1
|
Varaldo E, Rumbolo F, Prencipe N, Bioletto F, Settanni F, Mengozzi G, Grottoli S, Ghigo E, Brazzi L, Montrucchio G, Berton AM. Effectiveness of Copeptin, MR-proADM and MR-proANP in Predicting Adverse Outcomes, Alone and in Combination with Traditional Severity Scores, a Secondary Analysis in COVID-19 Patients Requiring Intensive Care Admission. J Clin Med 2024; 13:2019. [PMID: 38610784 PMCID: PMC11012433 DOI: 10.3390/jcm13072019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Objective: To investigate whether copeptin, MR-proADM and MR-proANP, alone or integrated with the SOFA, MuLBSTA and SAPS II scores, are capable of early recognition of COVID-19 ICU patients at increased risk of adverse outcomes. Methods: For this predefined secondary analysis of a larger cohort previously described, all consecutive COVID-19 adult patients admitted between March and December 2020 to the ICU of a referral, university hospital in Northern Italy were screened, and clinical severity scores were calculated upon admission. A blood sample for copeptin, MR-proADM and MR-proANP was collected within 48 h (T1), on day 3 (T3) and 7 (T7). Outcomes considered were ICU and in-hospital mortality, bacterial superinfection, recourse to renal replacement therapy (RRT) or veno-venous extracorporeal membrane oxygenation, need for invasive mechanical ventilation (IMV) and pronation. Results: Sixty-eight patients were enrolled, and in-hospital mortality was 69.1%. ICU mortality was predicted by MR-proANP measured at T1 (HR 1.005, 95% CI 1.001-1.010, p = 0.049), although significance was lost if the analysis was adjusted for procalcitonin and steroid treatment (p = 0.056). Non-survivors showed higher MR-proADM levels than survivors at all time points, and an increase in the ratio between values at baseline and at T7 > 4.9% resulted in a more than four-fold greater risk of in-hospital mortality (HR 4.417, p < 0.001). Finally, when considering patients with any reduction in glomerular filtration, an early copeptin level > 23.4 pmol/L correlated with a more than five-fold higher risk of requiring RRT during hospitalization (HR 5.305, p = 0.044). Conclusion: Timely evaluation of MR-proADM, MR-proANP and copeptin, as well as changes in the former over time, might predict mortality and other adverse outcomes in ICU patients suffering from severe COVID-19.
Collapse
Affiliation(s)
- Emanuele Varaldo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Francesca Rumbolo
- Clinical Chemistry and Microbiology Laboratory, S. Croce and Carle Cuneo Hospital, 12100 Cuneo, Italy
| | - Nunzia Prencipe
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Fabio Bioletto
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Fabio Settanni
- Division of Clinical Biochemistry, Department of Laboratory Medicine, University of Turin, 10126 Turin, Italy
| | - Giulio Mengozzi
- Division of Clinical Biochemistry, Department of Laboratory Medicine, University of Turin, 10126 Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- Anestesia e Rianimazione 1 U, Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- Anestesia e Rianimazione 1 U, Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Alessandro Maria Berton
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| |
Collapse
|
2
|
Pietraszko P, Zorawski M, Bielecka E, Sielatycki P, Zbroch E. Mid-Regional Proadrenomedullin in COVID-19-May It Act as a Predictor of Prolonged Cardiovascular Complications? Int J Mol Sci 2023; 24:16821. [PMID: 38069140 PMCID: PMC10705931 DOI: 10.3390/ijms242316821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
The rising prevalence of cardiovascular disease (CVD) and the impact of the SARS-CoV-2 pandemic have both led to increased mortality rates, affecting public health and the global economy. Therefore, it is essential to find accessible, non-invasive prognostic markers capable of identifying patients at high risk. One encouraging avenue of exploration is the potential of mid-regional proadrenomedullin (MR-proADM) as a biomarker in various health conditions, especially in the context of CVD and COVID-19. MR-proADM presents the ability to predict mortality, heart failure, and adverse outcomes in CVD, offering promise for improved risk assessment and treatment strategies. On the other hand, an elevated MR-proADM level is associated with disease severity and cytokine storms in patients with COVID-19, making it a predictive indicator for intensive care unit admissions and mortality rates. Moreover, MR-proADM may have relevance in long COVID, aiding in the risk assessment, triage, and monitoring of individuals at increased risk of developing prolonged cardiac issues. Our review explores the potential of MR-proADM as a predictor of enduring cardiovascular complications following COVID-19 infection.
Collapse
Affiliation(s)
| | | | | | | | - Edyta Zbroch
- Department of Internal Medicine and Hypertension, Medical University of Bialystok, 15-089 Bialystok, Poland; (P.P.); (M.Z.); (E.B.); (P.S.)
| |
Collapse
|
3
|
Barzanji A, Abdi K, Yaghobi M, Roshani D, Karimian A. Triage Room Principles and Recommendations for 2019 Novel Coronavirus. Adv Biomed Res 2021; 10:24. [PMID: 34760806 PMCID: PMC8531736 DOI: 10.4103/abr.abr_127_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/16/2020] [Accepted: 04/26/2021] [Indexed: 12/02/2022] Open
Abstract
Triage becomes necessary when resources and time are not sufficient to provide the best possible services to all patients. This condition is more common in situations with a large number of casualties, like infectious epidemics. What is apparent is that, in the case of a widespread outbreak of infectious disease, hospitals are on the front lines of infected patient admission and treatment. Since the training of health-care workers is one of the most important pillars of preventive measures in controlling this pandemic, this study was conducted with the aim of expressing the principles of triage of infectious disease epidemic with a COVID-19 approach.
Collapse
Affiliation(s)
- Arvin Barzanji
- Department of Anesthesiology, Faculty of Paramedical Sciences, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Kamel Abdi
- Department of Nursing, Faculty of Medicine, Komar University of Science and Technology, Sulaymaniya, Iraq
| | - Mokhtar Yaghobi
- Clinical Care Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Daem Roshani
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.,Department of Epidemiology and Biostatistics, Medical Faculty, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Aram Karimian
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| |
Collapse
|
4
|
Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
Collapse
Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
| |
Collapse
|
5
|
Gonzalez Del Castillo J, Clemente-Callejo C, Llopis F, Irimia A, Oltra-Hostalet F, Rechner C, Schwabe A, Fernandez-Rodriguez V, Sánchez-Mora C, Giol-Amich J, Prieto-García B, Bardés-Robles I, Ortega-de Heredia MD, García-Lamberechts EJ, Navarro-Bustos C. Midregional proadrenomedullin safely reduces hospitalization in a low severity cohort with infections in the ED: a randomized controlled multi-centre interventional pilot study. Eur J Intern Med 2021; 88:104-113. [PMID: 33906810 DOI: 10.1016/j.ejim.2021.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The midregional fragment of proadrenomedullin (MR-proADM) is known to provide accurate short-, mid- and long term prognostic information in the triage and multi-dimensional risk assessment of patients in the emergency department (ED). In two independent observational cohorts MR-proADM values identified low disease severity patients without risk of disease progression in the ED with no 28 days mortality that wouldn´t require hospitalization. In this interventional study we want to show that the combination of an MR-proADM algorithm with clinical assessment is able to identify low risk patients not requiring hospitalization to safely reduce the number of hospital admissions. METHODS A randomized-controlled interventional multicenter study in 4 EDs in Spain. The study protocol was approved by Ethics Committees. Control arm patients received Standard Care. MR-proADM guided arm patients with low MR-proADM value (≤0.87 nmol/L) were treated as out-patients, with high MR-proADM value (>0.87 nmol/L) were hospitalized. The hospitalization rate was compared between the study arms. RESULTS Two hundred patients with suspicion of infection were enrolled. In the MR-proADM guided arm the hospital admission rate in the intention-to-treat (ITT) population was 17% lower than in the control arm (40.6% vs. 57.6%, p=0.024) and 20% lower in the per protocol (PP) population (37.2% vs. 57.6%, p=0.009). No deaths of out-patients and no significant difference for the safety endpoints readmission and representation rates were observed. The readmission rate was only slightly higher in the MR-proADM guided arm compared to the control arm (PP population: at 14 days 9.3% vs. 7.1%, difference 2.1% (95% CI: -11.0% to 15.2%); and at 28 days 11.1% vs. 9.5%, difference 1.6% (95% CI: -12.2% to 15.4%)). The rate of 28 days representation was slightly lower in the MR-proADM guided arm compared to the control arm (20.4% vs. 26.2%, difference -5.8% (95% CI: -25.0% to 13.4%); PP population). CONCLUSIONS Implementing a MR-proADM algorithm optimizes ED workflows efficiently and sustainably. Hospitals can highly benefit from a reduced rate of hospitalizations by 20% using MR-proADM. The safety in the MR-proADM guided study arm was similar to the Standard Care arm. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03770533.
Collapse
Affiliation(s)
- Juan Gonzalez Del Castillo
- Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain.
| | | | - Ferran Llopis
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Andreea Irimia
- Emergency Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain.
| | | | - Cindy Rechner
- Thermo Fisher Scientific, BRAHMS GmbH, Hennigsdorf, Germany.
| | - Andrej Schwabe
- Thermo Fisher Scientific, BRAHMS GmbH, Hennigsdorf, Germany.
| | - Verónica Fernandez-Rodriguez
- Emergency Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Catalina Sánchez-Mora
- Clinical Biochemistry Department. Hospital Universitario Virgen de la Macarena, Seville, Spain.
| | - Jordi Giol-Amich
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Belén Prieto-García
- Clinical Biochemistry Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Ignasi Bardés-Robles
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | | | | |
Collapse
|
6
|
Conca A, Koch D, Regez K, Kutz A, Bächli C, Haubitz S, Schuetz P, Mueller B, Spirig R, Petry H. Self-Care Index and Post-Acute Care Discharge Score to Predict Discharge Destination of Adult Medical Inpatients: Protocol for a Multicenter Validation Study. JMIR Res Protoc 2021; 10:e21447. [PMID: 33263553 PMCID: PMC7843199 DOI: 10.2196/21447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/14/2020] [Accepted: 12/01/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Delays in patient discharge can not only lead to deterioration, especially among geriatric patients, but also incorporate unnecessary resources at the hospital level. Many of these delays and their negative impact may be preventable by early focused screening to identify patients at risk for transfer to a post-acute care facility. Early interprofessional discharge planning is crucial in order to fit the appropriate individual discharge destination. While prediction of discharge to a post-acute care facility using post-acute care discharge score, the self-care index, and a combination of both has been shown in a single-center pilot study, an external validation is still missing. OBJECTIVE This paper outlines the study protocol and methodology currently being used to replicate the previous pilot findings and determine whether the post-acute care discharge score, the self-care index, or the combination of both can reliably identify patients requiring transfer to post-acute care facilities. METHODS This study will use prospective data involving all phases of the quasi-experimental study "In-HospiTOOL" conducted at 7 Swiss hospitals in urban and rural areas. During an 18-month period, consecutive adult medical patients admitted to the hospitals through the emergency department will be included. We aim to include 6000 patients based on sample size calculation. These data will enable a prospective external validation of the prediction instruments. RESULTS We expect to gain more insight into the predictive capability of the above-mentioned prediction instruments. This approach will allow us to get important information about the generalizability of the three different models. The study was approved by the institutional review board on November 21, 2016, and funded in May 2020. Expected results are planned to be published in spring 2021. CONCLUSIONS This study will provide evidence on prognostic properties, comparative performance, reliability of scoring, and suitability of the instruments for the screening purpose in order to be able to recommend application in clinical practice. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/21447.
Collapse
Affiliation(s)
- Antoinette Conca
- Department of Nursing Science, University Witten/Herdecke, Witten, Germany
| | - Daniel Koch
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Katharina Regez
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Ciril Bächli
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sebastian Haubitz
- 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
| | - Beat Mueller
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Rebecca Spirig
- Department of Nursing Science, University Witten/Herdecke, Witten, Germany
| | - Heidi Petry
- Centre of Clinical Nursing Research and Development, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
7
|
Haag E, Molitor A, Gregoriano C, Müller B, Schuetz P. The value of biomarker-guided antibiotic therapy. Expert Rev Mol Diagn 2020; 20:829-840. [PMID: 32529871 DOI: 10.1080/14737159.2020.1782193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION There is an increasing interest to individualize patient management and decisions regarding antibiotic treatment. Biomarkers may provide relevant information for this purpose. AREAS COVERED Despite a growing number of clinical trials investigating several biomarkers, there remain open questions regarding the best type of biomarker, timing or frequency of testing, and optimal cutoffs among others. The most promising results in regard to diagnosis of bacterial infection and therapy monitoring are found for procalcitonin (PCT), although some recent trials were not able to validate the promising earlier findings. Furthermore, less specific markers like C-reactive protein (CRP) and new prognostic biomarkers such as proadrenomedullin (MR-proADM) may improve the prognostic assessment of patients and proteomics may help shorten time to microbiological results. The aim of this review is to summarize the current concept of biomarker-guided management and provide an outlook of promising ongoing investigations. EXPERT OPINION 'Antibiotic stewardship' is complex and needs more than just the measurement of one single biomarker. However, when integrated into the context of a thorough clinical examination, standard blood parameters and a well done risk stratification by clinical scores such as the SOFA-score, biomarkers have great potential to improve the diagnostic and prognostic assessment of patients.
Collapse
Affiliation(s)
- Ellen Haag
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Alexandra Molitor
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Claudia Gregoriano
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Beat Müller
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Kantonsspital Aarau , Aarau, Switzerland
| |
Collapse
|
8
|
Roenhoej Rønhøj R, Hasselbalch RB, Schultz M, Pries-Heje M, Plesner LL, Ravn L, Lind M, Jensen BN, Hoei-Hansen Høi-Hansen T, Carlson N, Torp-Pedersen C, Rasmussen LS, Rasmussen LJH, Eugen-Olsen J, Koeber Køber L, Iversen K. Abnormal routine blood tests as predictors of mortality in acutely admitted patients. Clin Biochem 2019; 77:14-19. [PMID: 31843666 DOI: 10.1016/j.clinbiochem.2019.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/07/2019] [Accepted: 12/12/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study aimed to improve early risk stratification in the emergency department by creating a simple blood test score based on routine biomarkers and assess its predictive ability for 30-day mortality of acutely admitted patients. METHODS This was a secondary analysis of data from the TRIAGE II study. It included unselected acutely admitted medical and surgical patients, who had albumin, C-reactive protein, creatinine, haemoglobin, leukocytes, potassium, sodium and thrombocytes levels analysed upon admission. Patients were classified according to the number of biomarker results outside the reference range into four risk groups termed "very low", "low", "intermediate", and "high" with 0-1, 2-3, 4-5 and 6-8 abnormal biomarker results, respectively. Logistic regression was used to calculate odds ratios for 30-day mortality and receiver operating characteristic was used to test the discriminative value. The primary analysis was done in patients triaged with ADAPT (Adaptive Process Triage). Subsequently, we analysed two other cohorts of acutely admitted patients. RESULTS The TRIAGE II cohort included 17,058 eligible patients, 30-day mortality was 5.2%. The primary analysis included 7782 patients. Logistic regression adjusted for age and sex showed an OR of 24.1 (95% CI 14.9-41.0) between the very low- and the high-risk group. The area under the curve (AUC) was 0.79 (95% CI 0.76-0.81) for the blood test score in predicting 30-day mortality. The subsequent analyses confirmed the results. CONCLUSIONS A blood test score based on number of routine biomarkers with an abnormal result was a predictor of 30-day mortality in acutely admitted patients.
Collapse
Affiliation(s)
- Rasmus Roenhoej Rønhøj
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
| | - Rasmus B Hasselbalch
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Martin Schultz
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Mia Pries-Heje
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Louis L Plesner
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Birgitte N Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | | | - Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark; The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Departments of Cardiology and Clinical Research, Nordsjaellands Hospital, Dyrehavevej 29, 3400 Hilleroed, Denmark; Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Line J H Rasmussen
- Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - Lars Koeber Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Emergency Medicine, Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| |
Collapse
|
9
|
Saeed K, Wilson DC, Bloos F, Schuetz P, van der Does Y, Melander O, Hausfater P, Legramante JM, Claessens YE, Amin D, Rosenqvist M, White G, Mueller B, Limper M, Callejo CC, Brandi A, Macchi MA, Cortes N, Kutz A, Patka P, Yañez MC, Bernardini S, Beau N, Dryden M, van Gorp ECM, Minieri M, Chan L, Rood PPM, Del Castillo JG. The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:40. [PMID: 30736862 PMCID: PMC6368690 DOI: 10.1186/s13054-019-2329-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 01/18/2019] [Indexed: 12/16/2022]
Abstract
Background There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need. Methods An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days. Results One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR [95%CI], 45.5 [10.0–207.6], 23.4 [11.1–49.3] and 32.6 [9.4–113.6], respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities. Conclusions In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment. Electronic supplementary material The online version of this article (10.1186/s13054-019-2329-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kordo Saeed
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK. .,University of Southampton, School of Medicine, Southampton, UK.
| | | | - Frank Bloos
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.,Center for Sepsis Control & Care (CSCC), Jena University Hospital, Jena, Germany
| | - Philipp Schuetz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Yuri van der Does
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Olle Melander
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Pierre Hausfater
- Emergency Department hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris and Sorbonne Universités GRC-14 BIOSFAST and INSERM UMR-S 1166, Paris, France
| | - Jacopo M Legramante
- Emergency Department, Policlinico Tor Vergata, Rome, Italy.,Department of Medical Systems, Universita di Tor Vergata, Rome, Italy
| | - Yann-Erick Claessens
- Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France
| | - Deveendra Amin
- Department of Critical Care, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL, 33756, USA
| | - Mari Rosenqvist
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.,Infectious Disease Unit, Skåne University Hospital, Malmö, Sweden
| | - Graham White
- Department of Blood Sciences, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK
| | - Beat Mueller
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht University, Utrecht, Netherlands
| | | | | | - Marc-Alexis Macchi
- Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France
| | - Nicholas Cortes
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.,University of Southampton, School of Medicine, Southampton, UK.,Gibraltar Health Authority, St Bernard's Hospital, Gibraltar, Spain
| | - Alexander Kutz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland
| | - Peter Patka
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Sergio Bernardini
- Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy.,Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Nathalie Beau
- Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France
| | - Matthew Dryden
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.,University of Southampton, School of Medicine, Southampton, UK.,Rare and Imported Pathogen Laboratories, Public Health England, Porton Down, UK
| | - Eric C M van Gorp
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marilena Minieri
- Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy
| | - Louisa Chan
- Department of accident and emergency, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK
| | - Pleunie P M Rood
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Juan Gonzalez Del Castillo
- Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| |
Collapse
|
10
|
Citgez E, Zuur-Telgen M, van der Palen J, van der Valk P, Stolz D, Brusse-Keizer M. Stable-State Midrange Proadrenomedullin Is Associated With Severe Exacerbations in COPD. Chest 2018; 154:51-57. [DOI: 10.1016/j.chest.2018.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 11/30/2022] Open
|
11
|
Mr-Proadm Elevation Upon Icu Admission Predicts the Outcome of Septic Patients and is Correlated with Upcoming Fluid Overload. Shock 2018; 48:418-426. [PMID: 28414691 DOI: 10.1097/shk.0000000000000877] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Among septic patients admitted to the intensive care unit (ICU), early recognition of those with the highest risk of death is of paramount importance. We evaluated the prognostic value of Procalcitonin (PCT), mid regional-proadrenomedullin (MR-proADM), copeptine and CT-proendothelin 1 (CT-ProET 1) concentrations. METHODS This was a prospective cohort study, which included 173 septic patient admitted to one ICU. Blood samples for biomarker measurements were obtained upon admission and on day 5. The predictive value of each biomarker regarding the risk of death at day 28 was assessed. The fluid balance was evaluated from admission to day 5. RESULTS All cause ICU mortality was 36.4%. All the biomarkers except CT-ProET-1 were significantly more elevated in the non-survivors than in the survivors upon day 1. This was especially true for MR-proADM (8.6 [5.9] vs. 4.4 [3.9] nmol/L; P < 0.0001) and for the CT-proET-1/MR-proADM ratio (52.9 [22.4] vs. 31.3 [26.6] arbitrary units; P < 0.0001). The best AUROCC values on day 1 were obtained with MR-ProADM and the CT-proET-1/MR-proADM ratio as well (0.75 [0.67-0.85] and 0.82 [0.75-0.89]; 95% CI, respectively). An improved accuracy was achieved on day 5. Moreover, MR-ProADM baseline levels and fluid balance over the 5-day period following ICU admission were strongly correlated (Rho = 0.41; P < 0.001). CONCLUSIONS In patients admitted to the ICU with sepsis, MR-ProADM on admission was the best predictor of short-term clinical outcome if compared with others. This could be related to its ability to predict fluid sequestration.
Collapse
|
12
|
Screening by Social Workers in Medical Patients with Risk of Post-Acute Care Needs: A Stepped Wedge Cluster Randomized Trial / Evaluation eines Screenings durch Sozialarbeiter bei medizinischen Patienten mit einem Risiko für post-akuten Nachsorgebedarf: eine stepped wedge clusterrandomisierte Studie. INTERNATIONAL JOURNAL OF HEALTH PROFESSIONS 2018. [DOI: 10.2478/ijhp-2018-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Background
Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process.
Aim
To investigate the effect of screening patients at risk for post-acute care needs by social workers on time with respect to social workers’ notification, length of stay and delays in discharge compared to usual care.
Methods
Cluster randomized stepped wedge trial design for five clusters (wards) and two steps (control to intervention) was used. A total of 400 patients (200 per period) with high risk of post-acute care needs (defined as Post-Acute Care Discharge score, PACD ≥ 7) were included. Social workers performed a screening to decide about self-referral to their services (intervention period), which was compared to a highly structured standard SW notification by physicians and nurses (control period). A Generalized Estimating Equations model adjusted the clustering and baseline differences.
Results
A total of 139 patients were referred to social services (intervention: n = 76; control: n = 63). Time to social workers’ notification was significantly shorter in the intervention period when adjusted for all the differences in baseline (Mdn 1.2 vs 1.7, Beta = -0.73, 95%-CI 1.39 to -0.09). Both the length of stay and the delayed discharge time in nights showed no significant differences (Mdn 10.0 vs 9.1, Beta = -0.12, 95%-CI 0.46 to .22 nights 95%-CI, resp. Mdn 0.0 vs 0.0, Beta = .11, 95%-CI -0.64 to 0.86).
Conclusion
Screening speeded up social workers’ notification but did not accelerate the discharge processes. The screening by social workers might show process improvement in settings with less structured discharge planning.
Collapse
|
13
|
Elke G, Bloos F, Wilson DC, Brunkhorst FM, Briegel J, Reinhart K, Loeffler M, Kluge S, Nierhaus A, Jaschinski U, Moerer O, Weyland A, Meybohm P. The use of mid-regional proadrenomedullin to identify disease severity and treatment response to sepsis - a secondary analysis of a large randomised controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:79. [PMID: 29562917 PMCID: PMC5863464 DOI: 10.1186/s13054-018-2001-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 02/19/2018] [Indexed: 02/08/2023]
Abstract
Background This study assessed the ability of mid-regional proadrenomedullin (MR-proADM) in comparison to conventional biomarkers (procalcitonin (PCT), lactate, C-reactive protein) and clinical scores to identify disease severity in patients with sepsis. Methods This is a secondary analysis of a randomised controlled trial in patients with severe sepsis or septic shock across 33 German intensive care units. The association between biomarkers and clinical scores with mortality was assessed by Cox regression analysis, area under the receiver operating characteristic and Kaplan-Meier curves. Patients were stratified into three severity groups (low, intermediate, high) for all biomarkers and scores based on cutoffs with either a 90% sensitivity or specificity. Results 1089 patients with a 28-day mortality rate of 26.9% were analysed. According to the Sepsis-3 definition, 41.2% and 58.8% fulfilled the criteria for sepsis and septic shock, with respective mortality rates of 20.0% and 32.1%. MR-proADM had the strongest association with mortality across all Sepsis-1 and Sepsis-3 subgroups and could facilitate a more accurate classification of low (e.g. MR-proADM vs. SOFA: N = 265 vs. 232; 9.8% vs. 13.8% mortality) and high (e.g. MR-proADM vs. SOFA: N = 161 vs. 155; 55.9% vs. 41.3% mortality) disease severity. Patients with decreasing PCT concentrations of either ≥ 20% (baseline to day 1) or ≥ 50% (baseline to day 4) but continuously high MR-proADM concentrations had a significantly increased mortality risk (HR (95% CI): 19.1 (8.0–45.9) and 43.1 (10.1–184.0)). Conclusions MR-proADM identifies disease severity and treatment response more accurately than established biomarkers and scores, adding additional information to facilitate rapid clinical decision-making and improve personalised sepsis treatment. Electronic supplementary material The online version of this article (10.1186/s13054-018-2001-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 12, 24105, Kiel, Germany.
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Center for Sepsis Control & Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | | | - Frank Martin Brunkhorst
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Center for Sepsis Control & Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Josef Briegel
- Department of Anaesthesiology, University Hospital Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Center for Sepsis Control & Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Markus Loeffler
- Clinical Trial Centre Leipzig, University of Leipzig, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ulrich Jaschinski
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Onnen Moerer
- Department of Anaesthesiology, University Hospital Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Andreas Weyland
- University Department for Anesthesia, Intensive and Emergency Medicine and Pain Management, Hospital Oldenburg, Rahel-Straus-Str. 10, 26133, Oldenburg, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | | |
Collapse
|
14
|
Conca A, Gabele A, Reutlinger B, Schuetz P, Kutz A, Haubitz S, Faessler L, Batschwaroff M, Schild U, Caldara Z, Regez K, Schirlo S, Vossler G, Kahles T, Nedeltchev K, Keller A, Huber A, De Geest S, Buergi U, Tobias P, Louis Simonet M, Mueller B, Schäfer-Keller P. Prediction of post-acute care demand in medical and neurological inpatients: diagnostic assessment of the post-acute discharge score - a prospective cohort study. BMC Health Serv Res 2018; 18:111. [PMID: 29439684 PMCID: PMC5812184 DOI: 10.1186/s12913-018-2897-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early identification of patients requiring transfer to post-acute care (PAC) facilities shortens hospital stays. With a focus on interprofessional assessment of biopsychosocial risk, this study's aim was to assess medical and neurological patients' post-acute care discharge (PACD) scores on days 1 and 3 after hospital admission regarding diagnostic accuracy and effectiveness as an early screening tool. The transfer to PAC facilities served as the outcome ("gold standard"). METHODS In this prospective cohort study, registered at ClinicalTrial.gov (NCT01768494) on January 2013, 1432 medical and 464 neurological patients (total n = 1896) were included consecutively between February and October 2013. PACD scores and other relevant data were extracted from electronic records of patient admissions, hospital stays, and interviews at day 30 post-hospital admission. To gauge the scores' accuracy, we plotted receiver operating characteristic (ROC) curves, calculated area under the curve (AUC), and determined sensitivity and specificity at various cut-off levels. RESULTS Medical patients' day 1 and day 3 PACD scores accurately predicted discharge to PAC facilities, with respective discriminating powers (AUC) of 0.77 and 0.82. With a PACD cut-off of ≥8 points, day 1 and 3 sensitivities were respectively 72.6% and 83.6%, with respective specificities of 66.5% and 70.0%. Neurological patients' scores showed lower accuracy both days: using the same cut-off, respective day 1 and day 3 AUCs were 0.68 and 0.78, sensitivities 41.4% and 68.7% and specificities 81.4% and 83.4%. CONCLUSION PACD scores at days 1 and 3 accurately predicted transfer to PAC facilities, especially in medical patients on day 3. To confirm and refine these results, PACD scores' value to guide discharge planning interventions and subsequent impact on hospital stay warrants further investigation. TRIAL REGISTRATION ClinialTrials.gov Identifier, NCT01768494 .
Collapse
Affiliation(s)
- Antoinette Conca
- Department of Clinical Nursing Science, Kantonsspital Aarau, Aarau, Switzerland. .,Pflege & MTTD, Fachabteilung Pflegeentwicklung. Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, CH, Switzerland.
| | - Angela Gabele
- Department of Clinical Nursing Science, Kantonsspital Aarau, Aarau, Switzerland
| | - Barbara Reutlinger
- Department of Clinical Nursing Science, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sebastian Haubitz
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas Faessler
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland.,Department of Psychology, University of Berne, Berne, Switzerland
| | - Marcus Batschwaroff
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Ursula Schild
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Zeljka Caldara
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Katharina Regez
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Susanne Schirlo
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Gabi Vossler
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department for Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Anja Keller
- Department of Social Services, Kantonsspital Aarau, Aarau, Switzerland
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sabina De Geest
- Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Ulrich Buergi
- Emergency Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Petra Tobias
- Emergency Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Martine Louis Simonet
- Service of General Internal Medicine, University Hospitals Geneva, Geneva, Switzerland
| | - Beat Mueller
- University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Petra Schäfer-Keller
- University of Applied Sciences and Arts Western Switzerland - School of Health Sciences Fribourg - HEdS-FR / HES-SO, Fribourg, Switzerland
| |
Collapse
|
15
|
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
| |
Collapse
|
16
|
FENG X, XIANG M, HUANG X, FENG X, FENG X. The Application of Clinical Nursing Pathway in the Classification Diagnosis and Treatment of Patients with Emergency Dyspnea. IRANIAN JOURNAL OF PUBLIC HEALTH 2017; 46:574-576. [PMID: 28540278 PMCID: PMC5439051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Xiaowei FENG
- Dept. of Emergency, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Meihuan XIANG
- Dept. of Integrated, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Xiuna HUANG
- Dept. of Emergency, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Xiaomei FENG
- Outpatient Operating Room, Traditional Chinese Medicine Hospital of Guangdong Province, Guangdong, China
| | - Xiaoling FENG
- Dept. of Nursing, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China,Corresponding Author:
| |
Collapse
|
17
|
Zuur-Telgen M, VanderValk P, van der Palen J, Kerstjens HAM, Brusse-Keizer M. Stable State Proadrenomedullin Level in COPD Patients: A Validation Study. COPD 2016; 14:219-227. [PMID: 27880050 DOI: 10.1080/15412555.2016.1250254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In patients with stable COPD, proadrenomedullin (MR-proADM) has been shown to be a good predictor for mortality. This study aims to provide an external validation of earlier observed cut-off values used by Zuur-Telgen et al. and Stolz.et al. in COPD patients in stable state and at hospitalization for an acute exacerbation of COPD (AECOPD). From the COMIC cohort study we included 545 COPD patients with a blood sample obtained in stable state (n = 490) and/or at hospitalization for an AECOPD (n = 101). Time to death was compared between patients with MR-proADM cut-off scores 0.71 and 0.75 nmol/L for stable state or 0.79 and 0.84 nmol/l for AECOPD. The predictive value of MR-proADM for survival was represented by the C statistic. Risk ratios were corrected for sex, age, BMI, presence of heart failure, and GOLD stage. Patients above the cut-off of 0.75 nmol/l had a 2-fold higher risk of dying than patient below this cut-off (95% CI: 1.20-3.41). The cut-off of 0.71 nmol/l showed only a borderline significantly higher risk of 1.67 (95% CI: 0.98-2.85). The corrected odds ratios for one-year mortality were 3.15 (95% CI 1.15-8.64) and 3.70 (95% CI 1.18-11.6) in patients with MR-proADM levels above versus below the cut-off of respectively 0.75 and 0.71 nmol/l measured in stable state. MR-proADM levels in samples at hospitalization for an AECOPD were not predictive for mortality in this validation cohort. MR-proADM in stable state is a powerful predictor for mortality.
Collapse
Affiliation(s)
- Maaike Zuur-Telgen
- a Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , the Netherlands.,b Department of Internal Medicine , Medisch Spectrum Twente , Enschede , the Netherlands
| | - Paul VanderValk
- a Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , the Netherlands
| | - Job van der Palen
- a Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , the Netherlands.,d Department of Research Methodology , Measurement, and Data Analysis, University of Twente , Enschede , the Netherlands
| | - Huib A M Kerstjens
- c Department of Pulmonary Medicine , Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Centre Groningen , Groningen , the Netherlands
| | | |
Collapse
|
18
|
Braun N, Hoess C, Kutz A, Christ-Crain M, Thomann R, Henzen C, Zimmerli W, Mueller B, Schuetz P. Obesity paradox in patients with community-acquired pneumonia: Is inflammation the missing link? Nutrition 2016; 33:304-310. [PMID: 27742103 DOI: 10.1016/j.nut.2016.07.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/18/2016] [Accepted: 07/24/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Positive associations between body mass index (BMI) and clinical outcomes have been found and are called "the obesity survival paradox." However, whether obesity has protective effects or if this paradox is because of confounding remains unclear. Herein, we analyzed the effects of weight on long-term mortality in a large cohort of patients with community-acquired pneumonia (CAP) and investigated whether the differential effects of obesity on inflammation pathways accounted for mortality differences. METHODS For this secondary analysis, we followed prospectively for 6 y 763 CAP patients who were previously included in a multicenter trial (the ProHOSP Trial). To assess associations of BMI with mortality and with several inflammatory biomarker levels, we calculated three regression models adjusted for severity: the pneumonia severity index (PSI); fully adjusted for PSI, age, sex, metabolic factors, cardiovascular diseases, and other comorbidities; and fully adjusted including biomarker levels. RESULTS Within the 763 patients studied, all-cause 6-y mortality was significantly lower in obese patients (BMI >30 kg/m2) compared with normal-weight patients (BMI 18.5-25 kg/m2), with a severity-adjusted hazard ratio of 0.641 (95% confidence interval 0.462-0.889) and robust results in fully adjusted and fully adjusted plus biomarker models. No associations of increased BMI and C-reactive protein, procalcitonin, or white blood cell count were found, but BMI > 30 kg/m2 was associated with higher proadrenomedullin levels. CONCLUSIONS Over a 6-y long-term follow-up, we found obesity to be associated with lower all-cause mortality in CAP patients, confirming the obesity paradox in this population. However, differences in inflammatory pathways did not explain these findings.
Collapse
Affiliation(s)
- Nina Braun
- Internal Medicine, Kantonsspital Münsterlingen, Switzerland; University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Claus Hoess
- Internal Medicine, Kantonsspital Münsterlingen, Switzerland
| | - Alexander Kutz
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Universitätsspital Basel, Basel, Switzerland
| | - Robert Thomann
- Department of Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Christoph Henzen
- Department of Internal Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Beat Mueller
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland.
| |
Collapse
|
19
|
Liu D, Xie L, Zhao H, Liu X, Cao J. Prognostic value of mid-regional pro-adrenomedullin (MR-proADM) in patients with community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis 2016; 16:232. [PMID: 27230573 PMCID: PMC4881068 DOI: 10.1186/s12879-016-1566-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 05/16/2016] [Indexed: 01/31/2023] Open
Abstract
Background The early identification of patients at risk of dying from community-acquired pneumonia (CAP) is critical for their treatment and for defining hospital resource consumption. Mid-regional pro-adrenomedullin (MR-proADM) has been extensively investigated for its prognostic value in CAP. However, the results are conflicting. The purpose of the present meta-analysis was to explore the diagnostic accuracy of MR-proADM for predicting mortality in patients suffering from CAP, particularly emergency department (ED) patients. Method We systematically searched the PubMed, Embase, Web of Knowledge and Cochrane databases. Studies were included if a 2 × 2 contingency table could be constructed based on both the MR-proADM level and the complications or mortality of patients diagnosed with CAP. The prognostic accuracy of MR-proADM in CAP was assessed using the bivariate meta-analysis model. We used the Q-test and I2 index to evaluate heterogeneity. Results MR-proADM displayed moderate diagnostic accuracy for predicting complications in CAP, with an overall area under the SROC curve (AUC) of 0.74 (95 % CI: 0.70–0.78). Eight studies with a total of 4119 patients in the emergency department (ED) were included. An elevated MR-proADM level was associated with increased risk of death from CAP (RR 6.16, 95 % CI 4.71–8.06); the I2 value was 0.0 %, and a fixed-effects model was used to pool RR. The pooled sensitivity and specificity were 0.74 (95 % CI: 0.67–0.79) and 0.73 (95 % CI: 0.70–0.77), respectively. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 2.8 (95 % CI, 2.3–3.3) and 0.36 (95 % CI, 0.29–0.45), respectively. In addition, the diagnostic odds ratio (DOR) was 8 (95 % CI, 5–11), and the overall area under the SROC curve was 0.76 (95 % CI, 0.72–0.80). Conclusions Our study has demonstrated that MR-proADM is predictive of increased complications and higher mortality rates in patients suffering from CAP. Future studies are warranted to determine the prognostic accuracy of MR-proADM in conjunction with severity scores or other biomarkers and to determine an optimal cut-off level. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1566-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Dan Liu
- Department of Respiratory Medicine, Tianjin Medical University General Hospital, Tianjin, 300070, China
| | - Lixin Xie
- Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Haiyan Zhao
- Department of Respiratory Medicine, Tianjin Medical University General Hospital, Tianjin, 300070, China
| | - Xueyao Liu
- Medical School, Nankai University, 94 Weijin Road, Tianjin, 300071, China.,Department of Pulmonary & Critical Care Medicine, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Jie Cao
- Department of Respiratory Medicine, Tianjin Medical University General Hospital, Tianjin, 300070, China.
| |
Collapse
|
20
|
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.
Collapse
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)
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
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.
Collapse
|
22
|
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.
Collapse
|
23
|
Schuetz P, Hausfater P, Amin D, Amin A, Haubitz S, Faessler L, Kutz A, Conca A, Reutlinger B, Canavaggio P, Sauvin G, Bernard M, Huber A, Mueller B. Biomarkers from distinct biological pathways improve early risk stratification in medical emergency patients: the multinational, prospective, observational TRIAGE study. Crit Care 2015; 19:377. [PMID: 26511878 PMCID: PMC4625457 DOI: 10.1186/s13054-015-1098-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 10/10/2015] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Early risk stratification in the emergency department (ED) is vital to reduce time to effective treatment in high-risk patients and to improve patient flow. Yet, there is a lack of investigations evaluating the incremental usefulness of multiple biomarkers measured upon admission from distinct biological pathways for predicting fatal outcome and high initial treatment urgency in unselected ED patients in a multicenter and multinational setting. METHOD We included consecutive, adult, medical patients seeking ED care into this observational, cohort study in Switzerland, France and the USA. We recorded initial clinical parameters and batch-measured prognostic biomarkers of inflammation (pro-adrenomedullin [ProADM]), stress (copeptin) and infection (procalcitonin). RESULTS During a 30-day follow-up, 331 of 7132 (4.6 %) participants reached the primary endpoint of death within 30 days. In logistic regression models adjusted for conventional risk factors available at ED admission, all three biomarkers strongly predicted the risk of death (AUC 0.83, 0.78 and 0.75), ICU admission (AUC 0.67, 0.69 and 0.62) and high initial triage priority (0.67, 0.66 and 0.58). For the prediction of death, ProADM significantly improved regression models including (a) clinical information available at ED admission (AUC increase from 0.79 to 0.84), (b) full clinical information at ED discharge (AUC increase from 0.85 to 0.88), and (c) triage information (AUC increase from 0.67 to 0.83) (p <0.01 for each comparison). Similarly, ProADM also improved clinical models for prediction of ICU admission and high initial treatment urgency. Results were robust in regard to predefined patient subgroups by center, main diagnosis, presenting symptoms, age and gender. CONCLUSIONS Combination of clinical information with results of blood biomarkers measured upon ED admission allows early and more adequate risk stratification in individual unselected medical ED patients. A randomized trial is needed to answer the question whether biomarker-guided initial patient triage reduces time to initial treatment of high-risk patients in the ED and thereby improves patient flow and clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT01768494 . Registered January 9, 2013.
Collapse
Affiliation(s)
- Philipp Schuetz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
- Medical Faculty of the University of Basel, Basel, Switzerland.
| | - Pierre Hausfater
- Emergency Department, Groupe Hospitalier Pitié-Salpêtrière Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Devendra Amin
- Department of critical care, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL, 33756, USA.
| | - Adina Amin
- Department of critical care, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL, 33756, USA.
| | - Sebastian Haubitz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Lukas Faessler
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Alexander Kutz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Antoinette Conca
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Barbara Reutlinger
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Pauline Canavaggio
- Emergency Department, Groupe Hospitalier Pitié-Salpêtrière Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Gabrielle Sauvin
- Emergency Department, Groupe Hospitalier Pitié-Salpêtrière Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Maguy Bernard
- Biochemistry Department, Hôpital Pitié-Salpêtrière and Univ-Paris Descartes, Paris, France.
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
| | - Beat Mueller
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland.
- Medical Faculty of the University of Basel, Basel, Switzerland.
| |
Collapse
|
24
|
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.
Collapse
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.
| |
Collapse
|
25
|
Kolditz M, Seyfarth HJ, Wilkens H, Ewert R, Bollmann T, Dinter C, Hertel S, Klose H, Opitz C, Grünig E, Höffken G, Halank M. MR-proADM Predicts Exercise Capacity and Survival Superior to Other Biomarkers in PH. Lung 2015; 193:901-10. [PMID: 26363916 DOI: 10.1007/s00408-015-9802-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/07/2015] [Indexed: 01/21/2023]
Abstract
PURPOSE Besides the established biomarker NT-proBNP, the new cardiovascular biomarkers MR-proANP, MR-proADM, Copeptin, and CT-proET-1 are promising to evaluate hemodynamics, exercise parameters, and prognosis in patients with pulmonary hypertension (PH). METHODS 125 consecutive patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) were prospectively enrolled at five German PH centers. Blood samples were taken during right heart catheterization. The primary study endpoint was the correlation between biomarkers and hemodynamic and exercise parameters. As secondary endpoint, prediction of 1-year mortality was evaluated. RESULTS MR-proADM showed the strongest correlations with 6MWD and VO2peak, whereas NT-proBNP showed the strongest correlations with PVR, PAPm, and CI. In multivariate analysis, only MR-proADM was independently associated with exercise variables, whereas only NT-proBNP independently predicted hemodynamic parameters. All biomarkers were associated with 1-year survival, with MR-proADM showing the highest C index of 0.78. In multivariate analysis, MR-proADM predicted survival independent of age, 6-MWD, CI, RAP, and NT-proBNP. The cut-off of 1.08 nmol/l provided a sensitivity of 83 % and specificity of 66 %. CONCLUSIONS Different biomarkers reflect distinctive disease aspects in PH. NT-proBNP best predicts hemodynamic impairment while MR-proADM strongly correlates with exercise capacity. Additionally, MR-proADM represents a promising new marker to evaluate prognosis in patients with PAH and CTEPH. Multi-marker strategies should further be evaluated.
Collapse
Affiliation(s)
- Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | | | - Heinrike Wilkens
- Department of Internal Medicine V, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, Ernst-Moritz-Arndt Universität Greifswald, Greifswald, Germany
| | - Tom Bollmann
- Department of Internal Medicine B, Ernst-Moritz-Arndt Universität Greifswald, Greifswald, Germany
| | | | - Sabine Hertel
- BRAHMS GmbH (Thermo Fisher Scientific), Hennigsdorf, Germany
| | - Hans Klose
- Department of Pneumology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Opitz
- Department of Internal Medicine/Cardiology, DRK Kliniken Berlin Köpenick, Berlin, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension at Thoraxclinic Heidelberg, Heidelberg, Germany
| | - Gert Höffken
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Michael Halank
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| |
Collapse
|
26
|
Alan M, Grolimund E, Kutz A, Christ-Crain M, Thomann R, Falconnier C, Hoess C, Henzen C, Zimmerli W, Mueller B, Schuetz P. Clinical risk scores and blood biomarkers as predictors of long-term outcome in patients with community-acquired pneumonia: a 6-year prospective follow-up study. J Intern Med 2015; 278:174-84. [PMID: 25529395 DOI: 10.1111/joim.12341] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Prediction of long-term outcomes in patients with community-acquired pneumonia (CAP) is incompletely understood. We investigated the value of clinical risk scores [pneumonia severity index (PSI) and CURB-65] (Confusion, Urea, Respiratory rate, Blood Pressure, Age >65 years) and blood biomarkers of different physiopathological pathways in predicting long-term survival in a well-characterized cohort of patients with CAP enrolled in an antibiotic stewardship trial. DESIGN, SETTING AND SUBJECTS Patients admitted with CAP to six medical centres in Switzerland were prospectively followed for 6 years. Cox regression models and area under the receiver operating characteristics curve (AUC) were used to investigate associations between initial risk assessment and all-cause mortality. MAIN OUTCOME MEASURE All-cause mortality during a 6-year follow-up period. RESULTS Six-year mortality in the present cohort (median age 73 years) was 45.1% [95% confidence interval (CI) 41.8-48.3%]. Initial PSI and CURB-65 scores both had excellent long-term prognostic accuracy, with a stepwise increase in mortality per risk class. The hazard ratios (95% CI) of the highest PSI and CURB-65 classes (reference: lowest class) were 38.0 (14.0-103.0) and 7.8 (2.2-14.5), respectively, after 6 years. The addition of inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers measured upon hospital admission further improved the prognostic capabilities of the PSI (AUC increase from 0.79 to 0.83; P < 0.0001) and the CURB-65 score (AUC increase from 0.73 to 0.80; P < 0.001). CONCLUSION Risk assessment using clinical scores allowed accurate long-term prognostication, which was further improved by the addition of two inflammatory (pro-adrenomedullin) and cardiac (pro-atrial natriuretic peptide) blood biomarkers. These data provide a rationale for a more risk-adapted, 'personalized' strategy for long-term management of patients with CAP.
Collapse
Affiliation(s)
- M Alan
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - E Grolimund
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - A Kutz
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - M Christ-Crain
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - R Thomann
- Department of Internal Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - C Falconnier
- Basel University Medical Clinic Liestal, Liestal, Switzerland
| | - C Hoess
- Department of Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - C Henzen
- Department of Internal Medicine, Kantonsspital Lucerne, Lucerne, Switzerland
| | - W Zimmerli
- Basel University Medical Clinic Liestal, Liestal, Switzerland
| | - B Mueller
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - P Schuetz
- University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | | |
Collapse
|
27
|
Cavallazzi R, El-Kersh K, Abu-Atherah E, Singh S, Loke YK, Wiemken T, Ramirez J. Midregional proadrenomedullin for prognosis in community-acquired pneumonia: a systematic review. Respir Med 2015; 108:1569-80. [PMID: 25448309 DOI: 10.1016/j.rmed.2014.09.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 09/27/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The initial prognostic assessment of patients with community-acquired pneumonia( CAP) has important clinical implications. We hypothesized that midregional proadrenomedullin(MR-proADM) is a valuable test for the prediction of outcomes in patients with CAP.Methods: We performed a systemic review of the literature and a meta-analysis to evaluate the prognostic value of MR-proADM for short and long-term mortality in patients with CAP.Results: Twelve studies were included in the systematic review. Elevated MR-proADM was associated with an increase in short-term mortality (OR Z 6.8; 95% CI: 4.65-10.13; P value < 0.001) and complications (OR = 5.0; 95% CI: 3.86-6.49; P value < 0.001). The pooled analysis of 4 studies showed an improvement in the discriminant ability by 8% (95% CI: 2%e14%)when MR-proADM was added to CURB-65/CRB-65. Studies that reported long-term prognosis indicated an increased risk of death in patients with elevated MR-proADM.Conclusion: Elevated level of MR-proADM is significantly associated with both short-term mortality and complications in patients with CAP. Studies also indicate that MR-proADM has prognostic value for prediction of long-term mortality in these patients. The addition of MR-proADM improves the discriminant ability of CURB-65/CRB-65.
Collapse
Affiliation(s)
- Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville, Louisville, KY, USA.
| | | | | | | | | | | | | |
Collapse
|
28
|
Usefulness of midregional proadrenomedullin to predict poor outcome in patients with community acquired pneumonia. PLoS One 2015; 10:e0125212. [PMID: 26030588 PMCID: PMC4452655 DOI: 10.1371/journal.pone.0125212] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/22/2015] [Indexed: 01/09/2023] Open
Abstract
Background midregional proadrenomedullin (MR-proADM) is a prognostic biomarker in patients with community-acquired pneumonia (CAP). We sought to confirm whether MR-proADM added to Pneumonia Severity Index (PSI) improves the potential prognostic value of PSI alone, and tested to what extent this combination could be useful in predicting poor outcome of patients with CAP in an Emergency Department (ED). Methods Consecutive patients diagnosed with CAP were enrolled in this prospective, single-centre, observational study. We analyzed the ability of MR-proADM added to PSI to predict poor outcome using receiver operating characteristic (ROC) curves, logistic regression and risk reclassification and comparing it with the ability of PSI alone. The primary outcome was “poor outcome”, defined as the incidence of an adverse event (ICU admission, hospital readmission, or mortality at 30 days after CAP diagnosis). Results 226 patients were included; 33 patients (14.6%) reached primary outcome. To predict primary outcome the highest area under curve (AUC) was found for PSI (0.74 [0.64-0.85]), which was not significantly higher than for MR-proADM (AUC 0.72 [0.63-0.81, p > 0.05]). The combination of PSI and MR-proADM failed to improve the predictive potential of PSI alone (AUC 0.75 [0.65-0.85, p=0.56]). Ten patients were appropriately reclassified when the combined PSI and MR-proADM model was used as compared with the model of PSI alone. Net reclassification improvement (NRI) index was statistically significant (7.69%, p = 0.03) with an improvement percentage of 3.03% (p = 0.32) for adverse event, and 4.66% (P = 0.02) for no adverse event. Conclusion MR-proADM in combination with PSI may be helpful in individual risk stratification for short-term poor outcome of CAP patients, allowing a better reclassification of patients compared with PSI alone.
Collapse
|
29
|
Abstract
AbstractThe recognition over 25 years ago that the host response plays an exquisite role in sepsis, led to the today still-standard sepsis definition. Unfortunately, the inflammatory response syndrome (SIRS) criteria turned out to be less useful than anticipated, lacking sensitivity, specificity and ease of clinical application. Had novel host-response biomarkers been available by that time, it arguably would have been preferable to white blood cell count as an unspecific and not-sensitive laboratory-based SIRS criterion. Several novel markers have been put forward as sepsis markers with better diagnostic and/or prognostic potential in sepsis including inflammatory markers such as procalcitonin (PCT), presepsin, proadrenomedullin (ProADM), endothelial dysfunction markers such as P-selectin, E-selectin, intercellular cell adhesion molecule [ICAM]-1 and vascular cell adhesion molecule [VCAM]-1 and genetic markers among others. The limitations to using clinical parameters and conventional diagnostic markers for patients with clinical suspicion of sepsis may directly lead to both, under treatment of patients with severe disease needing urgent antibiotic and fluid therapy, and unnecessary and prolonged exposure to antimicrobial agents adversely affecting patient outcomes and increasing antibiotic resistance. The aim of this review is to summarize the current evidence for emerging diagnostic, prognostic, and therapeutic-response sepsis biomarkers in different infections and clinical settings, and discuss the reliability, potential benefit and limitations of these marker when used in clinical routine for sepsis management.
Collapse
|
30
|
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.
Collapse
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
| | | |
Collapse
|
31
|
Grolimund E, Kutz A, Marlowe RJ, Vögeli A, Alan M, Christ-Crain M, Thomann R, Falconnier C, Hoess C, Henzen C, Zimmerli W, Mueller B, Schuetz P. Long-term Prognosis in COPD Exacerbation: Role of Biomarkers, Clinical Variables and Exacerbation Type. COPD 2014; 12:295-305. [PMID: 25230352 DOI: 10.3109/15412555.2014.949002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Long-term outcome prediction in COPD is challenging. We conducted a prospective 5-7-year follow-up study in patients with COPD to determine the association of exacerbation type, discharge levels of inflammatory biomarkers including procalctionin (PCT), C-reactive protein (CRP), white blood cell count (WBC) and plasma proadrenomedullin (ProADM), alone or combined with demographic/clinical characteristics, with long-term all-cause mortality in the COPD setting. The analyzed cohort comprised 469 patients with index hospitalization for pneumonic (n = 252) or non-pneumonic (n = 217) COPD exacerbation. Five-to-seven-year vital status was ascertained via structured phone interviews with patients or their household members/primary care physicians. We investigated predictive accuracy using univariate and multivariate Cox regression models and area under the receiver operating characteristic curve (AUC). After a median [25th-75th percentile] 6.1 [5.6-6.5] years, mortality was 55% (95%CI 50%-59%). Discharge ProADM concentration was strongly associated with 5-7-year non-survival: adjusted hazard ratio (HR)/10-fold increase (95%CI) 10.4 (6.2-17.7). Weaker associations were found for PCT and no significant associations were found for CRP or WBC. Combining ProADM with demographic/clinical variables including age, smoking status, BMI, New York Heart Association dyspnea class, exacerbation type, and comorbidities significantly improved long-term predictive accuracy over that of the demographic/clinical model alone: AUC (95%CI) 0.745 (0.701-0.789) versus 0.727 (0.681-0.772), (p) = .043. In patients hospitalized for COPD exacerbation, discharge ProADM levels appeared to accurately predict 5-7-year all-cause mortality and to improve long-term prognostic accuracy of multidimensional demographic/clinical mortality risk assessment.
Collapse
Affiliation(s)
- Eva Grolimund
- 1Medical University Clinic, Kantonsspital Aarau , Aarau , Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
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.
Collapse
Affiliation(s)
- Philipp Schuetz
- Department of Endocrinology, Diabetes and Clinical Nutrition, Medical University Clinic, Kantonsspital Aarau, Tellstrasse, 5001 Aarau, Switzerland
| | | |
Collapse
|
33
|
Corticosteroid treatment for community-acquired pneumonia--the STEP trial: study protocol for a randomized controlled trial. Trials 2014; 15:257. [PMID: 24974155 PMCID: PMC4083867 DOI: 10.1186/1745-6215-15-257] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 06/16/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is the third-leading infectious cause of death worldwide. The standard treatment of CAP has not changed for the past fifty years and its mortality and morbidity remain high despite adequate antimicrobial treatment. Systemic corticosteroids have anti-inflammatory effects and are therefore discussed as adjunct treatment for CAP. Available studies show controversial results, and the question about benefits and harms of adjunct corticosteroid therapy has not been conclusively resolved, particularly in the non-critical care setting. METHODS/DESIGN This randomized multicenter study compares a treatment with 7 days of prednisone 50 mg with placebo in adult patients hospitalized with CAP independent of severity. Patients are screened and enrolled within the first 36 hours of presentation after written informed consent is obtained. The primary endpoint will be time to clinical stability, which is assessed every 12 hours during hospitalization. Secondary endpoints will be, among others, all-cause mortality within 30 and 180 days, ICU stay, duration of antibiotic treatment, disease activity scores, side effects and complications, value of adrenal function testing and prognostic hormonal and inflammatory biomarkers to predict outcome and treatment response to corticosteroids. Eight hundred included patients will provide an 85% power for the intention-to-treat analysis of the primary endpoint. DISCUSSION This largest to date double-blind placebo-controlled multicenter trial investigates the effect of adjunct glucocorticoids in 800 patients with CAP requiring hospitalization. It aims to give conclusive answers about benefits and risks of corticosteroid treatment in CAP. The inclusion of less severe CAP patients will be expected to lead to a relatively low mortality rate and survival benefit might not be shown. However, our study has adequate power for the clinically relevant endpoint of clinical stability. Due to discontinuing glucocorticoids without tapering after seven days, we limit duration of glucocorticoid exposition, which may reduce possible side effects. TRIAL REGISTRATION 7 September 2009 on ClinicalTrials.gov: NCT00973154.
Collapse
|
34
|
Widmer D, Drozdov D, Rüegger K, Litke A, Arici B, Regez K, Guglielmetti M, Schild U, Conca A, Schäfer P, Kouegbe RB, Reutlinger B, Blum C, Schuetz P, Irani S, Huber A, Bürgi U, Müller B, Albrich WC. Effectiveness of Proadrenomedullin Enhanced CURB65 Score Algorithm in Patients with Community-Acquired Pneumonia in "Real Life", an Observational Quality Control Survey. J Clin Med 2014; 3:267-79. [PMID: 26237261 PMCID: PMC4449665 DOI: 10.3390/jcm3010267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND An intervention trial found a trend for shorter length of stay (LOS) in patients with community-acquired pneumonia (CAP) when the CURB65 score was combined with the prognostic biomarker proadrenomedullin (ProADM) (CURB65-A). However, the efficacy and safety of CURB65-A in real life situations remains unclear. METHODS From September, 2011, until April, 2012, we performed a post-study prospective observational quality control survey at the cantonal Hospital of Aarau, Switzerland of consecutive adults with CAP. The primary endpoint was length of stay (LOS) during the index hospitalization and within 30 days. We compared the results with two well-defined historic cohorts of CAP patients hospitalized in the same hospital with the use of multivariate regression, namely 83 patients in the observation study without ProADM (OPTIMA I) and the 169 patients in the intervention study (OPTIMA II RCT). RESULTS A total of 89 patients with confirmed CAP were included. As compared to patients with CURB65 only observed in the OPTIMA I study, adjusted regression analysis showed a significant shorter initial LOS (7.5 vs. 10.4 days; -2.32; 95% CI, -4.51 to -0.13; p = 0.04) when CURB65-A was used in clinical routine. No significant differences were found for LOS within 30 days. There were no significant differences in safety outcomes in regard to mortality and ICU admission between the cohorts. CONCLUSION This post-study survey provides evidence that the use of ProADM in combination with CURB65 (CURB65-A) in "real life" situations reduces initial LOS compared to the CURB65 score alone without apparent negative effects on patient safety.
Collapse
Affiliation(s)
- Daniel Widmer
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Daniel Drozdov
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Kristina Rüegger
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Alexander Litke
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Birsen Arici
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Katharina Regez
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Merih Guglielmetti
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Ursula Schild
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Antoinette Conca
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Petra Schäfer
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Rita Bossart Kouegbe
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Barbara Reutlinger
- Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Claudine Blum
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Philipp Schuetz
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Sarosh Irani
- Division of Pulmonary Medicine, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Ulrich Bürgi
- Department of Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Beat Müller
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland.
| | - Werner C Albrich
- Division of Infectious Diseases and Hospital Hygiene, Cantonal Hospital St. Gallen, Rorschacherstrasse 95, St. Gallen CH-9007, Switzerland.
| |
Collapse
|
35
|
Drozdov D, Thomer A, Meili M, Schwarz S, Kouegbe RB, Regez K, Guglielmetti M, Schild U, Conca A, Schäfer P, Reutlinger B, Ottiger C, Buchkremer F, Litke A, Schuetz P, Huber A, Bürgi U, Fux CA, Bock A, Müller B, Albrich WC. Procalcitonin, pyuria and proadrenomedullin in the management of urinary tract infections--'triple p in uti': study protocol for a randomized controlled trial. Trials 2013; 14:84. [PMID: 23522152 PMCID: PMC3614534 DOI: 10.1186/1745-6215-14-84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/28/2013] [Indexed: 11/30/2022] Open
Abstract
Background Urinary tract infections (UTIs) are among the most common infectious diseases and drivers of antibiotic use and in-hospital days. A reduction of antibiotic use potentially lowers the risk of antibiotic resistance. An early and adequate risk assessment combining medical, biopsychosocial and functional risk scores has the potential to optimize site-of-care decisions and thus allocation of limited health-care resources. The aim of this factorial design study is twofold: first, for Intervention A, it investigates antibiotic exposure of patients treated with a protocol based on the type of UTI, procalcitonin (PCT) and pyuria. Second, for Intervention B, it investigates the usefulness of the prognostic biomarker proadrenomedullin (ProADM) integrated into an interdisciplinary assessment bundle for site-of-care decisions. Methods and design This randomized controlled open-label trial has a factorial design (2 × 2). Randomization of patients will be based on a pre-specified computer-generated randomization list and independent for the two interventions. Adults with UTI presenting to the emergency department (ED) will be screened and enrolled after providing informed consent. For our first Intervention (A), we developed a protocol based on previous observational research to recommend initiation and duration of antibiotic use based on the clinical presentation of UTI, pyuria and PCT levels. For our second intervention (B), an algorithm was developed to support site-of care decisions based on the prognostic marker ProADM and distinct nursing factors on days 1 and 3. Both interventions will be compared with a control group conforming to the guidelines. The primary endpoints for the two interventions will be: (A) overall exposure to antibiotics and (B) length of physician-led hospitalization within a follow-up of 30 days. Endpoints are assessed at discharge from hospital, and 30 and 90 days after admission. We plan to screen 300 patients and enroll 250 for an anticipated estimated loss of follow-up of 20%. This will provide adequate power for the two interventions. Discussion This trial investigates two strategies for improved individualized medical care in patients with UTI. The minimally effective duration of antibiotic therapy is not known for UTIs, which is important for reducing the selection pressure for antibiotic resistance, costs and drug-related side effects. Triage decisions must be improved to reflect the true medical, biopsychosocial and functional risks in order to allocate patients to the most appropriate care setting and reduce hospital-acquired disability. Trial registration Trial registration number:
ISRCTN13663741
Collapse
Affiliation(s)
- Daniel Drozdov
- Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau 5001, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|