department of Endocrinology, Diabetology and Metabolism, Medical University Clinic, Kantonsspital Aarau and University of Basel, Switzerland, Tellstrasse, CH-5001, Aarau, Switzerland.
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11
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Schuetz P. Personalized medicine of patients with respiratory infections through the measurement of specific blood biomarkers: fact or fiction? Expert Rev Respir Med 2017; 11:605-607. [PMID: 28610545 DOI: 10.1080/17476348.2017.1338953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Philipp Schuetz
- a Medical University Department , Kantonsspital Aarau, Endocrinology/Diabetes/Clinical Nutrition and Internal Medicine , Aarau , Switzerland
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12
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Schuetz P, Birkhahn R, Sherwin R, Jones AE, Singer A, Kline JA, Runyon MS, Self WH, Courtney DM, Nowak RM, Gaieski DF, Ebmeyer S, Johannes S, Wiemer JC, Schwabe A, Shapiro NI. Serial Procalcitonin Predicts Mortality in Severe Sepsis Patients: Results From the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) Study. Crit Care Med 2017; 45:781-789. [PMID: 28257335 PMCID: PMC5389588 DOI: 10.1097/ccm.0000000000002321] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To prospectively validate that the inability to decrease procalcitonin levels by more than 80% between baseline and day 4 is associated with increased 28-day all-cause mortality in a large sepsis patient population recruited across the United States. DESIGN Blinded, prospective multicenter observational clinical trial following an Food and Drug Administration-approved protocol. SETTING Thirteen U.S.-based emergency departments and ICUs. PATIENTS Consecutive patients meeting criteria for severe sepsis or septic shock who were admitted to the ICU from the emergency department, other wards, or directly from out of hospital were included. INTERVENTIONS Procalcitonin was measured daily over the first 5 days. MEASUREMENTS AND MAIN RESULTS The primary analysis of interest was the relationship between a procalcitonin decrease of more than 80% from baseline to day 4 and 28-day mortality using Cox proportional hazards regression. Among 858 enrolled patients, 646 patients were alive and in the hospital on day 4 and included in the main intention-to-diagnose analysis. The 28-day all-cause mortality was two-fold higher when procalcitonin did not show a decrease of more than 80% from baseline to day 4 (20% vs 10%; p = 0.001). This was confirmed as an independent predictor in Cox regression analysis (hazard ratio, 1.97 [95% CI, 1.18-3.30; p < 0.009]) after adjusting for demographics, Acute Physiology and Chronic Health Evaluation II, ICU residence on day 4, sepsis syndrome severity, antibiotic administration time, and other relevant confounders. CONCLUSIONS Results of this large, prospective multicenter U.S. study indicate that inability to decrease procalcitonin by more than 80% is a significant independent predictor of mortality and may aid in sepsis care.
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Affiliation(s)
- Philipp Schuetz
- 1Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland; and Medical Faculty, University of Basel, Switzerland. 2Department of Emergency Medicine, New York Methodist Hospital, New York, NY. 3Emergency Departments, Sinai Grace Hospital and Detroit Receiving Hospital, Detroit, MI. 4Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS. 5Department of Emergency Medicine, Stony Brook University, Stony Brook, NY. 6Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. 7Department of Emergency Medicine, Vanderbilt University, Nashville, TN. 8Department of Emergency Medicine, Northwestern University, Chicago, IL. 9Department of Emergency Medicine, Henry Ford Health System, Detroit, MI. 10Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA. 11Global Medical Affairs, B·R·A·H·M·S GmbH, Hennigsdorf, Germany. 12Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department. Med Clin (Barc) 2017; 148:501-510. [PMID: 28391994 DOI: 10.1016/j.medcli.2017.02.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/08/2017] [Accepted: 02/16/2017] [Indexed: 01/10/2023]
Abstract
Between all patients treated in the Emergency Department (ED), 1.35% are diagnosed with community-acquired pneumonia (CAP). CAP is the main cause of death due to infectious disease (10-14%) and the most frequent reason of sepsis-septic shock in the ED. In the last decade, the search for objective tools to help establishing an early diagnosis, bacterial aetiology, severity, suspicion of bacteremia and the prognosis of mortality has increased. Biomarkers have shown their usefulness in this matter. Procalcitonin (obtains the highest accuracy for CAP diagnosis, bacterial aetiology and the presence of bacteremia), lactate (biomarker of hypoxia and tissue hypoperfusion) and proadrenomedullin (which has the greatest accuracy to predict mortality which in combination with the prognostic severity scales obtains even better results). The aim of this review is to highlight recently published scientific evidence and to compare the utility and prognostic accuracy of the biomarkers in CAP patients treated in the ED.
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Stojanovic I, Schneider JE, Wei L, Hong Z, Keane C, Schuetz P. Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a Chinese hospital system perspective. ACTA ACUST UNITED AC 2017; 55:561-570. [DOI: 10.1515/cclm-2016-0349] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/01/2016] [Indexed: 12/25/2022]
Abstract
AbstractBackground:Cost-impact models have indicated that in the USA, the use of antibiotic stewardship protocols based on procalcitonin (PCT) levels for patients with suspected acute respiratory tract infection results in cost savings. Our objective was to assess the cost impact of adopting PCT testing among patients with acute respiratory infections (ARI) from the perspective of a typical hospital system in urban China.Methods:To conduct an economic evaluation of PCT testing versus usual care we built a cost-impact model based on a previously published patient-level meta-analysis data of randomized trials including Chinese sites. The data were adapted to the China setting by applying the results to mean lengths of stay, costs, and practice patterns typically found in China. We estimated the annual ARI visit rate for the typical hospital system (assumed to be 1650 beds) and ARI diagnosis.Results:In the inpatient setting, the costs of PCT-guided care compared to usual care for a cohort of 16,405 confirmed ARI patients was almost 1.1 million Chinese yuan (CNY), compared to almost 1.8 million CNY for usual care, resulting in net savings of 721,563 CNY to a typical urban Chinese hospital system for 2015. In the ICU and outpatient settings, savings were 250,699 CNY and 2.4 million CNY, respectively. The overall annual net savings of PCT-guided care was nearly 3.4 million CNY.Conclusions:Substantial savings are associated with PCT protocols of ARI across common China hospital treatment settings mainly by direct reduction in unnecessary antibiotic utilization.
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Andersen SB, Baunbæk Egelund G, Jensen AV, Petersen PT, Rohde G, Ravn P. Failure of CRP decline within three days of hospitalization is associated with poor prognosis of Community-acquired Pneumonia. Infect Dis (Lond) 2016; 49:251-260. [DOI: 10.1080/23744235.2016.1253860] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Stine Bang Andersen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Gertrud Baunbæk Egelund
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Vestergaard Jensen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Pelle Trier Petersen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Gernot Rohde
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- CAPNETZ-Stiftung, Hannover Medical School, Hannover, Germany
| | - Pernille Ravn
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
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Procalcitonin: A new biomarker for the cardiologist. Int J Cardiol 2016; 223:390-397. [DOI: 10.1016/j.ijcard.2016.08.204] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/09/2016] [Accepted: 08/10/2016] [Indexed: 02/04/2023]
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Diagnostic and prognostic value of soluble CD14 subtype (Presepsin) for sepsis and community-acquired pneumonia in ICU patients. Ann Intensive Care 2016; 6:59. [PMID: 27389015 PMCID: PMC4936977 DOI: 10.1186/s13613-016-0160-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 06/20/2016] [Indexed: 12/21/2022] Open
Abstract
Background The soluble CD14 subtype, Presepsin, appears to be an accurate sepsis diagnostic marker, but data from intensive care units (ICUs) are scarce. This study was conducted to evaluate the diagnostic and prognostic value of Presepsin in ICU patients with severe sepsis (SS), septic shock (SSh) and severe community-acquired pneumonia (sCAP). Methods Presepsin and procalcitonin (PCT) levels were determined for patients at admission to ICU. Four groups have been differentiated: (1) absence or (2) presence of systemic inflammatory response syndrome, (3) SS or (4) SSh; and 2 groups, among the patients admitted for acute respiratory failure: absence or presence of sCAP. Biomarkers were tested for diagnosis of SS, SSh and sCAP and for prediction of ICU mortality. Results One hundred and forty-four patients were included: 44 SS and 56 SSh. Plasma levels of Presepsin and PCT were significantly higher in septic than in non-septic patients and in SSh as compared to others. The sepsis diagnostic accuracy of Presepsin was not superior to that of PCT (AUC: 0.75 vs 0.80). In the 72/144 patients admitted for acute respiratory failure, the capability of Presepsin to diagnose sCAP was significantly better than PCT. Presepsin levels were also predictive of ICU mortality in sepsis and in sCAP patients. Conclusion Plasma levels of Presepsin were useful for the diagnosis of SS, SSh and sCAP and may predict ICU mortality in these patients.
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An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Acute Myocardial Infarction. Sci Rep 2016; 6:27770. [PMID: 27291987 PMCID: PMC4904212 DOI: 10.1038/srep27770] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 05/24/2016] [Indexed: 02/07/2023] Open
Abstract
Acute hyperglycemia is a frequent finding in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI). The prognostic role of hyperglycemia in diabetic patients with AMI remains controversial. We retrospectively reviewed patients' medical records to obtain demographic data, clinical presentation, major adverse cardiac events (MACEs), several clinical scores and laboratory data, including the plasma glucose level at initial presentation and HbA1c levels. The glycemic gap, which represents changes in serum glucose levels during the index event, was calculated from the glucose level upon ED admission minus the HbA1c-derived average glucose (ADAG). We enrolled 331 patients after the review of medical records. An elevated glycemic gap between admission serum glucose levels and ADAG were associated with an increased risk of mortality in patients. The glycemic gap showed superior discriminative power regarding the development of MACEs when compared with the admission glucose level. The calculation of the glycemic gap may increase the discriminative powers of established clinical scoring systems in diabetic patients presenting to the ED with AMI. In conclusion, the glycemic gap could be used as an adjunct parameter to assess the severity and prognosis of diabetic patients presenting with AMI. However, the usefulness of the glycemic gap should be further explored in prospective longitudinal studies.
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Scicluna BP, Klein Klouwenberg PMC, van Vught LA, Wiewel MA, Ong DSY, Zwinderman AH, Franitza M, Toliat MR, Nürnberg P, Hoogendijk AJ, Horn J, Cremer OL, Schultz MJ, Bonten MJ, van der Poll T. A molecular biomarker to diagnose community-acquired pneumonia on intensive care unit admission. Am J Respir Crit Care Med 2016; 192:826-35. [PMID: 26121490 DOI: 10.1164/rccm.201502-0355oc] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Community-acquired pneumonia (CAP) accounts for a major proportion of intensive care unit (ICU) admissions for respiratory failure and sepsis. Diagnostic uncertainty complicates case management, which may delay appropriate cause-specific treatment. OBJECTIVES To characterize the blood genomic response in patients with suspected CAP and identify a candidate biomarker for the rapid diagnosis of CAP on ICU admission. METHODS The study comprised two cohorts of consecutively enrolled patients treated for suspected CAP on ICU admission. Patients were designated CAP (cases) and no-CAP patients (control subjects) by post hoc assessment. The first (discovery) cohort (101 CAP and 33 no-CAP patients) was enrolled between January 2011 and July 2012; the second (validation) cohort (70 CAP and 30 no-CAP patients) between July 2012 and June 2013. Blood was collected within 24 hours of ICU admission. MEASUREMENTS AND MAIN RESULTS Blood microarray analysis of CAP and no-CAP patients revealed shared and distinct gene expression patterns. A 78-gene signature was defined for CAP, from which a FAIM3:PLAC8 gene expression ratio was derived with area under curve of 0.845 (95% confidence interval, 0.764-0.917) and positive and negative predictive values of 83% and 81%, respectively. Robustness of the FAIM3:PLAC8 ratio was ascertained by quantitative polymerase chain reaction in the validation cohort. The FAIM3:PLAC8 ratio outperformed plasma procalcitonin and IL-8 and IL-6 in discriminating between CAP and no-CAP patients. CONCLUSIONS CAP and no-CAP patients presented shared and distinct blood genomic responses. We propose the FAIM3:PLAC8 ratio as a candidate biomarker to assist in the rapid diagnosis of CAP on ICU admission. Clinical trial registered with www.clinicaltrials.gov (NCT 01905033).
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Affiliation(s)
- Brendon P Scicluna
- 1 Center for Experimental Molecular Medicine and Center for Infection and Immunity Amsterdam
| | - Peter M C Klein Klouwenberg
- 2 Department of Intensive Care Medicine.,3 Department of Medical Microbiology, and.,4 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; and
| | - Lonneke A van Vught
- 1 Center for Experimental Molecular Medicine and Center for Infection and Immunity Amsterdam
| | - Maryse A Wiewel
- 1 Center for Experimental Molecular Medicine and Center for Infection and Immunity Amsterdam
| | - David S Y Ong
- 2 Department of Intensive Care Medicine.,3 Department of Medical Microbiology, and.,4 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; and
| | | | - Marek Franitza
- 6 Cologne Center for Genomics.,7 Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, and
| | | | - Peter Nürnberg
- 6 Cologne Center for Genomics.,7 Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, and.,8 Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - Arie J Hoogendijk
- 1 Center for Experimental Molecular Medicine and Center for Infection and Immunity Amsterdam
| | | | | | | | - Marc J Bonten
- 3 Department of Medical Microbiology, and.,4 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; and
| | - Tom van der Poll
- 1 Center for Experimental Molecular Medicine and Center for Infection and Immunity Amsterdam.,10 Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Scicluna BP, van Vught LA, van der Poll T, Klein Klouwenberg PMC, Cremer OL. Reply: FAIM3:PLAC8 Ratio Compared with Existing Biomarkers for Diagnosis of Severe Community-acquired Pneumonia: Comparing Apples to Oranges? Am J Respir Crit Care Med 2016; 193:102-3. [PMID: 26720792 DOI: 10.1164/rccm.201509-1752le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | | | | | | | - Olaf L Cremer
- 2 University Medical Center Utrecht Utrecht, the Netherlands
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Nickler M, Schaffner D, Christ-Crain M, Ottiger M, Thomann R, Hoess C, Henzen C, Mueller B, Schuetz P. Prospective evaluation of biomarkers for prediction of quality of life in community-acquired pneumonia. ACTA ACUST UNITED AC 2016; 54:1831-1846. [DOI: 10.1515/cclm-2016-0001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 03/10/2016] [Indexed: 01/22/2023]
Abstract
AbstractBackground:Most clinical research investigated prognostic biomarkers for their ability to predict cardiovascular events or mortality. It is unknown whether biomarkers allow prediction of quality of life (QoL) after survival of the acute event. Herein, we investigated the prognostic potential of well-established inflammatory/cardiovascular blood biomarkers including white blood cells (WBC), C-reactive protein (CRP), procalcitonin (PCT), pro-adrenomedullin (proADM) and pro-atrial natriuretic peptide (proANP) in regard to a decline in QoL in a well-defined cohort of patients with community-acquired pneumonia (CAP).Methods:Within this secondary analysis including 753 patients with a final inpatient diagnosis of CAP from a multicenter trial, we investigated associations between admission biomarker levels and decline in QoL assessed by the EQ-5D health questionnaire from admission to day 30 and after 6 years.Results:Admission proADM and proANP levels significantly predicted decline of the weighted EQ-5D index after 30 days (n=753) with adjusted odds ratios (ORs) of 2.0 ([95% CI 1.1–3.8]; p=0.027) and 3.7 ([95% CI 2.2–6.0]; p<0.001). Results for 6-year outcomes (n=349) were similar with ORs of 3.3 ([95% CI 1.3–8.3]; p=0.012) and 6.2 ([95% CI 2.7–14.2]; p<0.001). The markers were associated with most of the different QoL dimensions including mobility, self-care, and usual activities, but not pain/discomfort and to a lesser degree anxiety/depression and the visual analogue scale (VAS). Initial WBC, PCT and CRP values did not well predict QoL at any time point.Conclusions:ProADM and proANP accurately predict short- and long-term decline in QoL across most dimensions in CAP patients. It will be interesting to reveal underlying physiopathology in future studies.
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Nickel CH, Messmer AS, Ghanim L, Ilsemann-Karakoumis J, Giersdorf S, Hertel S, Ernst S, Geigy N, Bingisser R. Adrenomedullin for Risk Stratification of Emergency Patients With Nonspecific Complaints: An Interventional Multicenter Pilot Study. Medicine (Baltimore) 2016; 95:e2395. [PMID: 26735540 PMCID: PMC4706260 DOI: 10.1097/md.0000000000002395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Patients with nonspecific complaints (NSC) presenting to the emergency department (ED) are at risk of life-threatening conditions. New stress biomarkers such as the midregional portion of adrenomedullin (MR-proADM) promise to support decision-making. This study tested the following hypotheses: biomarker-assisted disposition of patients with NSC will not increase mortality. Second, discharge from the ED will increase if clinical risk assessment is combined with low MR-proADM levels. Third, inappropriate disposition to a lower level of care will decrease, if clinical assessment is combined with high MR-proADM levels, and fourth that this algorithm is feasible in the ED setting. Prospective, multicenter, randomized, controlled interventional feasibility study with a 30-day follow-up, including patients with NSC. Patients were randomly assigned to either the standard group (decision-making solely based on clinical assessment) or the Novum group (biomarker-assisted). Regarding disposition, patients were assigned to 1 of 3 risk classes: high-risk (admission to hospital), intermediate risk (community geriatric hospital), and low-risk patients (discharge). In the Novum group, in addition to clinical risk assessment, the information of the MR-proADM level was used. Unless there were overruling criteria, patients were transferred or discharged according to the risk assessment. Primary endpoint was 30-day mortality. Secondary endpoints were comparisons of patient disposition and related mortality rates, ED, and hospital length of stay and readmission. The final study cohort consisted of 398 patients (210 in the Standard group and 188 in the Novum group). Overruling, that is, disposition not according to the result of the proposed algorithm occurred in 51 cases. Baseline characteristics between Standard and Novum groups were similar. The mortality rate in the Novum group was 4.3%, as compared to the Standard group mortality of 6.2%, which was not significantly different (intention-to treat analysis). This was confirmed by the perprotocol analysis as well as by sensitivity analysis. For the secondary endpoints, no significant differences were detected. Biomarker-assisted disposition is safe in patients with NSC. Discharge rates did not increase. Feasibility could only partly be shown due to an unexpectedly high overruling rate. Inappropriate disposition to lower levels of care did not change. ClinicalTrials. gov Identifier: NCT00920491.
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Affiliation(s)
- Christian Hans Nickel
- From the Emergency Department, University Hospital, Basel (CHN, ASM, LG, JI-K, RB); Emergency Department, Kantonsspital Baselland, Liestal, Switzerland (NG); Research Department, Thermo Scientific Biomarkers, Hennigsdorf, Germany (SG, SH); and Emergency Department, Kantonsspital Olten, Olten, Switzerland (SE)
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Laukemann S, Kasper N, Kulkarni P, Steiner D, Rast AC, Kutz A, Felder S, Haubitz S, Faessler L, Huber A, Fux CA, Mueller B, Schuetz P. Can We Reduce Negative Blood Cultures With Clinical Scores and Blood Markers? Results From an Observational Cohort Study. Medicine (Baltimore) 2015; 94:e2264. [PMID: 26656373 PMCID: PMC5008518 DOI: 10.1097/md.0000000000002264] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Only a small proportion of blood cultures routinely performed in emergency department (ED) patients is positive. Multiple clinical scores and biomarkers have previously been examined for their ability to predict bacteremia. Conclusive clinical validation of these scores and biomarkers is essential.This observational cohort study included patients with suspected infection who had blood culture sampling at ED admission. We assessed 5 clinical scores and admission concentrations of procalcitonin (PCT), C-reactive protein (CRP), lymphocyte and white blood cell counts, the neutrophil-lymphocyte count ratio (NLCR), and the red blood cell distribution width (RDW). Two independent physicians assessed true blood culture positivity. We used logistic regression models with area under the curve (AUC) analysis.Of 1083 patients, 104 (9.6%) had positive blood cultures. Of the clinical scores, the Shapiro score performed best (AUC 0.729). The best biomarkers were PCT (AUC 0.803) and NLCR (AUC 0.700). Combining the Shapiro score with PCT levels significantly increased the AUC to 0.827. Limiting blood cultures only to patients with either a Shapiro score of ≥4 or PCT > 0.1 μg/L would reduce negative sampling by 20.2% while still identifying 100% of positive cultures. Similarly, a Shapiro score ≥3 or PCT >0.25 μg/L would reduce cultures by 41.7% and still identify 96.1% of positive blood cultures.Combination of the Shapiro score with admission levels of PCT can help reduce unnecessary blood cultures with minimal false negative rates.The study was registered on January 9, 2013 at the 'ClinicalTrials.gov' registration web site (NCT01768494).
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Affiliation(s)
- Svenja Laukemann
- From the University Department of Internal Medicine, Medical Faculty of the University of Basel, Kantonsspital Aarau, Switzerland (SL, NK, DS, ACR, AK, SF, LF, BM, PS); Asclepius Medical Communications LLC, Ridgewood, NJ, USA (PK); University Clinic of Infectious Diseases, University Hospital Bern (SH); Institute of Psychology, University of Bern (LF); Department of Laboratory Medicine, Kantonsspital (AH); and Clinic of Infectious Diseases, Kantonsspital Aarau, Switzerland (CAF)
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Schuetz P, Balk R, Briel M, Kutz A, Christ-Crain M, Stolz D, Bouadma L, Wolff M, Kristoffersen KB, Wei L, Burkhardt O, Welte T, Schroeder S, Nobre V, Tamm M, Bhatnagar N, Bucher HC, Luyt CE, Chastre J, Tubach F, Mueller B, Lacey MJ, Ohsfeldt RL, Scheibling CM, Schneider JE. Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective. Clin Chem Lab Med 2015; 53:583-92. [PMID: 25581762 DOI: 10.1515/cclm-2014-1015] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/09/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Whether or not antibiotic stewardship protocols based on procalcitonin levels results in cost savings remains unclear. Herein, our objective was to assess the economic impact of adopting procalcitonin testing among patients with suspected acute respiratory tract infection (ARI) from the perspective of a typical US integrated delivery network (IDN) with a 1,000,000 member catchment area or enrollment. METHODS To conduct an economic evaluation of procalcitonin testing versus usual care we built a cost-impact model based on patient-level meta-analysis data of randomized trials. The meta-analytic data was adapted to the US setting by applying the meta-analytic results to US lengths of stay, costs, and practice patterns. We estimated the annual ARI visit rate for the one million member cohort, by setting (inpatient, ICU, outpatient) and ARI diagnosis. RESULTS In the inpatient setting, the costs of procalcitonin-guided compared to usual care for the one million member cohort was $2,083,545, compared to $2,780,322, resulting in net savings of nearly $700,000 to the IDN for 2014. In the ICU and outpatient settings, savings were $73,326 and $5,329,824, respectively, summing up to overall net savings of $6,099,927 for the cohort. RESULTS were robust for all ARI diagnoses. For the whole US insured population, procalcitonin-guided care would result in $1.6 billion in savings annually. CONCLUSIONS Our results show substantial savings associated with procalcitonin protocols of ARI across common US treatment settings mainly by direct reduction in unnecessary antibiotic utilization. These results are robust to changes in key parameters, and the savings can be achieved without any negative impact on treatment outcomes.
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Schuetz P, Marlowe RJ, Mueller B. The prognostic blood biomarker proadrenomedullin for outcome prediction in patients with chronic obstructive pulmonary disease (COPD): a qualitative clinical review. Clin Chem Lab Med 2015; 53:521-39. [PMID: 25252756 DOI: 10.1515/cclm-2014-0748] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 08/24/2014] [Indexed: 01/29/2023]
Abstract
Plasma proadrenomedullin (ProADM) is a blood biomarker that may aid in multidimensional risk assessment of patients with chronic obstructive pulmonary disease (COPD). Co-secreted 1:1 with adrenomedullin (ADM), ProADM is a less biologically active, more chemically stable surrogate for this pluripotent regulatory peptide, which due to biological and ex vivo physical characteristics is difficult to reliably directly quantify. Upregulated by hypoxia, inflammatory cytokines, bacterial products, and shear stress and expressed widely in pulmonary cells and ubiquitously throughout the body, ADM exerts or mediates vasodilatory, natriuretic, diuretic, antioxidative, anti-inflammatory, antimicrobial, and metabolic effects. Observational data from four separate studies totaling 1366 patients suggest that as a single factor, ProADM is a significant independent, and accurate, long-term all-cause mortality predictor in COPD. This body of work also suggests that combined with different groups of demographic/clinical variables, ProADM provides significant incremental long-term mortality prediction power relative to the groups of variables alone. Additionally, the literature contains indications that ProADM may be a global cardiopulmonary stress marker, potentially supplying prognostic information when cardiopulmonary exercise testing results such as 6-min walk distance are unavailable due to time or other resource constraints or to a patient's advanced disease. Prospective, randomized, controlled interventional studies are needed to demonstrate whether ProADM use in risk-based guidance of site-of-care, monitoring, and treatment decisions improves clinical, quality-of-life, or pharmacoeconomic outcomes in patients with COPD.
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Zhydkov A, Christ-Crain M, Thomann R, Hoess C, Henzen C, Werner Z, Mueller B, Schuetz P. Utility of procalcitonin, C-reactive protein and white blood cells alone and in combination for the prediction of clinical outcomes in community-acquired pneumonia. Clin Chem Lab Med 2015; 53:559-66. [PMID: 25014522 DOI: 10.1515/cclm-2014-0456] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/13/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND The added value of biomarkers, such as procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC), as adjuncts to clinical risk scores for predicting the outcome of patients with community-acquired pneumonia (CAP) is in question. We investigated the prognostic accuracy of initial and follow-up levels of inflammatory biomarkers in predicting death and adverse clinical outcomes in a large and well-defined cohort of CAP patients. METHODS We measured PCT, CRP and WBC on days 1, 3, 5, and 7 and followed the patients over 30 days. We applied multivariate regression models and area under the curve (AUC) to investigate associations between these biomarkers, the clinical risk score CURB-65, and clinical outcomes [i.e., death and intensive care unit (ICU) admission]. RESULTS Of 925 patients with CAP, 50 patients died and 118 patients had an adverse clinical outcome. None of the initial biomarker levels significantly improved the CURB-65 score for mortality prediction. Follow-up biomarker levels showed significant independent association with mortality at days 3, 5, and 7 and with improvements in AUC. Initial PCT and CRP levels were independent prognostic predictors of adverse clinical outcome, and levels of all biomarkers during the course of disease provided additional prognostic information. CONCLUSIONS This study provides robust insights into the added prognostic value of inflammatory markers in CAP. Procalcitonin, CRP, and to a lesser degree WBC provided some prognostic information on CAP outcomes, particularly when considering their kinetics at days 5 and 7 and when looking at adverse clinical outcomes instead of mortality alone.
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Nickler M, Ottiger M, Steuer C, Huber A, Anderson JB, Müller B, Schuetz P. Systematic review regarding metabolic profiling for improved pathophysiological understanding of disease and outcome prediction in respiratory infections. Respir Res 2015; 16:125. [PMID: 26471192 PMCID: PMC4608151 DOI: 10.1186/s12931-015-0283-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/29/2015] [Indexed: 01/07/2023] Open
Abstract
Metabolic profiling through targeted quantification of a predefined subset of metabolites, performed by mass spectrometric analytical techniques, allows detailed investigation of biological pathways and thus may provide information about the interaction of different organic systems, ultimately improving understanding of disease risk and prognosis in a variety of diseases. Early risk assessment, in turn, may improve patient management in regard to cite-of-care decisions and treatment modalities. Within this review, we focus on the potential of metabolic profiling to improve our pathophysiological understanding of disease and management of patients. We focus thereby on lower respiratory tract infections (LRTI) including community-acquired pneumonia (CAP) and chronic obstructive pulmonary disease (COPD), an important disease responsible for high mortality, morbidity and costs worldwide. Observational data from numerous clinical and experimental studies have provided convincing data linking metabolic blood biomarkers such as lactate, glucose or cortisol to patient outcomes. Also, identified through metabolomic studies, novel innovative metabolic markers such as steroid hormones, biogenic amines, members of the oxidative status, sphingo- and glycerophospholipids, and trimethylamine-N-oxide (TMAO) have shown promising results. Since many uncertainties remain in predicting mortality in these patients, further prospective and retrospective observational studies are needed to uncover metabolic pathways responsible for mortality associated with LRTI. Improved understanding of outcome-specific metabolite signatures in LRTIs may optimize patient management strategies, provide potential new targets for future individual therapy, and thereby improve patients' chances for survival.
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Affiliation(s)
- Manuela Nickler
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.
| | - Manuel Ottiger
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.
| | - Christian Steuer
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland.
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland.
| | | | - Beat Müller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland.
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Opal S. Is Genomic Medicine Finally Coming of Age for the Diagnosis of Pneumonia? Am J Respir Crit Care Med 2015; 192:773-4. [DOI: 10.1164/rccm.201507-1340ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Liao WI, Wang JC, Chang WC, Hsu CW, Chu CM, Tsai SH. Usefulness of Glycemic Gap to Predict ICU Mortality in Critically Ill Patients With Diabetes. Medicine (Baltimore) 2015; 94:e1525. [PMID: 26356728 PMCID: PMC4616648 DOI: 10.1097/md.0000000000001525] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Stress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes.We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG = [(28.7 × HbA1c) - 46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score.We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P < 0.001). Critically ill patients with diabetes and a glycemic gap ≥80 mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80 mg/dL (P < 0.001). Incorporation of the glycemic gap into the APACHE-II score increased the discriminative performance for predicting ICU mortality by increasing the area under the ROC curve from 0.755 to 0.794 (NRI = 13.6%, P = 0.0013).The glycemic gap can be used to assess the severity and prognosis of critically ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality.
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Affiliation(s)
- Wen-I Liao
- From Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (W-IL, J-CW, S-HT); Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan (W-CC); Department of Emergency and Critical Care Medicine, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan (C-WH); and School of Public Health, National Defense Medical Center, Taipei, Taiwan (C-MC)
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Chen PC, Liao WI, Wang YC, Chang WC, Hsu CW, Chen YH, Tsai SH. An Elevated Glycemic Gap is Associated With Adverse Outcomes in Diabetic Patients With Community-Acquired Pneumonia. Medicine (Baltimore) 2015; 94:e1456. [PMID: 26313809 PMCID: PMC4602897 DOI: 10.1097/md.0000000000001456] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Several studies argue against the association between admission hyperglycemia and adverse outcomes in infected diabetic patients. When investigating the association, it is necessary to consider preexisting hyperglycemia. The objective of this study was to assess whether stress-induced hyperglycemia, determined by the glycemic gap between admission glucose levels and A1c-derived average glucose levels adversely affects outcomes in diabetic patients admitted to hospital with community-acquired pneumonia (CAP).We retrospectively analyzed the glycemic gap and adverse outcomes of diabetic patients hospitalized because of CAP from June 1, 2007 to August 31, 2012 in single medical center in Taiwan.A total of 203 patients admitted with principal diagnosis of CAP and available data of glycemic gap.Patients with glycemic gaps ≥40 mg/dL had greater AUROC values for the development of adverse outcomes compared with acute hyperglycemia and long-term glycemic controls. Patients with an elevated glycemic gap had an odds ratio of 3.84 for the incidence of combined adverse outcomes. Incorporation of the glycemic gap into pneumonia severity index, CURB-65 or SMART-COP scores, increased the discriminative performance of predicting the development of adverse outcomes.Glycemic gaps were associated with adverse outcomes of diabetic CAP patients. The discriminative performance of the calculated glycemic gaps was comparable with those of current clinical scoring systems and may further increase the AUROC of each system.
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Affiliation(s)
- Po-Chuan Chen
- From the Department of Emergency Medicine (PCC, WIL, YHC, SHT); Department of Family Medicine (YCW); Department of Radiology, Tri-Service General Hospital, National Defense Medical Center (WCC); and Department of Emergency and Critical Care Medicine, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan (CWH)
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Abstract
OBJECTIVE To develop predictive models for early triage of burn patients based on hypersusceptibility to repeated infections. BACKGROUND Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking. METHODS Secondary analysis of 459 burn patients (≥16 years old) with 20% or more total body surface area burns recruited from 6 US burn centers. We compared blood transcriptomes with a 180-hour cutoff on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) to those of 66 hypersusceptible patients [multiple (≥2) infection episodes (MIE)]. We used LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation. RESULTS Three predictive models were developed using covariates of (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status [AUROCGenomic = 0.946 (95% CI: 0.906-0.986); AUROCClinical = 0.864 (CI: 0.794-0.933); AUROCGenomic/AUROCClinical P = 0.044]. Combined model has an increased AUROCCombined of 0.967 (CI: 0.940-0.993) compared with the individual models (AUROCCombined/AUROCClinical P = 0.0069). Hypersusceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation, and chromatin remodeling. CONCLUSIONS Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures. Genomic signature suggests new insights into the pathophysiology of hypersusceptibility to infection may lead to novel potential therapeutic or prophylactic targets.
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Aliberti S, Giuliani F, Ramirez J, Blasi F. How to choose the duration of antibiotic therapy in patients with pneumonia. Curr Opin Infect Dis 2015; 28:177-84. [DOI: 10.1097/qco.0000000000000140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Kutz A, Briel M, Christ-Crain M, Stolz D, Bouadma L, Wolff M, Kristoffersen KB, Wei L, Burkhardt O, Welte T, Schroeder S, Nobre V, Tamm M, Bhatnagar N, Bucher HC, Luyt CE, Chastre J, Tubach F, Mueller B, Schuetz P. Prognostic value of procalcitonin in respiratory tract infections across clinical settings. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:74. [PMID: 25887979 PMCID: PMC4383063 DOI: 10.1186/s13054-015-0792-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 02/06/2015] [Indexed: 12/25/2022]
Abstract
Introduction Whether the inflammatory biomarker procalcitonin provides prognostic information across clinical settings and different acute respiratory tract infections (ARIs) is poorly understood. In the present study, we investigated the prognostic value of admission procalcitonin levels to predict adverse clinical outcome in a large ARI population. Methods We analysed data from 14 trials and 4,211 ARI patients to study associations of admission procalcitonin levels and setting specific treatment failure and mortality alone at 30 days. We used multivariable hierarchical logistic regression and conducted sensitivity analyses stratified by clinical settings and ARI diagnoses to assess the results’ consistency. Results Overall, 864 patients (20.5%) experienced treatment failure and 252 (6.0%) died. The ability of procalcitonin to differentiate patients with from those without treatment failure was highest in the emergency department setting (treatment failure area under the curve (AUC): 0.64 (95% confidence interval (CI): 0.61, 0.67), adjusted odds ratio (OR): 1.85 (95% CI: 1.61, 2.12), P <0.001; and mortality AUC: 0.67 (95% CI: 0.63, 0.71), adjusted OR: 1.82 (95% CI: 1.45, 2.29), P <0.001). In lower respiratory tract infections, procalcitonin was a good predictor of identifying patients at risk for mortality (AUC: 0.71 (95% CI: 0.68, 0.74), adjusted OR: 2.13 (95% CI: 1.82, 2.49), P <0.001). In primary care and intensive care unit patients, no significant association of initial procalcitonin levels and outcome was found. Conclusions Admission procalcitonin levels are associated with setting specific treatment failure and provide the most prognostic information regarding ARI in the emergency department setting.
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Affiliation(s)
- Alexander Kutz
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Hebelstrasse 10, Basel, 4031, Switzerland.
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Hebelstrasse 10, Basel, 4031, Switzerland.
| | - Daiana Stolz
- Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Hebelstrasse 10, Basel, 4031, Switzerland.
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis Diderot, Hôpital Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP), Henri Huchard Paris Cedex 18, Paris, 75877, France.
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis Diderot, Hôpital Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP), Henri Huchard Paris Cedex 18, Paris, 75877, France.
| | - Kristina B Kristoffersen
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Long Wei
- Department of Internal and Geriatric Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Huan Hu Xi San Road, Pudong New Area, Shanghai, 201306, China.
| | - Olaf Burkhardt
- Department of Pulmonary Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, 30659, Germany.
| | - Tobias Welte
- Department of Pulmonary Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, 30659, Germany.
| | - Stefan Schroeder
- Department of Anesthesiology and Intensive Care Medicine, Düren Hospital, Roonstraße 30, Düren, 52351, Germany.
| | - Vandack Nobre
- Intensive Care, Universidade Federal de Minas Gerais, 6627 - Pampulha, Belo Horizonte - MG, 31270-901, Brazil.
| | - Michael Tamm
- Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Hebelstrasse 10, Basel, 4031, Switzerland.
| | - Neera Bhatnagar
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S4L8, Canada.
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Hebelstrasse 10, Basel, 4031, Switzerland.
| | - Charles-Edouard Luyt
- Service de Réanimation Médicale, Université Paris 6-Pierre et Marie Curie, Hôpital Pitié-Salpêtrière, AP-HP, 47-83 boulevard de l'Hôpital, Paris, 75651, France.
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 6-Pierre et Marie Curie, Hôpital Pitié-Salpêtrière, AP-HP, 47-83 boulevard de l'Hôpital, Paris, 75651, France.
| | - Florence Tubach
- AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Département d'Epidémiologie Biostatistique et Recherche Clinique, Université Paris Diderot, Sorbonne Paris Cité, UMR 738, INSERM, UMR 738, INSERM, CIE801, 5 Rue Thomas Mann, Paris, Cedex 13, 75013, France.
| | - Beat Mueller
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Philipp Schuetz
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
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Rajas O, Ortega-Gómez M, Galván Román JM, Curbelo J, Fernández Jiménez G, Vega Piris L, Rodríguez Salvanes F, Arnalich B, Luquero Bueno S, Díaz López A, de la Fuente H, Suárez C, Ancochea J, Aspa J. The incidence of cardiovascular events after hospitalization due to CAP and their association with different inflammatory markers. BMC Pulm Med 2014; 14:197. [PMID: 25495677 PMCID: PMC4320510 DOI: 10.1186/1471-2466-14-197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/04/2014] [Indexed: 01/13/2023] Open
Abstract
Background Late prognosis of Community-Acquired Pneumonia (CAP) patients is related to cardiovascular events. Persistence of inflammation-related markers, defined by high circulatory levels of interleukin 6 and 10 (IL-6/IL-10), is associated with a higher post-event mortality rate for CAP patients. However, association between these markers and other components of the immune response, and the risk of cardiovascular events, has not been adequately explored. The main objectives of this study are: 1) to quantify the incidence of cardiovascular disease, in the year post-dating their hospital admittance due to CAP and, 2) to describe the distribution patterns of a wide spectrum of inflammatory markers upon admittance to and release from hospital, and to determine their relationship with the incidence of cardiovascular disease. Methods/design A cohort prospective study. All patients diagnosed and hospitalized with CAP will be candidates for inclusion. The study will take place in the Universitary Hospital La Princesa, Spain, during two years. Two samples of blood will be taken from each patient: the first upon admittance and the second one prior to release, in order to analyse various immune agents. The main determinants are: pro-adrenomedullin, copeptin, IL-1, IL-6, TNF-α, IL-17, IFN-γ, IL-10 and TGF-β, E-Selectin, ICAM-1, VCAM-1 and subpopulations of peripheral T lymphocytes (T regulator, Th1 and Th17), together with other clinical and analytical variables. Follow up will start at admittance and finish a year after discharge, registering incidence of death and cardiovascular events. The main objective is to establish the predictive power of different inflammatory markers in the prognosis of CAP, in the short and long term, and their relationship with cardiovascular disease. Discussion The level of some inflammatory markers (IL-6/IL-10) has been proposed as a means to differentiate the degree of severity of CAP, but their association with cardiovascular risk is not well established. In this study we aim to define new inflammatory markers associated with cardiovascular disease that could be helpful for the prognosis of CAP patients, by describing the distribution of a wide spectrum of inflammatory mediators and analyzing their association with the incidence of cardiovascular disease and mortality one year after release from hospital.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Javier Aspa
- Servicio de Neumología, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Hospital Universitario de la Princesa, IP, Madrid, España.
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Kutz A, Grolimund E, Christ-Crain M, Thomann R, Falconnier C, Hoess C, Henzen C, Zimmerli W, Mueller B, Schuetz P. Pre-analytic factors and initial biomarker levels in community-acquired pneumonia patients. BMC Anesthesiol 2014; 14:102. [PMID: 25419180 PMCID: PMC4240803 DOI: 10.1186/1471-2253-14-102] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 10/28/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Blood biomarkers are increasingly used to diagnose, guide therapy in, and risk-stratify community-acquired pneumonia (CAP) patients in emergency departments (EDs). How pre-analytic factors affect these markers' initial levels in this population is unknown. METHODS In this secondary analysis of consecutive ED patients with CAP from a large multicentre antibiotic stewardship trial, we used adjusted multivariate regression models to determine the magnitude and statistical significance of differences in mean baseline concentrations of five biomarkers (procalcitonin [PCT], C-reactive protein [CRP], white blood cells count [WBC], proadrenomedullin [ProADM], copeptin) associated with six pre-analytic factors (antibiotic or corticosteroid pretreatment, age, gender, chronic renal failure or chronic liver insufficiency). RESULTS Of 925 CAP patients (median age 73 years, 58.8% male), 25.5% had antibiotic pretreatment, 2.4%, corticosteroid pretreatment, 22.3%, chronic renal failure, 2.4% chronic liver insufficiency. Differences associated with pre-analytic factors averaged 6.1% ± 4.6%; the three largest statistically significant changes (95% confidence interval) were: PCT, +14.2% (+2.1% to +26.4%, p = 0.02) with liver insufficiency; ProADM, +13.2% (+10.2% to +16.1%, p < 0.01) with age above median; CRP, -12.8% (-25.4% to -0.2%, p = 0.05) with steroid pretreatment. In post hoc sensitivity analyses, reclassification statistics showed that these factors did not result in significant changes of biomarker levels across clinically used cut-off ranges. CONCLUSIONS Despite statistically significant associations of some pre-analytic factors and biomarker levels, a clinically relevant influence seems unlikely. Our observations reinforce the concept of using biomarkers in algorithms with widely-separated cut-offs and overruling criteria considering the entire clinical picture. TRIAL REGISTRATION Identifier ISRCTN95122877.
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Affiliation(s)
- Alexander Kutz
- University Department of Medicine, Tellstrasse, CH-5001 Kantonsspital Aarau, Switzerland
| | - Eva Grolimund
- University Department of Medicine, Tellstrasse, CH-5001 Kantonsspital Aarau, Switzerland
| | - Mirjam Christ-Crain
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - Robert Thomann
- Department of Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | | | - Claus Hoess
- Department of Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Christoph Henzen
- Department of Internal Medicine, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Werner Zimmerli
- Basel University Medical Clinic Liestal, Liestal, Switzerland
| | - Beat Mueller
- University Department of Medicine, Tellstrasse, CH-5001 Kantonsspital Aarau, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Tellstrasse, CH-5001 Kantonsspital Aarau, Switzerland
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Guía de consenso para el abordaje de la neumonía adquirida en la comunidad en el paciente anciano. Rev Esp Geriatr Gerontol 2014; 49:279-91. [PMID: 24873864 PMCID: PMC7103352 DOI: 10.1016/j.regg.2014.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 04/11/2014] [Indexed: 11/29/2022]
Abstract
La incidencia de la neumonía adquirida en la comunidad se incrementa con la edad y se asocia a una elevada morbimortalidad debido a los cambios fisiológicos asociados al envejecimiento y a una mayor presencia de enfermedades crónicas. Debido a la importancia que tiene desde un punto de epidemiológico y pronóstico, y a la enorme heterogeneidad descrita en el manejo clínico, creemos que existía la necesidad de realizar un documento de consenso específico para este perfil de paciente. El propósito de este fue realizar una revisión de las evidencias en relación con los factores de riesgo para la etiología, la presentación clínica, el manejo y el tratamiento de la neumonía adquirida en la comunidad en los ancianos con el fin de elaborar una serie de recomendaciones específicas basadas en el análisis crítico de la literatura. Este documento es fruto de la colaboración de diferentes especialistas en representación de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Sociedad Española de Geriatría y Gerontología (SEGG), Sociedad Española de Quimioterapia (SEQ), Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Sociedad Española de Hospitalización a Domicilio (SEHAD) y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC).
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Albrich WC, Madhi SA, Adrian PV, van Niekerk N, Telles JN, Ebrahim N, Messaoudi M, Paranhos-Baccalà G, Giersdorf S, Vernet G, Mueller B, Klugman KP. Pneumococcal colonisation density: a new marker for disease severity in HIV-infected adults with pneumonia. BMJ Open 2014; 4:e005953. [PMID: 25113557 PMCID: PMC4127937 DOI: 10.1136/bmjopen-2014-005953] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE A high genomic load of Pneumococcus from blood or cerebrospinal fluid has been associated with increased mortality. We aimed to analyse whether nasopharyngeal colonisation density in HIV-infected patients with community-acquired pneumonia (CAP) is associated with markers of disease severity or poor outcome. METHODS Quantitative lytA real-time PCR was performed on nasopharyngeal swabs in HIV-infected South African adults hospitalised for acute CAP at Chris Hani Baragwanath Hospital, Soweto, South Africa. Pneumonia aetiology was considered pneumococcal if any sputum culture or Gram stain, urinary pneumococcal C-polysaccharide-based antigen, blood culture or whole blood lytA real-time PCR revealed pneumococci. RESULTS There was a moderate correlation between the mean nasopharyngeal colonisation densities and increasing CURB65 scores among all-cause patients with pneumonia (Spearman correlation coefficient r=0.15, p=0.06) or with the Pitt bacteraemia score among patients with pneumococcal bacteraemia (p=0.63). In patients with pneumococcal pneumonia, nasopharyngeal pneumococcal colonisation density was higher among non-survivors than survivors (7.7 vs 6.1 log10 copies/mL, respectively, p=0.02) and among those who had pneumococci identified from blood cultures and/or by whole blood lytA real-time PCR than those with non-bacteraemic pneumococcal pneumonia (6.6 vs 5.6 log10 copies/mL, p=0.03). Nasopharyngeal colonisation density correlated positively with the biomarkers procalcitonin (Spearman correlation coefficient r=0.37, p<0.0001), proadrenomedullin (r=0.39, p=0.008) and copeptin (r=0.30, p=0.01). CONCLUSIONS In addition to its previously reported role as a diagnostic tool for pneumococcal pneumonia, quantitative nasopharyngeal colonisation density also correlates with mortality and prognostic biomarkers. It may also be useful as a severity marker for pneumococcal pneumonia in HIV-infected adults.
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Affiliation(s)
- Werner C Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St Gallen, St Gallen, Switzerland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases University of the Witwatersrand, Johannesburg, South Africa
| | - Peter V Adrian
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nadia van Niekerk
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - N Ebrahim
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Guy Vernet
- Emerging Pathogens Laboratory, Fondation Mérieux, Lyon, France
- Centre Pasteur du Cameroun, Yaoundé, Cameroun
| | - Beat Mueller
- Department of Internal Medicine, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Keith P Klugman
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Hubert Department of Global Health and Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Pneumonia Program, Bill and Melinda Gates Foundation, Seattle, Washington, USA
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Schuetz P, Mueller B. The role of immune and metabolic biomarkers for improved management of sepsis patients. Expert Rev Clin Immunol 2014; 10:1255-62. [PMID: 25069484 DOI: 10.1586/1744666x.2014.932250] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sepsis, the body`s overwhelming response to systemic infections, is responsible for significant morbidity, mortality, and financial burden. Pathogens and their antigens stimulate pro- and anti-inflammatory mediators and immune markers which characterize the host defense and orchestrate leukocyte recruitment to the acute site of infection. Different immune and metabolic biomarkers have been studied in relation to sepsis for their diagnostic and/or prognostic aid. Recent studies have provided abundant evidence that specific immune and metabolic biomarkers improve a physician`s ability to guide early sepsis recognition, severity assessment and therapeutic decisions in individual patients. This may allow for a transition from bundled sepsis care (protocols combining several medical practices) to more individualized management. First, lactate has now been widely used for risk stratification and guidance of fluid resuscitation. Second, procalcitonin correlates with risks of bacterial infections and helps guide therapeutic decisions about initiation and withdrawal of anti-microbial therapy. Third, prognostic markers such as pro-adrenomedullin improve early mortality prediction and thereby site-of-care decisions in respiratory infections. For these markers interventional trials have documented their value when integrated in clinical protocols.
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Affiliation(s)
- Philipp Schuetz
- Department of Endocrinology, Diabetes and Clinical Nutrition, Medical University Clinic, Kantonsspital Aarau, Tellstrasse, 5001 Aarau, Switzerland
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Lacoma A, Bas A, Tudela P, Giménez M, Mòdol JM, Pérez M, Ausina V, Dominguez J, Prat-Aymerich C. Correlation of inflammatory and cardiovascular biomarkers with pneumonia severity scores. Enferm Infecc Microbiol Clin 2013; 32:140-6. [PMID: 24054971 DOI: 10.1016/j.eimc.2013.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 07/09/2013] [Accepted: 07/10/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess the correlation of procalcitonin (PCT), C-reactive protein (CRP), neopterin, mid-regional pro-atrial natriuretic peptide (MR-proANP), and mid-regional pro-adrenomedullin (MR-proADM) with severity risk scores: severe CAP (SCAP) and SMART-COP in patients with community-acquired pneumonia (CAP), as well as short term prognosis and to determine the correlation with mortality risk scores. METHODS Eighty-five patients with a final diagnosis of pneumonia were consecutively included during a two month period. Epidemiological, clinical, microbiological, and radiological data were recorded. Patients were stratified according to the PSI, CURB-65, SCAP and SMART-COP. Complications were defined as respiratory failure/shock, need of ICU, and death. Plasma samples were collected at admission. RESULTS MR-proANP and MR-proADM showed significantly higher levels in high risk SCAP group in comparison to low risk. When considering SMART-COP none of the biomarkers showed statistical differences. MR-proADM levels were high in patients with high risk of needing intensive respiratory or vasopressor support according to SMRT-CO. Neopterin and MR-proADM were significantly higher in patients that developed complications. PCT and MR-proADM showed significantly higher levels in cases of a definite bacterial diagnosis in comparison to probable bacterial, and unknown origin. MR-proANP and MR-proADM levels increased statistically according to PSI and CURB-65. CONCLUSIONS Biomarker levels are higher in pneumonia patients with a poorer prognosis according to SCAP and SMART-COP indexes, and to the development of complications.
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Affiliation(s)
- Alicia Lacoma
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain
| | - Albert Bas
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain
| | - Pere Tudela
- Unitat de Curta Estada-Urgències, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain
| | - Montse Giménez
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain
| | - Josep Maria Mòdol
- Unitat de Curta Estada-Urgències, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain
| | - Miguel Pérez
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain
| | - Vicente Ausina
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain
| | - Jose Dominguez
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain
| | - Cristina Prat-Aymerich
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autonòma de Barcelona, Badalona, Spain; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain.
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Optimizing triage and hospitalization in adult general medical emergency patients: the triage project. BMC Emerg Med 2013; 13:12. [PMID: 23822525 PMCID: PMC3723418 DOI: 10.1186/1471-227x-13-12] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 06/26/2013] [Indexed: 02/07/2023] Open
Abstract
Background Patients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long, costly hospital stays due to suboptimal initial triage and site-of-care decisions. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site-of-care decisions and to simplify early discharge management. Different triage scores have been proposed, such as the Manchester triage system (MTS). Yet, these scores focus only on treatment priority, have suboptimal performance and lack validation in the Swiss health care system. Because the MTS will be introduced into clinical routine at the Kantonsspital Aarau, we propose a large prospective cohort study to optimize initial patient triage. Specifically, the aim of this trial is to derive a three-part triage algorithm to better predict (a) treatment priority; (b) medical risk and thus need for in-hospital treatment; (c) post-acute care needs of patients at the most proximal time point of ED admission. Methods/design Prospective, observational, multicenter, multi-national cohort study. We will include all consecutive medical patients seeking ED care into this observational registry. There will be no exclusions except for non-adult and non-medical patients. Vital signs will be recorded and left over blood samples will be stored for later batch analysis of blood markers. Upon ED admission, the post-acute care discharge score (PACD) will be recorded. Attending ED physicians will adjudicate triage priority based on all available results at the time of ED discharge to the medical ward. Patients will be reassessed daily during the hospital course for medical stability and readiness for discharge from the nurses and if involved social workers perspective. To assess outcomes, data from electronic medical records will be used and all patients will be contacted 30 days after hospital admission to assess vital and functional status, re-hospitalization, satisfaction with care and quality of life measures. We aim to include between 5000 and 7000 patients over one year of recruitment to derive the three-part triage algorithm. The respective main endpoints were defined as (a) initial triage priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following ED admission to assess patients risk and thus need for in-hospital treatment and (c) post acute care needs after hospital discharge, defined as transfer of patients to a post-acute care institution, for early recognition and planning of post-acute care needs. Other outcomes are time to first physician contact, time to initiation of adequate medical therapy, time to social worker involvement, length of hospital stay, reasons for discharge delays, patient’s satisfaction with care, overall hospital costs and patients care needs after returning home. Discussion Using a reliable initial triage system for estimating initial treatment priority, need for in-hospital treatment and post-acute care needs is an innovative and persuasive approach for a more targeted and efficient management of medical patients in the ED. The proposed interdisciplinary , multi-national project has unprecedented potential to improve initial triage decisions and optimize resource allocation to the sickest patients from admission to discharge. The algorithms derived in this study will be compared in a later randomized controlled trial against a usual care control group in terms of resource use, length of hospital stay, overall costs and patient’s outcomes in terms of mortality, re-hospitalization, quality of life and satisfaction with care. Trial registration ClinicalTrials.gov Identifier,
NCT01768494
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