1
|
Sathe NA, Zelnick LR, Morrell ED, Bhatraju PK, Kerchberger VE, Hough CL, Ware LB, Fohner AE, Wurfel MM. Development and External Validation of Models to Predict Persistent Hypoxemic Respiratory Failure for Clinical Trial Enrichment. Crit Care Med 2024; 52:764-774. [PMID: 38197736 PMCID: PMC11018468 DOI: 10.1097/ccm.0000000000006181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Improving the efficiency of clinical trials in acute hypoxemic respiratory failure (HRF) depends on enrichment strategies that minimize enrollment of patients who quickly resolve with existing care and focus on patients at high risk for persistent HRF. We aimed to develop parsimonious models predicting risk of persistent HRF using routine data from ICU admission and select research immune biomarkers. DESIGN Prospective cohorts for derivation ( n = 630) and external validation ( n = 511). SETTING Medical and surgical ICUs at two U.S. medical centers. PATIENTS Adults with acute HRF defined as new invasive mechanical ventilation (IMV) and hypoxemia on the first calendar day after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated discrimination, calibration, and practical utility of models predicting persistent HRF risk (defined as ongoing IMV and hypoxemia on the third calendar day after admission): 1) a clinical model with least absolute shrinkage and selection operator (LASSO) selecting Pa o2 /F io2 , vasopressors, mean arterial pressure, bicarbonate, and acute respiratory distress syndrome as predictors; 2) a model adding interleukin-6 (IL-6) to clinical predictors; and 3) a comparator model with Pa o2 /F io2 alone, representing an existing strategy for enrichment. Forty-nine percent and 69% of patients had persistent HRF in derivation and validation sets, respectively. In validation, both LASSO (area under the receiver operating characteristic curve, 0.68; 95% CI, 0.64-0.73) and LASSO + IL-6 (0.71; 95% CI, 0.66-0.76) models had better discrimination than Pa o2 /F io2 (0.64; 95% CI, 0.59-0.69). Both models underestimated risk in lower risk deciles, but exhibited better calibration at relevant risk thresholds. Evaluating practical utility, both LASSO and LASSO + IL-6 models exhibited greater net benefit in decision curve analysis, and greater sample size savings in enrichment analysis, compared with Pa o2 /F io2 . The added utility of LASSO + IL-6 model over LASSO was modest. CONCLUSIONS Parsimonious, interpretable models that predict persistent HRF may improve enrichment of trials testing HRF-targeted therapies and warrant future validation.
Collapse
Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lorraine B, Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison E Fohner
- Department of Epidemiology, School of Public Health, University of Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| |
Collapse
|
2
|
Zhang J, Guo Y, Mak M, Tao Z. Translational medicine for acute lung injury. J Transl Med 2024; 22:25. [PMID: 38183140 PMCID: PMC10768317 DOI: 10.1186/s12967-023-04828-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/24/2023] [Indexed: 01/07/2024] Open
Abstract
Acute lung injury (ALI) is a complex disease with numerous causes. This review begins with a discussion of disease development from direct or indirect pulmonary insults, as well as varied pathogenesis. The heterogeneous nature of ALI is then elaborated upon, including its epidemiology, clinical manifestations, potential biomarkers, and genetic contributions. Although no medication is currently approved for this devastating illness, supportive care and pharmacological intervention for ALI treatment are summarized, followed by an assessment of the pathophysiological gap between human ALI and animal models. Lastly, current research progress on advanced nanomedicines for ALI therapeutics in preclinical and clinical settings is reviewed, demonstrating new opportunities towards developing an effective treatment for ALI.
Collapse
Affiliation(s)
- Jianguo Zhang
- Department of Emergency Medicine, The Affiliated Hospital, Jiangsu University, Zhenjiang, 212001, Jiangsu, China
| | - Yumeng Guo
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China
| | - Michael Mak
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, 06520, USA
| | - Zhimin Tao
- Department of Emergency Medicine, The Affiliated Hospital, Jiangsu University, Zhenjiang, 212001, Jiangsu, China.
- Jiangsu Key Laboratory of Medical Science and Laboratory Medicine, Department of Laboratory Medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China.
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, 06520, USA.
- Zhenjiang Key Laboratory of High Technology Research on Exosomes Foundation and Transformation Application, School of Medicine, Jiangsu University, Zhenjiang, 212013, Jiangsu, China.
| |
Collapse
|
3
|
Suber TL, Wendell SG, Mullett SJ, Zuchelkowski B, Bain W, Kitsios GD, McVerry BJ, Ray P, Ray A, Mallampalli RK, Zhang Y, Shah F, Nouraie SM, Lee JS. Serum metabolomic signatures of fatty acid oxidation defects differentiate host-response subphenotypes of acute respiratory distress syndrome. Respir Res 2023; 24:136. [PMID: 37210531 PMCID: PMC10199668 DOI: 10.1186/s12931-023-02447-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/09/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Fatty acid oxidation (FAO) defects have been implicated in experimental models of acute lung injury and associated with poor outcomes in critical illness. In this study, we examined acylcarnitine profiles and 3-methylhistidine as markers of FAO defects and skeletal muscle catabolism, respectively, in patients with acute respiratory failure. We determined whether these metabolites were associated with host-response ARDS subphenotypes, inflammatory biomarkers, and clinical outcomes in acute respiratory failure. METHODS In a nested case-control cohort study, we performed targeted analysis of serum metabolites of patients intubated for airway protection (airway controls), Class 1 (hypoinflammatory), and Class 2 (hyperinflammatory) ARDS patients (N = 50 per group) during early initiation of mechanical ventilation. Relative amounts were quantified by liquid chromatography high resolution mass spectrometry using isotope-labeled standards and analyzed with plasma biomarkers and clinical data. RESULTS Of the acylcarnitines analyzed, octanoylcarnitine levels were twofold increased in Class 2 ARDS relative to Class 1 ARDS or airway controls (P = 0.0004 and < 0.0001, respectively) and was positively associated with Class 2 by quantile g-computation analysis (P = 0.004). In addition, acetylcarnitine and 3-methylhistidine were increased in Class 2 relative to Class 1 and positively correlated with inflammatory biomarkers. In all patients within the study with acute respiratory failure, increased 3-methylhistidine was observed in non-survivors at 30 days (P = 0.0018), while octanoylcarnitine was increased in patients requiring vasopressor support but not in non-survivors (P = 0.0001 and P = 0.28, respectively). CONCLUSIONS This study demonstrates that increased levels of acetylcarnitine, octanoylcarnitine, and 3-methylhistidine distinguish Class 2 from Class 1 ARDS patients and airway controls. Octanoylcarnitine and 3-methylhistidine were associated with poor outcomes in patients with acute respiratory failure across the cohort independent of etiology or host-response subphenotype. These findings suggest a role for serum metabolites as biomarkers in ARDS and poor outcomes in critically ill patients early in the clinical course.
Collapse
Affiliation(s)
- Tomeka L Suber
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA.
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Stacy G Wendell
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Steven J Mullett
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Benjamin Zuchelkowski
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - William Bain
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Georgios D Kitsios
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Prabir Ray
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anuradha Ray
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rama K Mallampalli
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Seyed Mehdi Nouraie
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Montefiore Hospital, University of Pittsburgh School of Medicine, NW 628, 3459 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Janet S Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University at St. Louis, St. Louis, MO, USA
| |
Collapse
|
4
|
Wijeysundera DN, Mistry N, Mazer CD. The Future of Clinical Trials Methodology: Accomplishments and Challenges Ahead. Anesth Analg 2022; 134:664-667. [PMID: 35299204 DOI: 10.1213/ane.0000000000005935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Duminda N Wijeysundera
- From the Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nikhil Mistry
- Department of Anesthesia, St Michael's Hospital, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- From the Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada.,Departments of Anesthesiology and Pain Medicine, and Physiology, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Yang L, Luo W, Zhang Q, Hong S, Wang Y, Samorodov AV, Chattipakorn N, Pavlov VN, Liang G. Cardamonin inhibits LPS-induced inflammatory responses and prevents acute lung injury by targeting myeloid differentiation factor 2. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2021; 93:153785. [PMID: 34638032 DOI: 10.1016/j.phymed.2021.153785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/22/2021] [Accepted: 09/29/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Acute lung injury (ALI) is a systemic inflammatory process, which has no pharmacological therapy in clinic. Accumulating evidence has demonstrated that natural compounds from herbs have potent anti-inflammatory efficacy in several disease models, which could be the potential candidates for the treatment of ALI. HYPOTHESIS/PURPOSE Anti-inflammatory screening from natural product bank may provide new anti-inflammatory compounds for therapeutic target discovery and ALI treatment. METHODS 165 natural compounds were screened for their anti-inflammatory activity in LPS-stimulated macrophages. PCR array, SPR and ELISA were used to determine the potential target of the most active compound, Cardamonin (CAR). The pharmacological effect of CAR was further evaluated in both LPS-stimulated macrophages and ALI mice model. RESULTS Out of the screened 165 compounds, CAR significantly inhibited LPS-induced inflammatory cytokine secretion in macrophages. We further showed that CAR significantly inhibited NF-κB and JNK signaling activation, and thereby inflammatory cytokine production via directly interacting with MD2 in vitro. In vivo, our data show that CAR treatment inhibited LPS-induced lung damage, systemic inflammatory cytokine production, and reduced macrophage infiltration in the lungs, accompanied with reduced TLR4/MD2 complex in lung tissues, Treatment with CAR also dose-dependently increased survival in the septic mice induced by DH5α bacterial infection. CONCLUSION We demonstrate that a natural product, CAR, attenuates LPS-induced lung injury and sepsis by inhibiting inflammation via interacting with MD2, leading to the inactivation of the TLR4/MD2-MyD88-MAPK/NF-κB pathway.
Collapse
Affiliation(s)
- Libin Yang
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Wu Luo
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China; Medical Research Center, the First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Qiuyan Zhang
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Shanshan Hong
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Yi Wang
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Aleksandr V Samorodov
- Department of Pharmacology, Bashkir State Medical University, Ufa City 450005, Russia
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Valentin N Pavlov
- Department of Pharmacology, Bashkir State Medical University, Ufa City 450005, Russia.
| | - Guang Liang
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China; School of Pharmaceutical Sciences, Hangzhou Medical College, Hangzhou, Zhejiang 311399, China; Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325001, China.
| |
Collapse
|
6
|
Khan YA, Fan E, Ferguson ND. Precision Medicine and Heterogeneity of Treatment Effect in Therapies for Acute Respiratory Distress Syndrome. Chest 2021; 160:1729-1738. [PMID: 34270967 PMCID: PMC8277554 DOI: 10.1016/j.chest.2021.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically heterogenous syndrome, rather than a distinct disease. This heterogeneity at least partially explains the difficulty in studying treatments for these patients and contributes to the numerous trials of therapies for the syndrome that have not shown benefit. Recent studies have identified different subphenotypes within the heterogenous patient population. These different subphenotypes likely have variable clinical responses to specific therapies, a concept known as heterogeneity of treatment effect (HTE). Recognizing different subphenotypes and HTE has important implications for the clinical management of patients with ARDS. In this review, we will present studies that have identified different subphenotypes and discuss how they can modify the effects of therapies evaluated in trials that are commonly considered to have demonstrated no overall benefit in patients with ARDS.
Collapse
Affiliation(s)
- Yasin A Khan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.
| |
Collapse
|
7
|
Sanwal R, Joshi K, Ditmans M, Tsai SSH, Lee WL. Ultrasound and Microbubbles for Targeted Drug Delivery to the Lung Endothelium in ARDS: Cellular Mechanisms and Therapeutic Opportunities. Biomedicines 2021; 9:biomedicines9070803. [PMID: 34356867 PMCID: PMC8301318 DOI: 10.3390/biomedicines9070803] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/27/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by increased permeability of the alveolar–capillary membrane, a thin barrier composed of adjacent monolayers of alveolar epithelial and lung microvascular endothelial cells. This results in pulmonary edema and severe hypoxemia and is a common cause of death after both viral (e.g., SARS-CoV-2) and bacterial pneumonia. The involvement of the lung in ARDS is notoriously heterogeneous, with consolidated and edematous lung abutting aerated, less injured regions. This makes treatment difficult, as most therapeutic approaches preferentially affect the normal lung regions or are distributed indiscriminately to other organs. In this review, we describe the use of thoracic ultrasound and microbubbles (USMB) to deliver therapeutic cargo (drugs, genes) preferentially to severely injured areas of the lung and in particular to the lung endothelium. While USMB has been explored in other organs, it has been under-appreciated in the treatment of lung injury since ultrasound energy is scattered by air. However, this limitation can be harnessed to direct therapy specifically to severely injured lungs. We explore the cellular mechanisms governing USMB and describe various permutations of cargo administration. Lastly, we discuss both the challenges and potential opportunities presented by USMB in the lung as a tool for both therapy and research.
Collapse
Affiliation(s)
- Rajiv Sanwal
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON M5B 1T8, Canada; (R.S.); (K.J.); (M.D.); (S.S.H.T.)
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Kushal Joshi
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON M5B 1T8, Canada; (R.S.); (K.J.); (M.D.); (S.S.H.T.)
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada
- Institute of Biomedical Engineering, Science and Technology (iBEST), Toronto, ON M5B 1T8, Canada
| | - Mihails Ditmans
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON M5B 1T8, Canada; (R.S.); (K.J.); (M.D.); (S.S.H.T.)
- Biomedical Engineering Graduate Program, Ryerson University, Toronto, ON M5B 2K3, Canada
| | - Scott S. H. Tsai
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON M5B 1T8, Canada; (R.S.); (K.J.); (M.D.); (S.S.H.T.)
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada
- Institute of Biomedical Engineering, Science and Technology (iBEST), Toronto, ON M5B 1T8, Canada
| | - Warren L. Lee
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON M5B 1T8, Canada; (R.S.); (K.J.); (M.D.); (S.S.H.T.)
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada
- Institute of Biomedical Engineering, Science and Technology (iBEST), Toronto, ON M5B 1T8, Canada
- Biomedical Engineering Graduate Program, Ryerson University, Toronto, ON M5B 2K3, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
- Correspondence: ; Tel.: +416-864-6060 (ext. 77655)
| |
Collapse
|
8
|
Tiba MH, McCracken BM, Leander DC, Colmenero CI, Nemzek JA, Sjoding MW, Konopka KE, Flott TL, VanEpps JS, Daniels RC, Ward KR, Stringer KA, Dickson RP. A novel swine model of the acute respiratory distress syndrome using clinically relevant injury exposures. Physiol Rep 2021; 9:e14871. [PMID: 33991456 PMCID: PMC8123544 DOI: 10.14814/phy2.14871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 12/18/2022] Open
Abstract
To date, existing animal models of the acute respiratory distress syndrome (ARDS) have failed to translate preclinical discoveries into effective pharmacotherapy or diagnostic biomarkers. To address this translational gap, we developed a high-fidelity swine model of ARDS utilizing clinically relevant lung injury exposures. Fourteen male swine were anesthetized, mechanically ventilated, and surgically instrumented for hemodynamic monitoring, blood, and tissue sampling. Animals were allocated to one of three groups: (1) Indirect lung injury only: animals were inoculated by direct injection of Escherichia coli into the kidney parenchyma, provoking systemic inflammation and distributive shock physiology; (2) Direct lung injury only: animals received volutrauma, hyperoxia, and bronchoscope-delivered gastric particles; (3) Combined indirect and direct lung injury: animals were administered both above-described indirect and direct lung injury exposures. Animals were monitored for up to 12 h, with serial collection of physiologic data, blood samples, and radiographic imaging. Lung tissue was acquired postmortem for pathological examination. In contrast to indirect lung injury only and direct lung injury only groups, animals in the combined indirect and direct lung injury group exhibited all of the physiological, radiographic, and histopathologic hallmarks of human ARDS: impaired gas exchange (mean PaO2 /FiO2 ratio 124.8 ± 63.8), diffuse bilateral opacities on chest radiographs, and extensive pathologic evidence of diffuse alveolar damage. Our novel porcine model of ARDS, built on clinically relevant lung injury exposures, faithfully recapitulates the physiologic, radiographic, and histopathologic features of human ARDS and fills a crucial gap in the translational study of human lung injury.
Collapse
Affiliation(s)
- Mohamad H. Tiba
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Brendan M. McCracken
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Danielle C. Leander
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Carmen I. Colmenero
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Jean A. Nemzek
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Unit of Laboratory Animal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Michael W. Sjoding
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMIUSA
- Department of Computational Medicine and BioinformaticsUniversity of MichiganAnn ArborMIUSA
| | - Kristine E. Konopka
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of PathologyUniversity of MichiganAnn ArborMIUSA
| | - Thomas L. Flott
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Clinical PharmacyCollege of PharmacyUniversity of MichiganAnn ArborMIUSA
| | - J. Scott VanEpps
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Biomedical EngineeringUniversity of MichiganAnn ArborMIUSA
- Biointerfaces InstituteUniversity of MichiganAnn ArborMIUSA
| | - Rodney C. Daniels
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Biomedical EngineeringUniversity of MichiganAnn ArborMIUSA
- Department of PediatricsPediatric Critical Care MedicineUniversity of MichiganAnn ArborMIUSA
| | - Kevin R. Ward
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Biomedical EngineeringUniversity of MichiganAnn ArborMIUSA
| | - Kathleen A. Stringer
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Department of Clinical PharmacyCollege of PharmacyUniversity of MichiganAnn ArborMIUSA
| | - Robert P. Dickson
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Department of Microbiology & ImmunologyUniversity of MichiganAnn ArborMIUSA
| |
Collapse
|
9
|
Pb S, Mittal S, Madan K, Mohan A, Tiwari P, Hadda V, Pandey RM, Guleria R. Awake prone positioning in non-intubated patients for the management of hypoxemia in COVID-19: A systematic review and meta-analysis. Monaldi Arch Chest Dis 2021; 91. [PMID: 33926179 DOI: 10.4081/monaldi.2021.1623] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/28/2021] [Indexed: 11/23/2022] Open
Abstract
Coronavirus disease-2019 (COVID-19) may lead to hypoxemia, requiring intensive care in many patients. Awake prone positioning (PP) is reported to improve oxygenation and is a relatively safe modality. We performed a systematic review of the literature to evaluate the available evidence and performed meta-analysis of the effect of awake PP in non-intubated patients on improvement in oxygenation and reducing the need for intubation. We searched the PubMed and EMBASE databases to identify studies using awake PP as a therapeutic strategy in the management of COVID-19. Studies were included if they reported respiratory outcomes and included five or more subjects. The quality of individual studies was assessed by the Qualsyst tool. A meta-analysis was performed to estimate the proportion of patients requiring intubation. The degree of improvement in oxygenation parameters (PaO2: FiO2 or PaO2 or SpO2) was also calculated. Sixteen studies (seven prospective trials, three before-after studies, six retrospective series) were selected for review. The pooled proportion of patients who required mechanical ventilation was 0.25 (95% confidence interval (CI) 0.16-0.34). There was a significant improvement in PaO2: FiO2 ratio, PaO2, and SpO2 during awake PP. To conclude, there is limited evidence to support the efficacy of awake PP for the management of hypoxemia in COVID-19. Further RCTs are required to study the impact of awake PP on key parameters like avoidance of mechanical ventilation, length of stay, and mortality.
Collapse
Affiliation(s)
- Sryma Pb
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi.
| |
Collapse
|
10
|
Juschten J, Tuinman PR, Guo T, Juffermans NP, Schultz MJ, Loer SA, Girbes ARJ, de Grooth HJ. Between-trial heterogeneity in ARDS research. Intensive Care Med 2021; 47:422-434. [PMID: 33713156 PMCID: PMC7955690 DOI: 10.1007/s00134-021-06370-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
Purpose Most randomized controlled trials (RCTs) in patients with acute respiratory distress syndrome (ARDS) revealed indeterminate or conflicting study results. We aimed to systematically evaluate between-trial heterogeneity in reporting standards and trial outcome. Methods A systematic review of RCTs published between 2000 and 2019 was performed including adult ARDS patients receiving lung-protective ventilation. A random-effects meta-regression model was applied to quantify heterogeneity (non-random variability) and to evaluate trial and patient characteristics as sources of heterogeneity. Results In total, 67 RCTs were included. The 28-day control-group mortality rate ranged from 10 to 67% with large non-random heterogeneity (I2 = 88%, p < 0.0001). Reported baseline patient characteristics explained some of the outcome heterogeneity, but only six trials (9%) reported all four independently predictive variables (mean age, mean lung injury score, mean plateau pressure and mean arterial pH). The 28-day control group mortality adjusted for patient characteristics (i.e. the residual heterogeneity) ranged from 18 to 45%. Trials with significant benefit in the primary outcome reported a higher control group mortality than trials with an indeterminate outcome or harm (mean 28-day control group mortality: 44% vs. 28%; p = 0.001). Conclusion Among ARDS RCTs in the lung-protective ventilation era, there was large variability in the description of baseline characteristics and significant unexplainable heterogeneity in 28-day control group mortality. These findings signify problems with the generalizability of ARDS research and underline the urgent need for standardized reporting of trial and baseline characteristics. Supplementary Information The online version of this article (10.1007/s00134-021-06370-w) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- J Juschten
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. .,Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - P R Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - T Guo
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Division of System Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - N P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - M J Schultz
- Department of Intensive Care, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A R J Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J de Grooth
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
11
|
Reilly JP, Meyer NJ, Shashaty MG, Anderson BJ, Ittner C, Dunn TG, Lim B, Forker C, Bonk MP, Kotloff E, Feng R, Cantu E, Mangalmurti NS, Calfee CS, Matthay MA, Mikacenic C, Walley KR, Russell J, Christiani DC, Wurfel MM, Lanken PN, Reilly MP, Christie JD. The ABO histo-blood group, endothelial activation, and acute respiratory distress syndrome risk in critical illness. J Clin Invest 2021; 131:139700. [PMID: 32931480 PMCID: PMC7773362 DOI: 10.1172/jci139700] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDThe ABO histo-blood group is defined by carbohydrate modifications and is associated with risk for multiple diseases, including acute respiratory distress syndrome (ARDS). We hypothesized that genetically determined blood subtype A1 is associated with increased risk of ARDS and markers of microvascular dysfunction and coagulation.METHODSWe conducted analyses in 3 cohorts of critically ill trauma and sepsis patients (n = 3710) genotyped on genome-wide platforms to determine the association of the A1 blood type genotype with ARDS risk. We subsequently determined whether associations were present in FUT2-defined nonsecretors who lack ABO antigens on epithelium, but not endothelium. In a patient subgroup, we determined the associations of blood type with plasma levels of endothelial glycoproteins and disseminated intravascular coagulation (DIC). Lastly, we tested whether blood type A was associated with less donor lung injury recovery during human ex vivo lung perfusion (EVLP).RESULTSThe A1 genotype was associated with a higher risk of moderate to severe ARDS relative to type O in all 3 populations. In sepsis, this relationship was strongest in nonpulmonary infections. The association persisted in nonsecretors, suggesting a vascular mechanism. The A1 genotype was also associated with higher DIC risk as well as concentrations of thrombomodulin and von Willebrand factor, which in turn were associated with ARDS risk. Blood type A was also associated with less lung injury recovery during EVLP.CONCLUSIONWe identified a replicable association between ABO blood type A1 and risk of ARDS among the critically ill, possibly mediated through microvascular dysfunction and coagulation.FUNDINGNIH HL122075, HL125723, HL137006, HL137915, DK097307, HL115354, HL101779, and the University of Pennsylvania McCabe Fund Fellowship Award.
Collapse
Affiliation(s)
- John P. Reilly
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
| | - Nuala J. Meyer
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
| | - Michael G.S. Shashaty
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
- Center for Clinical Epidemiology and Biostatics, and
| | - Brian J. Anderson
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
| | | | - Thomas G. Dunn
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
| | - Brian Lim
- Division of Pulmonary, Allergy, and Critical Care
| | | | | | | | - Rui Feng
- Center for Clinical Epidemiology and Biostatics, and
| | - Edward Cantu
- Center for Translational Lung Biology
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nilam S. Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
| | - Carolyn S. Calfee
- Department of Medicine and
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Michael A. Matthay
- Department of Medicine and
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Keith R. Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Russell
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - David C. Christiani
- T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | | | - Muredach P. Reilly
- Irving Institute for Clinical and Translational Research, Columbia University Irving Medical Center, New York, New York, USA
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology
- Center for Clinical Epidemiology and Biostatics, and
| |
Collapse
|
12
|
Clinical trials in critical care: can a Bayesian approach enhance clinical and scientific decision making? THE LANCET RESPIRATORY MEDICINE 2020; 9:207-216. [PMID: 33227237 DOI: 10.1016/s2213-2600(20)30471-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 02/07/2023]
Abstract
Recent Bayesian reanalyses of prominent trials in critical illness have generated controversy by contradicting the initial conclusions based on conventional frequentist analyses. Many clinicians might be sceptical that Bayesian analysis, a philosophical and statistical approach that combines prior beliefs with data to generate probabilities, provides more useful information about clinical trials than the frequentist approach. In this Personal View, we introduce clinicians to the rationale, process, and interpretation of Bayesian analysis through a systematic review and reanalysis of interventional trials in critical illness. In the majority of cases, Bayesian and frequentist analyses agreed. In the remainder, Bayesian analysis identified interventions where benefit was probable despite the absence of statistical significance, where interpretation depended substantially on choice of prior distribution, and where benefit was improbable despite statistical significance. Bayesian analysis in critical care medicine can help to distinguish harm from uncertainty and establish the probability of clinically important benefit for clinicians, policy makers, and patients.
Collapse
|
13
|
Mole S, Harry A, Fowler A, Hotee S, Warburton J, Waite S, Beerahee M, Behm DJ, Badorrek P, Müller M, Faulenbach C, Lazaar AL, Hohlfeld JM. Investigating the effect of TRPV4 inhibition on pulmonary-vascular barrier permeability following segmental endotoxin challenge. Pulm Pharmacol Ther 2020; 64:101977. [PMID: 33189900 DOI: 10.1016/j.pupt.2020.101977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/20/2020] [Accepted: 11/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute Respiratory Distress Syndrome (ARDS) is associated with increased pulmonary-vascular permeability. In the lung, transient receptor potential vanilloid 4 (TRPV4), a Ca2+-permeable cation channel, is a regulator of endothelial permeability and pulmonary edema. We performed a Phase I, placebo-controlled, double-blind, randomized, parallel group, proof-of-mechanism study to investigate the effects of TRPV4 channel blocker, GSK2798745, on pulmonary-vascular barrier permeability using a model of lipopolysaccharide (LPS)-induced lung inflammation. METHODS Healthy participants were randomized 1:1 to receive 2 single doses of GSK2798745 or placebo, 12 h apart. Two hours after the first dose, participants underwent bronchoscopy and segmental LPS instillation. Total protein concentration and neutrophil counts were measured in bronchoalveolar lavage (BAL) samples collected before and 24 h after LPS challenge, as markers of barrier permeability and inflammation, respectively. The primary endpoint was baseline adjusted total protein concentration in BAL at 24 h after LPS challenge. A Bayesian framework was used to estimate the posterior probability of any percentage reduction (GSK2798745 relative to placebo). Safety endpoints included the incidence of adverse events (AEs), vital signs, 12-lead electrocardiogram, clinical laboratory and haematological evaluations, and spirometry. RESULTS Forty-seven participants were dosed and 45 completed the study (22 on GSK2798745 and 23 on placebo). Overall, GSK2798745 was well tolerated. Small reductions in mean baseline adjusted BAL total protein (~9%) and neutrophils (~7%) in the LPS-challenged segment were observed in the GSK2798745 group compared with the placebo group; however, the reductions did not meet pre-specified success criteria of at least a 95% posterior probability that the percentage reduction in the mean 24-h post LPS BAL total protein level (GSK2798745 relative to placebo) exceeded zero. Median plasma concentrations of GSK2798745 were predicted to inhibit TRPV4 on lung vascular endothelial cells by ~70-85% during the 24 h after LPS challenge; median urea-corrected BAL concentrations of GSK2798745 were 3.0- to 8.7-fold higher than those in plasma. CONCLUSIONS GSK2798745 did not affect segmental LPS-induced elevation of BAL total protein or neutrophils, despite blood and lung exposures that were predicted to be efficacious. CLINICALTRIALS. GOV IDENTIFIER NCT03511105.
Collapse
Affiliation(s)
- Sarah Mole
- GlaxoSmithKline, Gunnells Wood Road, Stevenage, UK.
| | - Anya Harry
- GlaxoSmithKline, 1250 South Collegeville Road, Collegeville, PA, 19426, USA
| | - Andy Fowler
- GlaxoSmithKline, Stockley Park, West Uxbridge, Middlesex, UB11 1BT, UK
| | - Sarah Hotee
- GlaxoSmithKline, Gunnells Wood Road, Stevenage, UK
| | | | - Sarah Waite
- GlaxoSmithKline, Stockley Park, West Uxbridge, Middlesex, UB11 1BT, UK
| | | | - David J Behm
- GlaxoSmithKline, 1250 South Collegeville Road, Collegeville, PA, 19426, USA
| | - Philipp Badorrek
- Fraunhofer-Institut Fuer Toxikologie und Experimentelle Medizin [ITEM], Nikolai-Fuchs-Straße 1, 30625, Hannover, Germany
| | - Meike Müller
- Fraunhofer-Institut Fuer Toxikologie und Experimentelle Medizin [ITEM], Nikolai-Fuchs-Straße 1, 30625, Hannover, Germany
| | - Cornelia Faulenbach
- Fraunhofer-Institut Fuer Toxikologie und Experimentelle Medizin [ITEM], Nikolai-Fuchs-Straße 1, 30625, Hannover, Germany
| | - Aili L Lazaar
- GlaxoSmithKline, 1250 South Collegeville Road, Collegeville, PA, 19426, USA
| | - Jens M Hohlfeld
- Fraunhofer-Institut Fuer Toxikologie und Experimentelle Medizin [ITEM], Nikolai-Fuchs-Straße 1, 30625, Hannover, Germany; Hannover Medical School and German Centre for Lung Research, Medizinische Hochschule Hannover OE6876, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| |
Collapse
|
14
|
Dormire KD, Whitehead AJ, Wayant C, Bowers A, Vassar M. Evaluation of misrepresented findings in the abstracts of acute respiratory distress syndrome randomized trials with nonsignificant primary endpoints. THE CLINICAL RESPIRATORY JOURNAL 2020; 15:287-292. [PMID: 33080096 DOI: 10.1111/crj.13295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 10/08/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We investigated the randomized controlled trials (RCTs) related to acute respiratory distress syndrome (ARDS) to assess the presentation and frequency of misrepresented research findings, also known as spin. METHODS We searched PubMed (MEDLINE) for studies published from January 1, 2011 to December 31, 2019. We included randomized controlled trials with an ARDS intervention and a nonsignificant primary endpoint. Trial screening and data extraction was performed on all studies independently and in duplicate. The primary endpoint was to investigate the frequency and manifestation of spin in RCT abstracts. Our secondary endpoint was to investigate associations between funding source and spin. RESULTS Our PubMed search returned 766 articles with 37 meeting inclusion criteria. Spin was present in 14 (14/37, 37.8%; 95% CI 22.5%-55.2%) abstracts. The most common manifestations of spin were claiming benefit based on a significant secondary endpoint (6/14, 42.9%), followed by the use of 'trend' statements, such as 'trend toward significance' (2/14, 14.3%; 95% CI 1.8%-42.8%). The most common spin in abstract conclusions was in the form of claiming benefit due to a significant secondary endpoint (3/4, 75%; 95% CI 19.4%-99.4%). Our secondary endpoint did not identify a significant difference in the prevalence of spin in publicly funded (5/19, 26.3%; 95% CI 9.1%-51.2%) compared to privately funded (4/12, 33.3%; 95% CI 9.9%-65.1%) studies (p>.05). CONCLUSIONS RCTs of ARDS interventions with nonsignificant primary endpoints often included spin in the abstract. Spin in the abstract may influence clinician appraisal and interpretation of diagnostic or treatment modalities.
Collapse
Affiliation(s)
- Kody D Dormire
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Aldon J Whitehead
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Cole Wayant
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Aaron Bowers
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| |
Collapse
|
15
|
Bos LDJ, Scicluna BP, Ong DSY, Cremer O, van der Poll T, Schultz MJ. Understanding Heterogeneity in Biologic Phenotypes of Acute Respiratory Distress Syndrome by Leukocyte Expression Profiles. Am J Respir Crit Care Med 2020; 200:42-50. [PMID: 30645145 DOI: 10.1164/rccm.201809-1808oc] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rationale: Two biologic phenotypes of acute respiratory distress syndrome (ARDS) have been identified based on plasma protein markers in four previous studies. Objectives: To determine if blood leukocyte gene expression is different between the "reactive" and "uninflamed" phenotype. Methods: This is a new study adding blood leukocyte transcriptomics and bioinformatics analysis to an existing patient cohort of ARDS in patients with sepsis admitted to two ICUs during a 1.5-year period. Canonical pathway analysis was performed. Measurements and Main Results: A total of 210 patients with sepsis and ARDS were included, of whom 128 had a reactive and 82 an uninflamed phenotype. A total of 3,332/11,443 (29%) transcripts were significantly different between the phenotypes. Canonical pathway analysis showed upregulation of oxidative phosphorylation genes indicative of mitochondrial dysfunction (52% of genes in pathway). The uninflamed phenotype was characterized by upregulation of mitogen-activated protein kinase pathways. Conclusions: A third of genes are differentially expressed between biologic phenotypes of ARDS supporting the observation that the subgroups of ARDS are incomparable in terms of pathophysiology. These data provide additional support for biologic heterogeneity in patients with ARDS and suggests that a personalized approach to intervention focusing on oxidative phosphorylation is pivotal in this condition.
Collapse
Affiliation(s)
- Lieuwe D J Bos
- 1 Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology.,2 Department of Respiratory Medicine
| | - Brendon P Scicluna
- 3 Center of Experimental Molecular Medicine, and.,4 Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Infection and Immunity, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands
| | - David S Y Ong
- 5 Department of Microbiology, Julius Center for Health Sciences and Primary Care.,6 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, and
| | - Olaf Cremer
- 7 Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands; and
| | | | - Marcus J Schultz
- 1 Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology.,8 Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| |
Collapse
|
16
|
Contemporary strategies to improve clinical trial design for critical care research: insights from the First Critical Care Clinical Trialists Workshop. Intensive Care Med 2020; 46:930-942. [PMID: 32072303 PMCID: PMC7224097 DOI: 10.1007/s00134-020-05934-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/11/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Conducting research in critically-ill patient populations is challenging, and most randomized trials of critically-ill patients have not achieved pre-specified statistical thresholds to conclude that the intervention being investigated was beneficial. METHODS In 2019, a diverse group of patient representatives, regulators from the USA and European Union, federal grant managers, industry representatives, clinical trialists, epidemiologists, and clinicians convened the First Critical Care Clinical Trialists (3CT) Workshop to discuss challenges and opportunities in conducting and assessing critical care trials. Herein, we present the advantages and disadvantages of available methodologies for clinical trial design, conduct, and analysis, and a series of recommendations to potentially improve future trials in critical care. CONCLUSION The 3CT Workshop participants identified opportunities to improve critical care trials using strategies to optimize sample size calculations, account for patient and disease heterogeneity, increase the efficiency of trial conduct, maximize the use of trial data, and to refine and standardize the collection of patient-centered and patient-informed outcome measures beyond mortality.
Collapse
|
17
|
Cereda M, Xin Y, Goffi A, Herrmann J, Kaczka DW, Kavanagh BP, Perchiazzi G, Yoshida T, Rizi RR. Imaging the Injured Lung: Mechanisms of Action and Clinical Use. Anesthesiology 2019; 131:716-749. [PMID: 30664057 PMCID: PMC6692186 DOI: 10.1097/aln.0000000000002583] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
Collapse
Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, ON, Canada
| | - Jacob Herrmann
- Departments of Anesthesia and Biomedical Engineering, University of Iowa, IA
| | - David W. Kaczka
- Departments of Anesthesia, Radiology, and Biomedical Engineering, University of Iowa, IA
| | | | - Gaetano Perchiazzi
- Hedenstierna Laboratory and Uppsala University Hospital, Uppsala University, Sweden
| | - Takeshi Yoshida
- Hospital for Sick Children, University of Toronto, ON, Canada
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
18
|
Kross EK, Pollak KI, Curtis JR. Addressing the Psychological Symptoms of Critical Illness: The Importance of "Negative" Trials in Guiding Next Steps. JAMA 2019; 321:649-650. [PMID: 30776299 DOI: 10.1001/jama.2019.0072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Kathryn I Pollak
- Cancer Control and Population Sciences, Duke Cancer Institute, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| |
Collapse
|
19
|
Increased 90-Day Mortality in Spontaneously Breathing Patients With Paraquat Poisoning. Crit Care Med 2019; 47:219-228. [DOI: 10.1097/ccm.0000000000003518] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
20
|
Sjoding MW, Hofer TP, Co I, McSparron JI, Iwashyna TJ. Differences between Patients in Whom Physicians Agree and Disagree about the Diagnosis of Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2019; 16:258-264. [PMID: 30321489 PMCID: PMC6376946 DOI: 10.1513/annalsats.201806-434oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/12/2018] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Because the Berlin definition of acute respiratory distress syndrome (ARDS) has only moderate reliability, physicians disagree about the diagnosis of ARDS in some patients. Understanding the clinical differences between patients with agreement and disagreement about the diagnosis of ARDS may provide insight into the epidemiology and pathophysiology of this syndrome, and inform strategies to improve the reliability of ARDS diagnosis. OBJECTIVES To characterize patients with diagnostic disagreement about ARDS among critical-care-trained physicians and compare them with patients with a consensus that ARDS developed. METHODS Patients with acute hypoxemic respiratory failure (arterial oxygen tension/pressure [PaO2]/fraction of inspired oxygen [FiO2] < 300 during invasive mechanical ventilation) were independently reviewed for ARDS by multiple critical-care physicians and categorized as consensus-ARDS, disagreement about the diagnosis, or no ARDS. RESULTS Among 738 patients reviewed, 110 (15%) had consensus-ARDS, 100 (14%) had disagreement, and 528 (72%) did not have ARDS. ARDS diagnosis rates ranged from 9% to 47% across clinicians. Patients with disagreement had baseline comorbidity rates similar to those of patients with consensus-ARDS, but lower rates of ARDS risk factors and less severe measures of lung injury. Mean days of severe hypoxemia (PaO2/FiO2 < 100) were 3.2 (95% confidence interval [CI], 2.6-3.9), 2.0 (95% CI, 1.5-2.4), and 0.8 (95% CI, 0.7-0.9) among patients with consensus-ARDS, disagreement, and no ARDS, respectively. Hospital mortality was 37% (95% CI, 28-46%), 35% (95% CI, 26-44%), and 19% (95% CI, 15-22%) across groups. Simple combinations of specific ARDS risk factors and lowest PaO2/FiO2 value could effectively discriminate patients (area under the receiver operating characteristic curve = 0.90; 95% CI, 0.88-0.92). For example, 63% of patients with pneumonia, shock, and PaO2/FiO2 < 110 had consensus-ARDS, whereas 100% of patients without pneumonia or shock and PaO2/FiO2 > 180 did not have ARDS. CONCLUSIONS Disagreement about the diagnosis of ARDS is common and can be partly explained by the difficulty of dichotomizing patients along a continuous spectrum of ARDS manifestations. Considering both the presence of key ARDS risk factors and hypoxemia severity can help guide clinicians in identifying patients with diagnosis of ARDS agreed upon by a consensus of physicians.
Collapse
Affiliation(s)
- Michael W. Sjoding
- Department of Internal Medicine
- Center for Computational Medicine and Bioinformatics, and
| | - Timothy P. Hofer
- Department of Internal Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Ivan Co
- Department of Internal Medicine
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Theodore J. Iwashyna
- Department of Internal Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Social Research, Ann Arbor, Michigan; and
- Section Editor, AnnalsATS
| |
Collapse
|
21
|
Burgess JK, Heijink IH. The Safety and Efficiency of Addressing ARDS Using Stem Cell Therapies in Clinical Trials. STEM CELL-BASED THERAPY FOR LUNG DISEASE 2019. [PMCID: PMC7121814 DOI: 10.1007/978-3-030-29403-8_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Janette K. Burgess
- The University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, The Netherlands
| | - Irene H. Heijink
- The University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, The Netherlands
| |
Collapse
|
22
|
Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. Reply to Tremlett and Kanthimathinathan and to Koopman and Kneyber. Am J Respir Crit Care Med 2018; 198:823-824. [DOI: 10.1164/rccm.201806-1039le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Robinder G. Khemani
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Kaushik Parvathaneni
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Nadir Yehya
- University of PennsylvaniaPhiladelphia, Pennsylvaniaand
| | - Anoopindar K. Bhalla
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Neal J. Thomas
- Penn State Hershey Children’s HospitalHershey, Pennsylvania
| | - Christopher J. L. Newth
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| |
Collapse
|
23
|
Xin Y, Cereda M, Hamedani H, Pourfathi M, Siddiqui S, Meeder N, Kadlecek S, Duncan I, Profka H, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Unstable Inflation Causing Injury. Insight from Prone Position and Paired Computed Tomography Scans. Am J Respir Crit Care Med 2018; 198:197-207. [PMID: 29420904 PMCID: PMC6058981 DOI: 10.1164/rccm.201708-1728oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 01/16/2023] Open
Abstract
RATIONALE It remains unclear how prone positioning improves survival in acute respiratory distress syndrome. Using serial computed tomography (CT), we previously reported that "unstable" inflation (i.e., partial aeration with large tidal density swings, indicating increased local strain) is associated with injury progression. OBJECTIVES We prospectively tested whether prone position contains the early propagation of experimental lung injury by stabilizing inflation. METHODS Injury was induced by tracheal hydrochloric acid in rats; after randomization to supine or prone position, injurious ventilation was commenced using high tidal volume and low positive end-expiratory pressure. Paired end-inspiratory (EI) and end-expiratory (EE) CT scans were acquired at baseline and hourly up to 3 hours. Each sequential pair (EI, EE) of CT images was superimposed in parametric response maps to analyze inflation. Unstable inflation was then measured in each voxel in both dependent and nondependent lung. In addition, five pigs were imaged (EI and EE) prone versus supine, before and (1 hour) after hydrochloric acid aspiration. MEASUREMENTS AND MAIN RESULTS In rats, prone position limited lung injury propagation and increased survival (11/12 vs. 7/12 supine; P = 0.01). EI-EE densities, respiratory mechanics, and blood gases deteriorated more in supine versus prone rats. At baseline, more voxels with unstable inflation occurred in dependent versus nondependent regions when supine (41 ± 6% vs. 18 ± 7%; P < 0.01) but not when prone. In supine pigs, unstable inflation predominated in dorsal regions and was attenuated by prone positioning. CONCLUSIONS Prone position limits the radiologic progression of early lung injury. Minimizing unstable inflation in this setting may alleviate the burden of acute respiratory distress syndrome.
Collapse
Affiliation(s)
- Yi Xin
- Department of Radiology and
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Nicholas J. Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia; and
| | | | - Brian P. Kavanagh
- Department of Critical Care Medicine and
- Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
24
|
Shankar-Hari M, Harrison DA, Rowan KM, Rubenfeld GD. Estimating attributable fraction of mortality from sepsis to inform clinical trials. J Crit Care 2018; 45:33-39. [DOI: 10.1016/j.jcrc.2018.01.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 11/17/2022]
|
25
|
Lee JW, Kato H. Should We Stop for Growth Arrest-specific 6 in Acute Respiratory Distress Syndrome? Anesthesiology 2018; 129:8-10. [PMID: 29620573 DOI: 10.1097/aln.0000000000002204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jae-Woo Lee
- From the Department of Anesthesiology, University of California, San Francisco, San Francisco, California
| | | |
Collapse
|
26
|
Shankar P, Robson SC, Otterbein LE, Shaefi S. Clinical Implications of Hyperoxia. Int Anesthesiol Clin 2018; 56:68-79. [DOI: 10.1097/aia.0000000000000176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Harhay MO, Ratcliffe SJ, Halpern SD. Measurement Error Due to Patient Flow in Estimates of Intensive Care Unit Length of Stay. Am J Epidemiol 2017; 186:1389-1395. [PMID: 28605399 DOI: 10.1093/aje/kwx222] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 04/17/2017] [Indexed: 12/17/2022] Open
Abstract
Clinical endpoints measured in terms of duration, such as intensive care unit (ICU) length of stay (LOS), are widely used in randomized clinical trials (RCTs) and observational research. In analyses of patient-level data from a recent RCT, in which ICU LOS was the primary endpoint, and in administrative data, we showed that additional ICU time is often accrued by patients after they are deemed ready for discharge. This "immutable" time (which cannot plausibly be altered by interventions under study) varies by day, week, and year, adding on average one-third of a day to total LOS. We then used statistical simulations, informed by the administrative data and RCT, to assess the impact of immutable time on the measurement and statistical comparison of patients' ICU LOS. These simulations demonstrated that immutable time combines with clinically necessary ICU time (neither of which is likely to be normally distributed) to produce overall LOS distributions that might either mask true treatment effects or suggest false treatment effects relative to analyses of time to discharge readiness. The extent and direction of bias were complex functions of the statistical method used, mortality rates and distributions, and the magnitude of immutable time relative to intervention-associated reductions in LOS.
Collapse
Affiliation(s)
- Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah J Ratcliffe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott D Halpern
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
28
|
Sjoding MW, Hofer TP, Co I, Courey A, Cooke CR, Iwashyna TJ. Interobserver Reliability of the Berlin ARDS Definition and Strategies to Improve the Reliability of ARDS Diagnosis. Chest 2017; 153:361-367. [PMID: 29248620 DOI: 10.1016/j.chest.2017.11.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/27/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Failure to reliably diagnose ARDS may be a major driver of negative clinical trials and underrecognition and treatment in clinical practice. We sought to examine the interobserver reliability of the Berlin ARDS definition and examine strategies for improving the reliability of ARDS diagnosis. METHODS Two hundred five patients with hypoxic respiratory failure from four ICUs were reviewed independently by three clinicians, who evaluated whether patients had ARDS, the diagnostic confidence of the reviewers, whether patients met individual ARDS criteria, and the time when criteria were met. RESULTS Interobserver reliability of an ARDS diagnosis was "moderate" (kappa = 0.50; 95% CI, 0.40-0.59). Sixty-seven percent of diagnostic disagreements between clinicians reviewing the same patient was explained by differences in how chest imaging studies were interpreted, with other ARDS criteria contributing less (identification of ARDS risk factor, 15%; cardiac edema/volume overload exclusion, 7%). Combining the independent reviews of three clinicians can increase reliability to "substantial" (kappa = 0.75; 95% CI, 0.68-0.80). When a clinician diagnosed ARDS with "high confidence," all other clinicians agreed with the diagnosis in 72% of reviews. There was close agreement between clinicians about the time when a patient met all ARDS criteria if ARDS developed within the first 48 hours of hospitalization (median difference, 5 hours). CONCLUSIONS The reliability of the Berlin ARDS definition is moderate, driven primarily by differences in chest imaging interpretation. Combining independent reviews by multiple clinicians or improving methods to identify bilateral infiltrates on chest imaging are important strategies for improving the reliability of ARDS diagnosis.
Collapse
Affiliation(s)
- Michael W Sjoding
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Ivan Co
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Anthony Courey
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Colin R Cooke
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI; Institute for Social Research, Ann Arbor, MI
| |
Collapse
|
29
|
Shankar-Hari M, McAuley DF. Acute Respiratory Distress Syndrome Phenotypes and Identifying Treatable Traits. The Dawn of Personalized Medicine for ARDS. Am J Respir Crit Care Med 2017; 195:280-281. [PMID: 28145757 DOI: 10.1164/rccm.201608-1729ed] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Manu Shankar-Hari
- 1 Department of Critical Care Medicine Guy's and St Thomas' NHS Foundation Trust London, United Kingdom.,2 Division of Asthma, Allergy and Lung Biology King's College London London, United Kingdom
| | - Daniel F McAuley
- 3 Wellcome-Wolfson Institute for Experimental Medicine Queen's University of Belfast Belfast, Northern Ireland and.,4 Regional Intensive Care Unit Royal Victoria Hospital Belfast, Northern Ireland
| |
Collapse
|
30
|
Cereda M, Xin Y, Hamedani H, Bellani G, Kadlecek S, Clapp J, Guerra L, Meeder N, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Tidal changes on CT and progression of ARDS. Thorax 2017. [PMID: 28634220 PMCID: PMC5738538 DOI: 10.1136/thoraxjnl-2016-209833] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Uncertain prediction of outcome in acute respiratory distress syndrome (ARDS) impedes individual patient management and clinical trial design. Objectives To develop a radiological metric of injurious inflation derived from matched inspiratory and expiratory CT scans, calibrate it in a model of experimental lung injury, and test it in patients with ARDS. Methods 73 anaesthetised rats (acid aspiration model) were ventilated (protective or non-protective) for up to 4 hours to generate a spectrum of lung injury. CT was performed (inspiratory and expiratory) at baseline each hour, paired inspiratory and expiratory images were superimposed and voxels tracked in sequential scans. In nine patients with ARDS, paired inspiratory and expiratory CT scans from the first intensive care unit week were analysed. Results In experimental studies, regions of lung with unstable inflation (ie, partial or reversible airspace filling reflecting local strain) were the areas in which subsequent progression of injury was greatest in terms of progressive infiltrates (R=0.77) and impaired compliance (R=0.67, p<0.01). In patients with ARDS, a threshold fraction of tissue with unstable inflation was apparent: >28% in all patients who died and ≤28% in all who survived, whereas segregation of survivors versus non-survivors was not possible based on oxygenation or lung mechanics. Conclusions A single set of superimposed inspiratory–expiratory CT scans may predict progression of lung injury and outcome in ARDS; if these preliminary results are validated, this could facilitate clinical trial recruitment and individualised care.
Collapse
Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, University of Milan-Bicocca, Monza, Italy
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin Clapp
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luca Guerra
- Department of Nuclear Medicine, University of Milan-Bicocca, Monza, Italy
| | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennia Rajaei
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas J Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Viriginia, USA
| | - James C Gee
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian P Kavanagh
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
31
|
Using Clinical Trial Simulators to Analyse the Sources of Variance in Clinical Trials of Novel Therapies for Acute Viral Infections. PLoS One 2016; 11:e0156622. [PMID: 27332704 PMCID: PMC4917234 DOI: 10.1371/journal.pone.0156622] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/17/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND About 90% of drugs fail in clinical development. The question is whether trials fail because of insufficient efficacy of the new treatment, or rather because of poor trial design that is unable to detect the true efficacy. The variance of the measured endpoints is a major, largely underestimated source of uncertainty in clinical trial design, particularly in acute viral infections. We use a clinical trial simulator to demonstrate how a thorough consideration of the variability inherent in clinical trials of novel therapies for acute viral infections can improve trial design. METHODS AND FINDINGS We developed a clinical trial simulator to analyse the impact of three different types of variation on the outcome of a challenge study of influenza treatments for infected patients, including individual patient variability in the response to the drug, the variance of the measurement procedure, and the variance of the lower limit of quantification of endpoint measurements. In addition, we investigated the impact of protocol variation on clinical trial outcome. We found that the greatest source of variance was inter-individual variability in the natural course of infection. Running a larger phase II study can save up to $38 million, if an unlikely to succeed phase III trial is avoided. In addition, low-sensitivity viral load assays can lead to falsely negative trial outcomes. CONCLUSIONS Due to high inter-individual variability in natural infection, the most important variable in clinical trial design for challenge studies of potential novel influenza treatments is the number of participants. 100 participants are preferable over 50. Using more sensitive viral load assays increases the probability of a positive trial outcome, but may in some circumstances lead to false positive outcomes. Clinical trial simulations are powerful tools to identify the most important sources of variance in clinical trials and thereby help improve trial design.
Collapse
|
32
|
Challenges, priorities and novel therapies for hypoxemic respiratory failure and pulmonary hypertension in the neonate. J Perinatol 2016; 36 Suppl 2:S32-6. [PMID: 27225964 DOI: 10.1038/jp.2016.47] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 01/31/2023]
Abstract
Future priorities for the management of hypoxemic respiratory failure (HRF) and pulmonary hypertension include primary prevention of neonatal lung diseases, 'precision medicine' and translating promising clinical and preclinical research into novel therapies. Promising areas of investigation include noninvasive ventilation strategies, emerging pulmonary vasodilators (for example, cinaciguat, intravenous bosentan, rho-kinase inhibitors, peroxisome proliferator-activated receptor-γ agonists) and hemodynamic support (arginine vasopressin). Research challenges include the optimal timing for primary prevention interventions and development of validated biomarkers that predict later disease or serve as surrogates for long-term respiratory outcomes. Differentiating respiratory disease endotypes using biomarkers and experimental therapies tailored to the underlying pathobiology are central to the concept of 'precision medicine' (that is, prevention and treatment strategies that take individual variability into account). The ideal biomarker should be expressed early in the neonatal course to offer an opportunity for effective and targeted interventions to modify outcomes. The feasibility of this approach will depend on the identification and validation of accurate, rapid and affordable point-of-care biomarker tests. Trials targeting patient-specific pathobiology may involve less risk than traditional randomized controlled trials that enroll all at-risk neonates. Such approaches would reduce trial costs, potentially with fewer negative trials and improved health outcomes. Initiatives such as the Prematurity and Respiratory Outcomes Program, supported by the National Heart, Lung, and Blood Institute, provide a framework to develop refined outcome measures and early biomarkers that will enhance our understanding of novel, mechanistic therapeutic targets that can be tested in clinical trials in neonates with HRF.
Collapse
|
33
|
|
34
|
Silva PL, Rocco PRM, Pelosi P. FG-4497: a new target for acute respiratory distress syndrome? Expert Rev Respir Med 2015; 9:405-9. [PMID: 26181437 DOI: 10.1586/17476348.2015.1065181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The morbidity and mortality rates associated with acute respiratory distress syndrome (ARDS) remain high and the development of new therapeutic strategies is urgently required. Some pharmacological treatments, proposed or under evaluation for ARDS, seek to protect the endothelium and consequently mitigate fluid extravasation into the alveolar space. FG-4497 is a new compound which acts as a prolyl hydroxylase domain 2 inhibitor and mimics hypoxia in the activation of hypoxia-inducible factor-2α signaling, decreasing VE-cadherin phosphorylation and thus promoting integrity of adherens junctions. In this special report, we discuss the pharmacological characteristics of FG-4497, its effect on lung parenchyma and other organs and future perspectives in ARDS. In short, FG-4497 may be considered a novel pharmacological option targeting endothelial cell repair in lung diseases such as ARDS. Further experimental and clinical studies are warranted to better understand the mechanisms of action of FG-4497 in different types of lung injury.
Collapse
Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, 21941-902, Rio de Janeiro, Brazil
| | | | | |
Collapse
|