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van der Wal LI, Grim CCA, Del Prado MR, van Westerloo DJ, Schultz MJ, Helmerhorst HJF, de Vries MC, de Jonge E. Perspectives of ICU Patients on Deferred Consent in the Context of Post-ICU Quality of Life: A Substudy of a Randomized Clinical Trial. Crit Care Med 2024; 52:694-703. [PMID: 38180043 PMCID: PMC11008447 DOI: 10.1097/ccm.0000000000006184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Deferred consent enables research to be conducted in the ICU when patients are unable to provide consent themselves, and there is insufficient time to obtain consent from surrogates before commencing (trial) treatment. The aim of this study was to evaluate how former ICU patients reflect on their participation in a study with deferred consent and examine whether their opinions are influenced by the quality of life (QoL) following hospital discharge. DESIGN Survey study by questionnaire. SETTING Eight ICUs in The Netherlands. PATIENTS Former ICU patients who participated in the ICONIC trial, a multicenter randomized clinical trial that evaluated oxygenation targets in mechanically ventilated ICU patients. INTERVENTIONS Participants enrolled in the ICONIC trial in one of the eight participating centers in The Netherlands received a questionnaire 6 months after randomization. The questionnaire included 12 close-ended questions on their opinion about the deferred consent procedure. QoL was measured using the EQ-5D-5L questionnaire. By calculating the EQ-5D index, patients were divided into four QoL quartiles, where Q1 reflects the lowest and Q4 is the highest. MEASUREMENTS AND MAIN RESULTS Of 362 participants who were contacted, 197 responded (54%). More than half of the respondents (59%) were unaware of their participation in the ICONIC study. In total 61% were content with the deferred consent procedure, 1% were not content, 25% neutral, 9% did not know, and 9% answered "other." Those with a higher QoL were more likely to be content ( p = 0.02). In all QoL groups, the legal representative was the most often preferred individual to provide consent. CONCLUSIONS Former ICU patients who participated in the ICONIC study often did not remember their participation but were predominantly positive regarding the use of deferred consent. Those with a higher QoL were most likely to be content.
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Affiliation(s)
- L Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michael R Del Prado
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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2
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Ernst SM, van Marion R, Atmodimedjo PN, de Jonge E, Mathijssen RHJ, Paats MS, de Bruijn P, Koolen SL, von der Thüsen JH, Aerts JGJV, van Schaik RHN, Dubbink HJ, Dingemans AMC. Clinical utility of circulating tumor DNA in patients with advanced KRAS G12C-mutated non-small cell lung cancer treated with sotorasib. J Thorac Oncol 2024:S1556-0864(24)00165-5. [PMID: 38615940 DOI: 10.1016/j.jtho.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/04/2024] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION For patients with KRASG12C-mutated NSCLC who are treated with sotorasib, there is a lack of biomarkers to guide treatment decisions. We therefore investigated the clinical utility of pre-treatment and on-treatment circulating tumor DNA (ctDNA), as well as treatment-emergent alterations upon disease progression. METHODS Patients with KRASG12C-mutated NSCLC treated with sotorasib were prospectively enrolled in our biomarker study (NCT05221372). Plasma samples were collected prior to sotorasib treatment, at first response evaluation and at disease progression. The TruSight Oncology 500 panel was used for ctDNA and variant allele frequency (VAF) analysis. Tumor response and progression-free survival (PFS) was assessed per RECIST v1.1. RESULTS Pre-treatment KRASG12C ctDNA was detected in 50 of 66 patients (76%). Patients with detectable KRASG12C had inferior PFS (HR 2.13 [95% CI 1.06 - 4.30], p=0.031) and overall survival (OS) (HR 2.61 [95% CI 1.16 - 5.91], p=0.017). At first response evaluation (n=40), 29 patients (73%) had a molecular response. Molecular non-responders had inferior OS (HR 3.58 [95% CI 1.65 - 7.74], p<0.00059). The disease control rate was significantly higher in those with a molecular response (97% versus 64%, p=0.015). KRAS amplifications were identified as recurrent treatment-emergent alterations. CONCLUSIONS Our data suggest detectable pre-treatment KRASG12C ctDNA as a marker for poor prognosis, and on-treatment ctDNA clearance as a marker for treatment response. We identified KRAS amplifications as a potential recurring resistance mechanism to sotorasib. Identifying patients with superior prognosis could aid in optimizing time of treatment initiation, and identifying patients at risk of early progression could allow for earlier treatment decisions.
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Affiliation(s)
- Sophie M Ernst
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Ronald van Marion
- Department of Pathology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Peggy N Atmodimedjo
- Department of Pathology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Evert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Marthe S Paats
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Stijn L Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; Department of Pharmacy, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Jan H von der Thüsen
- Department of Pathology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Joachim G J V Aerts
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Hendrikus J Dubbink
- Department of Pathology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Anne-Marie C Dingemans
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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3
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Crucitta S, Cucchiara F, Marconcini R, Bulleri A, Manacorda S, Capuano A, Cioni D, Nuzzo A, de Jonge E, Mathjissen RHJ, Neri E, van Schaik RHN, Fogli S, Danesi R, Del Re M. TGF-β mRNA levels in circulating extracellular vesicles are associated with response to anti-PD1 treatment in metastatic melanoma. Front Mol Biosci 2024; 11:1288677. [PMID: 38633217 PMCID: PMC11021649 DOI: 10.3389/fmolb.2024.1288677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/27/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction: Immune checkpoint inhibitors (ICIs) represent the standard therapy for metastatic melanoma. However, a few patients do not respond to ICIs and reliable predictive biomarkers are needed. Methods: This pilot study investigates the association between mRNA levels of programmed cell death-1 (PD-1) ligand 1 (PD-L1), interferon-gamma (IFN-γ), and transforming growth factor-β (TGF-β) in circulating extracellular vesicles (EVs) and survival in 30 patients with metastatic melanoma treated with first line anti-PD-1 antibodies. Blood samples were collected at baseline and RNA extracted from EVs; the RNA levels of PD-L1, IFN-γ, and TGF-β were analysed by digital droplet PCR (ddPCR). A biomarker-radiomic correlation analysis was performed in a subset of patients. Results: Patients with high TGF-β expression (cut-off fractional abundance [FA] >0.19) at baseline had longer median progression-free survival (8.4 vs. 1.8 months; p = 0.006) and overall survival (17.9 vs. 2.63 months; p = 0.0009). Moreover, radiomic analysis demonstrated that patients with high TGF-β expression at baseline had smaller lesions (2.41 ± 3.27 mL vs. 42.79 ± 101.08 mL, p < 0.001) and higher dissimilarity (12.01 ± 28.23 vs. 5.65 ± 8.4; p = 0.018). Discussion: These results provide evidence that high TGF-β expression in EVs is associated with a better response to immunotherapy. Further investigation on a larger patient population is needed to validate the predictive power of this potential biomarker of response to ICIs.
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Affiliation(s)
- Stefania Crucitta
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico Cucchiara
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Riccardo Marconcini
- Unit of Medical Oncology 2, Department of Medicine and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Alessandra Bulleri
- Unit of Radiodiagnostics 1, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Simona Manacorda
- Unit of Medical Oncology 2, Department of Medicine and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Annalisa Capuano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Section of Pharmacology, Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Dania Cioni
- Unit of Radiodiagnostics 1, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Amedeo Nuzzo
- Unit of Medical Oncology 2, Department of Medicine and Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Evert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ron H. J. Mathjissen
- Department of Medical Oncology, Erasmus University Medical Center Cancer Institute, Rotterdam, Netherlands
| | - Emanuele Neri
- Unit of Radiodiagnostics 1, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Stefano Fogli
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy
| | - Marzia Del Re
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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van Paassen J, Hiemstra PS, van der Linden AC, de Jonge E, Zwaginga JJ, Klautz RJM, Arbous MS. MUC5AC concentrations in lung lavage fluids are associated with acute lung injury after cardiac surgery. Respir Res 2024; 25:117. [PMID: 38454475 PMCID: PMC10921709 DOI: 10.1186/s12931-024-02747-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/23/2024] [Indexed: 03/09/2024] Open
Abstract
Heart surgery may be complicated by acute lung injury and adult respiratory distress syndrome. Expression and release of mucins MUC5AC and MUC5B in the lungs has been reported to be increased in acute lung injury. The aim of our study was to [1] investigate the perioperative changes of MUC5AC, MUC5B and other biomarkers in mini-bronchoalveolar lavage (minBAL), and [2] relate these to clinical outcomes after cardiac surgery. In this prospective cohort study in 49 adult cardiac surgery patients pre- and post-surgery non-fiberscopic miniBAL fluids were analysed for MUC5AC, MUC5B, IL-8, human neutrophil elastase, and neutrophils. All measured biomarkers increased after surgery. Perioperative MUC5AC-change showed a significant negative association with postoperative P/F ratio (p = 0.018), and a positive association with ICU stay (p = 0.027). In conclusion, development of lung injury after cardiac surgery and prolonged ICU stay are associated with an early increase of MUC5AC as detected in mini-BAL.
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Affiliation(s)
- Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, Leiden, B4-57, 2333 ZA, the Netherlands.
| | - Pieter S Hiemstra
- Department of Pulmonology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, Leiden, B4-57, 2333 ZA, the Netherlands
| | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert J M Klautz
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, Leiden, B4-57, 2333 ZA, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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5
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Bakker T, Klopotowska JE, Dongelmans DA, Eslami S, Vermeijden WJ, Hendriks S, Ten Cate J, Karakus A, Purmer IM, van Bree SHW, Spronk PE, Hoeksema M, de Jonge E, de Keizer NF, Abu-Hanna A. The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial. Lancet 2024; 403:439-449. [PMID: 38262430 DOI: 10.1016/s0140-6736(23)02465-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Drug-drug interactions (DDIs) can harm patients admitted to the intensive care unit (ICU). Yet, clinical decision support systems (CDSSs) aimed at helping physicians prevent DDIs are plagued by low-yield alerts, causing alert fatigue and compromising patient safety. The aim of this multicentre study was to evaluate the effect of tailoring potential DDI alerts to the ICU setting on the frequency of administered high-risk drug combinations. METHODS We implemented a cluster randomised stepped-wedge trial in nine ICUs in the Netherlands. Five ICUs already used potential DDI alerts. Patients aged 18 years or older admitted to the ICU with at least two drugs administered were included. Our intervention was an adapted CDSS, only providing alerts for potential DDIs considered as high risk. The intervention was delivered at the ICU level and targeted physicians. We hypothesised that showing only relevant alerts would improve CDSS effectiveness and lead to a decreased number of administered high-risk drug combinations. The order in which the intervention was implemented in the ICUs was randomised by an independent researcher. The primary outcome was the number of administered high-risk drug combinations per 1000 drug administrations per patient and was assessed in all included patients. This trial was registered in the Netherlands Trial Register (identifier NL6762) on Nov 26, 2018, and is now closed. FINDINGS In total, 10 423 patients admitted to the ICU between Sept 1, 2018, and Sept 1, 2019, were assessed and 9887 patients were included. The mean number of administered high-risk drug combinations per 1000 drug administrations per patient was 26·2 (SD 53·4) in the intervention group (n=5534), compared with 35·6 (65·0) in the control group (n=4353). Tailoring potential DDI alerts to the ICU led to a 12% decrease (95% CI 5-18%; p=0·0008) in the number of administered high-risk drug combinations per 1000 drug administrations per patient, after adjusting for clustering and prognostic factors. INTERPRETATION This cluster randomised stepped-wedge trial showed that tailoring potential DDI alerts to the ICU setting significantly reduced the number of administered high-risk drug combinations. Our list of high-risk drug combinations can be used in other ICUs, and our strategy of tailoring alerts based on clinical relevance could be applied to other clinical settings. FUNDING ZonMw.
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Affiliation(s)
- Tinka Bakker
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Methodology, Amsterdam Public Health, Amsterdam, Netherlands.
| | - Joanna E Klopotowska
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Digital Health, Amsterdam Public Health, Amsterdam, Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Quality of Care, Amsterdam Public Health, Amsterdam, Netherlands
| | - Saeid Eslami
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Wytze J Vermeijden
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, Netherlands
| | - Stefaan Hendriks
- Department of Intensive Care, Albert Schweitzer Ziekenhuis, Dordrecht, Netherlands
| | - Julia Ten Cate
- Department of Intensive Care, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Attila Karakus
- Department of Intensive Care Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, Netherlands
| | | | - Peter E Spronk
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, Netherlands
| | - Martijn Hoeksema
- Zaans Medisch Centrum, Department of Anesthesiology, Intensive Care and Pain Management, Zaandam, Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Quality of Care, Amsterdam Public Health, Amsterdam, Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Methodology, Amsterdam Public Health, Amsterdam, Netherlands
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6
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Klopotowska JE, Leopold JH, Bakker T, Yasrebi-de Kom I, Engelaer FM, de Jonge E, Haspels-Hogervorst EK, van den Bergh WM, Renes MH, Jong BTD, Kieft H, Wieringa A, Hendriks S, Lau C, van Bree SHW, Lammers HJW, Wierenga PC, Bosman RJ, de Jong VM, Slijkhuis M, Franssen EJF, Vermeijden WJ, Masselink J, Purmer IM, Bosma LE, Hoeksema M, Wesselink E, de Lange DW, de Keizer NF, Dongelmans DA, Abu-Hanna A. Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: A multicentre retrospective observational study. Br J Clin Pharmacol 2024; 90:164-175. [PMID: 37567767 DOI: 10.1111/bcp.15882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/13/2023] Open
Abstract
AIMS Knowledge about adverse drug events caused by drug-drug interactions (DDI-ADEs) is limited. We aimed to provide detailed insights about DDI-ADEs related to three frequent, high-risk potential DDIs (pDDIs) in the critical care setting: pDDIs with international normalized ratio increase (INR+ ) potential, pDDIs with acute kidney injury (AKI) potential, and pDDIs with QTc prolongation potential. METHODS We extracted routinely collected retrospective data from electronic health records of intensive care units (ICUs) patients (≥18 years), admitted to ten hospitals in the Netherlands between January 2010 and September 2019. We used computerized triggers (e-triggers) to preselect patients with potential DDI-ADEs. Between September 2020 and October 2021, clinical experts conducted a retrospective manual patient chart review on a subset of preselected patients, and assessed causality, severity, preventability, and contribution to ICU length of stay of DDI-ADEs using internationally prevailing standards. RESULTS In total 85 422 patients with ≥1 pDDI were included. Of these patients, 32 820 (38.4%) have been exposed to one of the three pDDIs. In the exposed group, 1141 (3.5%) patients were preselected using e-triggers. Of 237 patients (21%) assessed, 155 (65.4%) experienced an actual DDI-ADE; 52.9% had severity level of serious or higher, 75.5% were preventable, and 19.3% contributed to a longer ICU length of stay. The positive predictive value was the highest for DDI-INR+ e-trigger (0.76), followed by DDI-AKI e-trigger (0.57). CONCLUSION The highly preventable nature and severity of DDI-ADEs, calls for action to optimize ICU patient safety. Use of e-triggers proved to be a promising preselection strategy.
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Affiliation(s)
- Joanna E Klopotowska
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Jan-Hendrik Leopold
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Tinka Bakker
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Izak Yasrebi-de Kom
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Frouke M Engelaer
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther K Haspels-Hogervorst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maurits H Renes
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bas T de Jong
- Department of Intensive Care, Isala Hospital, Zwolle, The Netherlands
| | - Hans Kieft
- Department of Intensive Care, Isala Hospital, Zwolle, The Netherlands
| | - Andre Wieringa
- Department of Clinical Pharmacy, Isala Hospital, Zwolle, The Netherlands
| | - Stefaan Hendriks
- Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Cedric Lau
- Department of Hospital Pharmacy, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Sjoerd H W van Bree
- Department of Intensive Care, Hospital Gelderse Vallei, Ede, The Netherlands
| | | | - Peter C Wierenga
- Department of Hospital Pharmacy, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Rob J Bosman
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
| | - Vincent M de Jong
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
| | - Mirjam Slijkhuis
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Eric J F Franssen
- Department of Clinical Pharmacy, OLVG Hospital, Amsterdam, The Netherlands
| | - Wytze J Vermeijden
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Joost Masselink
- Department of Hospital Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Liesbeth E Bosma
- Department of Hospital Pharmacy, Haga Hospital, The Hague, The Netherlands
| | - Martin Hoeksema
- Department of Intensive Care, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Elsbeth Wesselink
- Department of Hospital Pharmacy, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
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7
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Buck SAJ, Meertens M, van Ooijen FMF, Oomen-de Hoop E, de Jonge E, Coenen MJH, Bergman AM, Koolen SLW, de Wit R, Huitema ADR, van Schaik RHN, Mathijssen RHJ. A common germline variant in CYP11B1 is associated with adverse clinical outcome of treatment with abiraterone or enzalutamide. Biomed Pharmacother 2023; 169:115890. [PMID: 37988848 DOI: 10.1016/j.biopha.2023.115890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023] Open
Abstract
Extragonadal androgens play a pivotal role in prostate cancer disease progression on androgen receptor signaling inhibitors (ARSi), including abiraterone and enzalutamide. We aimed to investigate if germline variants in genes involved in extragonadal androgen synthesis contribute to resistance to ARSi and may predict clinical outcomes on ARSi. We included ARSi naive metastatic prostate cancer patients treated with abiraterone or enzalutamide and determined 18 germline variants in six genes involved in extragonadal androgen synthesis. Variants were tested in univariate and multivariable analysis for the relation with overall survival (OS) and time to progression (TTP) by Cox regression, and PSA response by logistic regression. A total of 275 patients were included. From the investigated genes CYP17A1, HSD3B1, CYP11B1, AKR1C3, SRD5A1 and SRD5A2, only rs4736349 in CYP11B1 in homozygous form (TT), present in 54 patients (20%), was related with a significantly worse OS (HR = 1.71, 95% CI 1.09 - 2.68, p = 0.019) and TTP (HR = 1.50, 95% CI 1.08 - 2.09, p = 0.016), and was related with a significantly less frequent PSA response (OR = 0.48, 95% CI 0.24 - 0.96, p = 0.038) on abiraterone or enzalutamide in a multivariable analysis. The frequent germline variant rs4736349 in CYP11B1 is, as homozygote, an independent negative prognostic factor for treatment with abiraterone or enzalutamide in ARSi naive metastatic prostate cancer patients. Our findings warrant prospective investigation of this potentially important predictive biomarker.
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Affiliation(s)
- Stefan A J Buck
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.
| | - Marinda Meertens
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | | | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Evert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H Coenen
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Andries M Bergman
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ronald de Wit
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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8
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Yasrebi-de Kom IAR, Dongelmans DA, Abu-Hanna A, Schut MC, de Lange DW, van Roon EN, de Jonge E, Bouman CSC, de Keizer NF, Jager KJ, Klopotowska JE. Acute kidney injury associated with nephrotoxic drugs in critically ill patients: a multicenter cohort study using electronic health record data. Clin Kidney J 2023; 16:2549-2558. [PMID: 38045998 PMCID: PMC10689186 DOI: 10.1093/ckj/sfad160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Indexed: 12/05/2023] Open
Abstract
Background Nephrotoxic drugs frequently cause acute kidney injury (AKI) in adult intensive care unit (ICU) patients. However, there is a lack of large pharmaco-epidemiological studies investigating the associations between drugs and AKI. Importantly, AKI risk factors may also be indications or contraindications for drugs and thereby confound the associations. Here, we aimed to estimate the associations between commonly administered (potentially) nephrotoxic drug groups and AKI in adult ICU patients whilst adjusting for confounding. Methods In this multicenter retrospective observational study, we included adult ICU admissions to 13 Dutch ICUs. We measured exposure to 44 predefined (potentially) nephrotoxic drug groups. The outcome was AKI during ICU admission. The association between each drug group and AKI was estimated using etiological cause-specific Cox proportional hazard models and adjusted for confounding. To facilitate an (independent) informed assessment of residual confounding, we manually identified drug group-specific confounders using a large drug knowledge database and existing literature. Results We included 92 616 ICU admissions, of which 13 492 developed AKI (15%). We found 14 drug groups to be associated with a higher hazard of AKI after adjustment for confounding. These groups included established (e.g. aminoglycosides), less well established (e.g. opioids) and controversial (e.g. sympathomimetics with α- and β-effect) drugs. Conclusions The results confirm existing insights and provide new ones regarding drug associated AKI in adult ICU patients. These insights warrant caution and extra monitoring when prescribing nephrotoxic drugs in the ICU and indicate which drug groups require further investigation.
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Affiliation(s)
- Izak A R Yasrebi-de Kom
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Dave A Dongelmans
- Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Martijn C Schut
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Laboratory Medicine, Amsterdam, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care and Dutch Poison Information Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eric N van Roon
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Catherine S C Bouman
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Nicolette F de Keizer
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Kitty J Jager
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Joanna E Klopotowska
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
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9
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van der Wal LI, Grim CCA, del Prado MR, van Westerloo DJ, Boerma EC, Rijnhart-de Jong HG, Reidinga AC, Loef BG, van der Heiden PLJ, Sigtermans MJ, Paulus F, Cornet AD, Loconte M, Schoonderbeek FJ, de Keizer NF, Bakhshi-Raiez F, Le Cessie S, Serpa Neto A, Pelosi P, Schultz MJ, Helmerhorst HJF, de Jonge E. Conservative versus Liberal Oxygenation Targets in Intensive Care Unit Patients (ICONIC): A Randomized Clinical Trial. Am J Respir Crit Care Med 2023; 208:770-779. [PMID: 37552556 PMCID: PMC10563190 DOI: 10.1164/rccm.202303-0560oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/07/2023] [Indexed: 08/10/2023] Open
Abstract
Rationale: Supplemental oxygen is widely administered to ICU patients, but appropriate oxygenation targets remain unclear. Objectives: This study aimed to determine whether a low-oxygenation strategy would lower 28-day mortality compared with a high-oxygenation strategy. Methods: This randomized multicenter trial included mechanically ventilated ICU patients with an expected ventilation duration of at least 24 hours. Patients were randomized 1:1 to a low-oxygenation (PaO2, 55-80 mm Hg; or oxygen saturation as measured by pulse oximetry, 91-94%) or high-oxygenation (PaO2, 110-150 mm Hg; or oxygen saturation as measured by pulse oximetry, 96-100%) target until ICU discharge or 28 days after randomization, whichever came first. The primary outcome was 28-day mortality. The study was stopped prematurely because of the COVID-19 pandemic when 664 of the planned 1,512 patients were included. Measurements and Main Results: Between November 2018 and November 2021, a total of 664 patients were included in the trial: 335 in the low-oxygenation group and 329 in the high-oxygenation group. The median achieved PaO2 was 75 mm Hg (interquartile range, 70-84) and 115 mm Hg (interquartile range, 100-129) in the low- and high-oxygenation groups, respectively. At Day 28, 129 (38.5%) and 114 (34.7%) patients had died in the low- and high-oxygenation groups, respectively (risk ratio, 1.11; 95% confidence interval, 0.9-1.4; P = 0.30). At least one serious adverse event was reported in 12 (3.6%) and 17 (5.2%) patients in the low- and high-oxygenation groups, respectively. Conclusions: Among mechanically ventilated ICU patients with an expected mechanical ventilation duration of at least 24 hours, using a low-oxygenation strategy did not result in a reduction of 28-day mortality compared with a high-oxygenation strategy. Clinical trial registered with the National Trial Register and the International Clinical Trials Registry Platform (NTR7376).
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Affiliation(s)
| | | | | | | | - E. Christiaan Boerma
- Department of Sustainable Health, Campus Fryslân, University of Groningen, Groningen, The Netherlands
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Auke C. Reidinga
- Department of Intensive Care, Martini Hospital, Groningen, The Netherlands
| | - Bert G. Loef
- Department of Intensive Care, Martini Hospital, Groningen, The Netherlands
| | | | | | | | - Alexander D. Cornet
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | | | - Nicolette F. de Keizer
- Department of Medical Informatics, Amsterdam Public Health – Digital Health, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Ferishta Bakhshi-Raiez
- Department of Medical Informatics, Amsterdam Public Health – Digital Health, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Saskia Le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Albert Einstein Israelite Hospital, São Paulo, Brazil
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Paolo Pelosi
- Department of Anesthesiology and Intensive Care and
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, Scientific Institute for Research, Hospitalization and Healthcare for Oncology and Neurosciences, Genoa, Italy
| | - Marcus J. Schultz
- Department of Intensive Care and
- Mahidol – Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; and
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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10
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Ernst SM, Uzun S, Paats MS, van Marion R, Atmodimedjo PN, de Jonge E, van Schaik RH, Aerts JG, von der Thüsen JH, Dubbink HJ, Dingemans AMC. Efficacy and Tolerability of Osimertinib and Sotorasib Combination Treatment for Osimertinib Resistance Caused by KRAS G12C Mutation: A Report of Two Cases. JCO Precis Oncol 2023; 7:e2300451. [PMID: 38096473 PMCID: PMC10735074 DOI: 10.1200/po.23.00451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/15/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
Two cases show osimertinib/sotorasib combination could be effective in KRAS G12C-driven osimertinib resistance.
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Affiliation(s)
- Sophie M. Ernst
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Sevim Uzun
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
- Department of Respiratory Medicine, Haaglanden Medisch Centrum, Den Haag, the Netherlands
| | - Marthe S. Paats
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Ronald van Marion
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peggy N. Atmodimedjo
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Evert de Jonge
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ron H.N. van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Joachim G.J.V. Aerts
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Jan H. von der Thüsen
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hendrikus J. Dubbink
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Anne-Marie C. Dingemans
- Department of Respiratory Medicine, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
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11
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Candel BGJ, Nissen SK, Nickel CH, Raven W, Thijssen W, Gaakeer MI, Lassen AT, Brabrand M, Steyerberg EW, de Jonge E, de Groot B. Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department. Crit Care Med 2023; 51:881-891. [PMID: 36951452 PMCID: PMC10262984 DOI: 10.1097/ccm.0000000000005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr). DESIGN International multicenter cohort study. SETTING Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark. PATIENTS All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC). MEASUREMENTS AND MAIN RESULTS Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories. CONCLUSIONS The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years.
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Affiliation(s)
- Bart Gerard Jan Candel
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | | | - Mikkel Brabrand
- Institute of Regional Health Research, Center South-West Jutland, University of Southern Denmark, Esbjerg, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South-West Jutland, Esbjerg, Denmark
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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12
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Veerman GM, Boosman RJ, Jebbink M, Oomen-de Hoop E, van der Wekken AJ, Bahce I, Hendriks LE, Croes S, Steendam CM, de Jonge E, Koolen SL, Steeghs N, van Schaik RH, Smit EF, Dingemans AMC, Huitema AD, Mathijssen RH. Influence of germline variations in drug transporters ABCB1 and ABCG2 on intracerebral osimertinib efficacy in patients with non-small cell lung cancer. EClinicalMedicine 2023; 59:101955. [PMID: 37125403 PMCID: PMC10139887 DOI: 10.1016/j.eclinm.2023.101955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 05/02/2023] Open
Abstract
Background Central nervous system (CNS) metastases are present in approximately 40% of patients with metastatic epidermal growth factor receptor-mutated (EGFRm+) non-small cell lung cancer (NSCLC). The EGFR-tyrosine kinase inhibitor osimertinib is a substrate of transporters ABCB1 and ABCG2 and metabolized by CYP3A4. We investigated relationships between single nucleotide polymorphisms (SNPs) ABCB1 3435C>T, ABCG2 421C>A and 34G>A, and CYP3A4∗22 and CNS treatment efficacy of osimertinib in EGFRm+ NSCLC patients. Methods Patients who started treatment with osimertinib for EGFRm+ NSCLC between November 2014 and June 2021 were included in this retrospective observational multicentre cohort study. For patients with baseline CNS metastases, the primary endpoint was CNS progression-free survival (CNS-PFS; time from osimertinib start until CNS disease progression or death). For patients with no or unknown baseline CNS metastases, the primary endpoint was CNS disease-free survival (CNS-DFS; time from osimertinib start until occurrence of new CNS metastases). Relationships between SNPs and baseline characteristics with CNS-PFS and CNS-DFS were studied with competing-risks survival analysis. Secondary endpoints were relationships between SNPs and PFS, overall survival, severe toxicity, and osimertinib pharmacokinetics. Findings From 572 included patients, 201 had baseline CNS metastases. No SNP was associated with CNS-PFS. Genotype ABCG2 34GA/AA and/or ABCB1 3435CC --present in 35% of patients-- was significantly associated with decreased CNS-DFS (hazard ratio 0.28; 95% CI 0.11-0.73; p = 0.009) in the multivariate analysis. This remained significant after applying a Bonferroni correction and internal validation through bootstrapping. ABCG2 421CA/AA was related to more severe toxicity (27.0% versus 16.5%; p = 0.010). Interpretation ABCG2 34G>A and ABCB1 3435C>T are predictors for developing new CNS metastases during osimertinib treatment, probably because of diminished drug levels in the CNS. ABCG2 421C>A was significantly related with the incidence of severe toxicity. Pre-emptive genotyping for these SNPs could individualize osimertinib therapy. Addition of ABCG2 inhibitors for patients without ABCG2 34G>A should be studied further, to prevent new CNS metastases during osimertinib treatment. Funding No funding was received for this trial.
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Affiliation(s)
- G.D. Marijn Veerman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
- Corresponding author. Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Rene J. Boosman
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Merel Jebbink
- Department of Pulmonary Medicine, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Anthonie J. van der Wekken
- Department of Pulmonary Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Idris Bahce
- Department of Pulmonary Medicine, Amsterdam University Medical Centres, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Lizza E.L. Hendriks
- Department of Pulmonary Medicine, Maastricht University Medical Centre, GROW – School for Oncology and Reproduction, Maastricht, the Netherlands
| | - Sander Croes
- Department of Pulmonary Medicine, Maastricht University Medical Centre, GROW – School for Oncology and Reproduction, Maastricht, the Netherlands
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, CARIM – School for Cardiovascular Disease, Maastricht, the Netherlands
| | - Christi M.J. Steendam
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Pulmonary Medicine, Amphia Hospital, Breda, the Netherlands
| | - Evert de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Stijn L.W. Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology and Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ron H.N. van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Egbert F. Smit
- Department of Pulmonary Medicine, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pulmonary Medicine, Leiden University Hospital, Leiden, the Netherlands
| | - Anne-Marie C. Dingemans
- Department of Pulmonary Medicine, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Alwin D.R. Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Pharmacology, Princess Maxima Center for Paediatric Oncology, Utrecht, the Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ron H.J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, the Netherlands
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13
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Van Paassen J, De Graaf-Dijkstra A, Brunsveld-Reinders AH, de Jonge E, Klautz RJM, Tsonaka R, Jan Zwaginga J, Arbous MS. Leukocyte and platelet activation in cardiac surgery patients with and without lung injury; a prospective cohort study. Interdiscip Cardiovasc Thorac Surg 2023; 36:7143387. [PMID: 37099705 DOI: 10.1093/icvts/ivad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/16/2023] [Accepted: 04/25/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIONS Development of acute lung injury after cardiac surgery is associated with an unfavourable outcome. Acute respiratory distress syndrome in general is, besides cytokine- and interleukin activation, associated with activation of platelets, monocytes and neutrophils. In relation to pulmonary outcome after cardiac surgery, leucocyte- and platelet-activation is described in animal studies, only. Therefore, we explored the peri-operative time course of platelet- and leucocyte- activation in cardiac surgery and related these findings to acute lung injury assessed via PaO2/FiO2 (P/F) ratio measurements. METHODS a prospective cohort study was performed, including 80 cardiac surgery patients. At five timepoints, blood samples were directly assessed by flowcytometry. For time course analyses in low (<200) versus high (>/=200) P/F ratio groups repeated measurements techniques with linear mixed models were used. RESULTS Already before the start of surgery platelet activatability (p = 0.003 for Trombine Receptor Activator Peptide and p = 0.017 for Adenosine Di Phosphate) was higher, and expression of neutrophil activation markers was lower (CD18/CD11; p = 0.001, CD62L; p = 0.013) in the low P/F group. After correction for these baseline differences, the peri-and postoperative Trombine Receptor Activator Peptide induced thrombocyte activatability was decreased in the low P/F ratio group (p 0.008), and a changed pattern of neutrophil activation markers was observed. CONCLUSIONS Prior to surgery, an upregulated inflammatory state with higher platelet- activatability, and indications for higher neutrophil turnover was demonstrated in cardiac surgery patients that developed lung injury. It is difficult to distinguish whether these factors are mediators, or also etiologically related to development of lung injury after cardiac surgery and further research is warranted. TRIAL REGISTRATION Clinical Registration number: ICTRP: NTR 5314, 26-05-2015.
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Affiliation(s)
- Judith Van Paassen
- Leiden University Medical Center, department of Intensive Care, Netherlands
| | - Alice De Graaf-Dijkstra
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands
- Leiden University Medical Center, department of Quality and Patient Safety, Netherlands
| | - Anja H Brunsveld-Reinders
- Leiden University Medical Center, department of Intensive Care, Netherlands
- Leiden University Medical Center, department of Quality and Patient Safety, Netherlands
| | - Evert de Jonge
- Leiden University Medical Center, department of Intensive Care, Netherlands
| | - Robert J M Klautz
- Leiden University Medical Center, department of Cardiothoracic Surgery, Netherlands
| | - Roula Tsonaka
- Leiden University Medical Center, deportment of Biomedical Data Sciences, Netherlands
| | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, Netherlands
- Leiden University Medical Center, department of Hematology, Netherlands
| | - M Sesmu Arbous
- Leiden University Medical Center, department of Intensive Care, Netherlands
- Leiden University Medical Center, department of Clinical Epidemiology, Netherlands
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Candel BGJ, Raven W, Nissen SK, Morsink MEB, Gaakeer MI, Brabrand M, van Zwet EW, de Jonge E, de Groot B. THE ASSOCIATION BETWEEN SYSTOLIC BLOOD PRESSURE AND HEART RATE IN EMERGENCY DEPARTMENT PATIENTS: A MULTICENTER COHORT STUDY. J Emerg Med 2023:S0736-4679(23)00255-X. [PMID: 37394368 DOI: 10.1016/j.jemermed.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/25/2023] [Accepted: 04/10/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. OBJECTIVE To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years). METHODS A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). RESULTS A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. CONCLUSION No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Marlies E B Morsink
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South West Jutland, University of Southern Denmark, Esbjerg, Denmark; Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, the Netherlands; Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
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Ernst SM, van Marion R, Atmodimedjo PN, de Jonge E, Mathijssen RH, Paats MS, de Bruijn P, van Schaik RH, Dubbink HJ, Dingemans AMC. Abstract 2137: Clinical utility of circulating tumor DNA in patients with advanced KRAS G12C-mutated NSCLC treated with sotorasib. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-2137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Introduction: The CodeBreaK 200 trial showed that in patients (pts) with advanced KRAS G12C mutated (KRAS+) NSCLC sotorasib, a KRAS G12C-specific inhibitor, is superior to docetaxel for progression free survival (PFS) (HR 0.66) with a one-year PFS of 25%. We hypothesized that the detection of circulating tumor DNA (ctDNA) in plasma could allow for treatment response prediction and longitudinal monitoring. We analyzed serial plasma samples at baseline and within 3 months of start of sotorasib to evaluate ctDNA changes and correlation with clinical response.
Methods: Pts with sotorasib treated KRAS+ NSCLC were prospectively enrolled in our biomarker START-TKI study (NCT05221372) after written informed consent. Plasma samples were collected prior to treatment (T0) and at first response evaluation (T1). The TruSight Oncology 500 ctDNA panel was used for mutation detection in cell-free DNA (cfDNA). cfDNA KRAS/TP53/STK11/KEAP1 status was determined and compared to tumor tissue pathology reports to filter out false positives. Radiological response and PFS was assessed per RECIST 1.1.
Results: Between May 2021 and August 2022, 35 pts were included (table 1). Of these, 29 (83%) had detectable ctDNA KRAS G12C at T0, and 24 had both T0 and T1 samples. A decrease in variant allele frequency (VAF) at T1 compared to T0 was observed in 88% (n=21); 42% (n=10) showed complete clearance of ctDNA KRAS G12C. Six-months PFS was 83% in T0 negative pts (n=6) versus 43% in T0 positive pts (n=29); and 65% in pts with complete clearance (n=10) versus 14% in pts with incomplete clearance (n=11). VAF increase was seen in 3 pts, of which 1 had progression at T1.
Conclusions: In pts with KRAS+ NSCLC treated with sotorasib, baseline ctDNA and ctDNA clearance within 3 months of treatment correlated with treatment response. Pts with undetectable KRAS ctDNA at baseline, or with complete clearance at first evaluation, had superior PFS. PFS will be updated as follow-up duration extends.
Table 1. Patient cohort Liver metastasis KRAS p.G12C ctDNA at T0, median VAF % (range) KRAS p.G12C ctDNA at T1, median VAF % (range) Median change in VAF % (range) TP53/STK11/KEAP1 ctDNA T0 T1 response Reason EOT ꝉ Time on treatment (months) * Negative at T0 (n=6) No = 6 0 NE NE NE 1x PR; 4x SD; 1x PD 2x PD; 4x ongoing >8 months 6 (1 - 11) Positive at T0 (n=29) No = 20; Yes = 9 2.6 (0.1 - 46.7) 0.6 (0.1 - 38.9) -95% (-100 - +39) 4x TP53; 2x STK11; 1x STK11●; 2x KEAP1; 2x KEAP1●; 2x TP53 + KEAP1; 1x TP53 + STK11● 4x PR; 21x SD; 2x PD; 2x NE 19x PD; 3x toxicity; 6x ongoing >4 months; 1x loss to follow up 3 (1 - 15) Complete clearance at T1 (n=10) No = 6; Yes = 4 1.4 (0.1 - 8.4) 0 100% 2x TP53; 1x TP53 + KEAP1; 1x KEAP1; 1x KEAP1● 1x PR; 9x SD 6x PD; 1x toxicity; 2x ongoing >6 months; 1x loss to follow up 5 (1 - 11) Incomplete clearance at T1 (n=11) No = 7; Yes = 4 3.6 (1.3 - 46.7) 0.4 (0.1 - 29.4) -89% (-23 - -99) 2x TP53; 1x STK11; 1x STK11●; 2x TP53 + STK11●; 1x TP53 + STK11 + KEAP1; 1x STK11 + KEAP1 3x PR; 7x SD; 1x PD 8x PD; 2x toxicity; 1x ongoing >4 months 3 (1 - 8) Increase in VAF at T1 (n=3) No = 2; Yes = 1 1.0 (0.5 - 35.2) 1.1 (0.6 - 38.9) +11% (+10 - +39) 1x TP53●; 1x TP53 + KEAP1; 1x STK11● + KEAP1● 1x PD; 2x SD 3x PD 3 (1 - 15) Positive T0, no T1 available (n=5) No = 5 6.2 (0.3 - 24.6) NE NE 1x TP53; 1x TP53●; 1x KEAP1; 1x STK11 + KEAP1 3x SD; 2x NE 2x PD; 3x ongoing >3 months 2 (1 - 3) NE = Not evaluated; ● = Positive cell-free DNA (cfDNA), not tested in tumor tissue; PR = Partial response; SD = Stable disease; PD = Progressive disease; EOT = End of treatment; ꝉ for PFS analysis patients who discontinued treatment due to toxicity were censored at treatment discontinuation, and patients with ongoing sotorasib treatment were censored at data cut off (16-Nov-2022); * = excluding ongoing patients.
Citation Format: Sophie M. Ernst, Ronald van Marion, Peggy N. Atmodimedjo, Evert de Jonge, Ron H. Mathijssen, Marthe S. Paats, Peter de Bruijn, Ron H.N. van Schaik, Hendrikus J. Dubbink, Anne-Marie C. Dingemans. Clinical utility of circulating tumor DNA in patients with advanced KRAS G12C-mutated NSCLC treated with sotorasib [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2137.
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van der Wal LI, Grim CCA, van Westerloo DJ, Schultz MJ, de Jonge E, Helmerhorst HJF. Corrigendum to "Higher versus lower oxygenation strategies in the general intensive care unit population: A systematic review, meta-analysis and meta-regression of randomized controlled trials" [Journal of Critical Care, volume 72(2022) 154151]. J Crit Care 2023; 74:154245. [PMID: 36621390 DOI: 10.1016/j.jcrc.2022.154245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Lea Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands; Mahidol - Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of medicine, University of Oxford, Oxford, United Kingdom
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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van der Wal LI, Grim CCA, van Westerloo DJ, Schultz MJ, de Jonge E, Helmerhorst HJF. Higher versus lower oxygenation strategies in the general intensive care unit population: A systematic review, meta-analysis and meta-regression of randomized controlled trials. J Crit Care 2022; 72:154151. [PMID: 36182731 DOI: 10.1016/j.jcrc.2022.154151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/18/2022] [Accepted: 09/06/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Oxygen therapy is vital in adult intensive care unit (ICU) patients, but it is indistinct whether higher or lower oxygen targets are favorable. Our aim was to update the findings of randomized controlled trials (RTCs) comparing higher and lower oxygen strategies. MATERIALS AND METHODS MEDLINE, EMBASE, and Web of Science were searched. RCTs comparing higher (liberal, hyperoxia) and lower (conservative, normoxia) oxygen in adult mechanically ventilated ICU patients were included. The main outcome was 90-day mortality; other outcomes include serious adverse events (SAE), support free days and length of stay (LOS). RESULTS No significant difference was observed for 90-day mortality. A lower incidence was found for SAEs, favoring lower oxygenation (OR, 0.86; 95%CI, 0.77-0.96; I 2 13%). No differences were observed in either support free days at day 28 or ICU and hospital LOS. CONCLUSIONS No difference was found for 90-day mortality, support free days and ICU and hospital LOS. However, a lower incidence of SAEs was found for lower oxygenation. These findings may have clinical implications for practice guidelines, yet it remains of paramount importance to continue conducting clinical trials, comparing groups with a clinically relevant contrast and focusing on the impact of important side effects.
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Affiliation(s)
- Lea Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, the Netherlands; Mahidol - Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of medicine, University of Oxford, Oxford, United Kingdom
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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Grim CCA, Helmerhorst HJF, de Jonge E. The authors reply. Crit Care Med 2022; 50:e598-e599. [PMID: 35612450 DOI: 10.1097/ccm.0000000000005526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Chloe C A Grim
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
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19
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Candel BGJ, Raven W, Lameijer H, Thijssen WAMH, Termorshuizen F, Boerma C, de Keizer NF, de Jonge E, de Groot B. Correction: The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients. Crit Care 2022; 26:132. [PMID: 35545789 PMCID: PMC9092866 DOI: 10.1186/s13054-022-04008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Emergency Medicine, Máxima Medical Centre, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Wendy A M H Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Fabian Termorshuizen
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Botta M, Tsonas AM, Sinnige JS, De Bie AJR, Bindels AJGH, Ball L, Battaglini D, Brunetti I, Buiteman-Kruizinga LA, van der Heiden PLJ, de Jonge E, Mojoli F, Robba C, Schoe A, Paulus F, Pelosi P, Neto AS, Horn J, Schultz MJ. Effect of Automated Closed-loop ventilation versus convenTional VEntilation on duration and quality of ventilation in critically ill patients (ACTiVE) - study protocol of a randomized clinical trial. Trials 2022; 23:348. [PMID: 35461264 PMCID: PMC9034629 DOI: 10.1186/s13063-022-06286-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/07/2022] [Indexed: 12/16/2022] Open
Abstract
Background INTELLiVENT–Adaptive Support Ventilation (ASV) is a fully automated closed-loop mode of ventilation for use in critically ill patients. Evidence for benefit of INTELLiVENT–ASV in comparison to ventilation that is not fully automated with regard to duration of ventilation and quality of breathing is largely lacking. We test the hypothesis that INTELLiVENT–ASV shortens time spent on a ventilator and improves the quality of breathing. Methods The “Effects of Automated Closed–loop VenTilation versus Conventional Ventilation on Duration and Quality of Ventilation” (ACTiVE) study is an international, multicenter, two-group randomized clinical superiority trial. In total, 1200 intensive care unit (ICU) patients with an anticipated duration of ventilation of > 24 h will be randomly assigned to one of the two ventilation strategies. Investigators screen patients aged 18 years or older at start of invasive ventilation in the ICU. Patients either receive automated ventilation by means of INTELLiVENT–ASV, or ventilation that is not automated by means of a conventional ventilation mode. The primary endpoint is the number of days free from ventilation and alive at day 28; secondary endpoints are quality of breathing using granular breath-by-breath analysis of ventilation parameters and variables in a time frame of 24 h early after the start of invasive ventilation, duration of ventilation in survivors, ICU and hospital length of stay (LOS), and mortality rates in the ICU and hospital, and at 28 and 90 days. Discussion ACTiVE is one of the first randomized clinical trials that is adequately powered to compare the effects of automated closed-loop ventilation versus conventional ventilation on duration of ventilation and quality of breathing in invasively ventilated critically ill patients. The results of ACTiVE will support intensivist in their choices regarding the use of automated ventilation. Trial registration ACTiVE is registered in clinicaltrials.gov (study identifier: NCT04593810) on 20 October 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06286-w.
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Affiliation(s)
- Michela Botta
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jante S Sinnige
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ashley J R De Bie
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Lorenzo Ball
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Denise Battaglini
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Iole Brunetti
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Laura A Buiteman-Kruizinga
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Francesco Mojoli
- Department of Anesthesia and Intensive Care, San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Abraham Schoe
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Faculty of Health, ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genova, Genova, Italy
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Research and Development, Hamilton Medical AG, Bonaduz, Switzerland
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Candel BGJ, Raven W, Lameijer H, Thijssen WAMH, Temorshuizen F, Boerma C, de Keizer NF, de Jonge E, de Groot B. The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients. Crit Care 2022; 26:112. [PMID: 35440007 PMCID: PMC9020059 DOI: 10.1186/s13054-022-03986-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 01/20/2023] Open
Abstract
Background Treatment and the clinical course during Emergency Department (ED) stay before Intensive Care Unit (ICU) admission may affect predicted mortality risk calculated by the Acute Physiology and Chronic Health Evaluation (APACHE)-IV, causing lead-time bias. As a result, comparing standardized mortality ratios (SMRs) among hospitals may be difficult if they differ in the location where initial stabilization takes place. The aim of this study was to assess to what extent predicted mortality risk would be affected if the APACHE-IV score was recalculated with the initial physiological variables from the ED. Secondly, to evaluate whether ED Length of Stay (LOS) was associated with a change (delta) in these APACHE-IV scores. Methods An observational multicenter cohort study including ICU patients admitted from the ED. Data from two Dutch quality registries were linked: the Netherlands Emergency department Evaluation Database (NEED) and the National Intensive Care Evaluation (NICE) registry. The ICU APACHE-IV, predicted mortality, and SMR based on data of the first 24 h of ICU admission were compared with an ED APACHE-IV model, using the most deviating physiological variables from the ED or ICU. Results A total of 1398 patients were included. The predicted mortality from the ICU APACHE-IV (median 0.10; IQR 0.03–0.30) was significantly lower compared to the ED APACHE-IV model (median 0.13; 0.04–0.36; p < 0.01). The SMR changed from 0.63 (95%CI 0.54–0.72) to 0.55 (95%CI 0.47–0.63) based on ED APACHE-IV. Predicted mortality risk changed more than 5% in 321 (23.2%) patients by using the ED APACHE-IV. ED LOS > 3.9 h was associated with a slight increase in delta APACHE-IV of 1.6 (95% CI 0.4–2.8) compared to ED LOS < 1.7 h. Conclusion Predicted mortality risks and SMRs calculated by the APACHE IV scores are not directly comparable in patients admitted from the ED if hospitals differ in their policy to stabilize patients in the ED before ICU admission. Future research should focus on developing models to adjust for these differences. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03986-2.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Emergency Medicine, Máxima Medical Centre, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Wendy A M H Thijssen
- Department of Emergency Medicine, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Fabian Temorshuizen
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Verhoeven JGHP, Hesselink DA, Peeters AMA, de Jonge E, von der Thüsen JH, van Schaik RHN, Matic M, Baan CC, Manintveld OC, Boer K. Donor-Derived Cell-Free DNA for the Detection of Heart Allograft Injury: The Impact of the Timing of the Liquid Biopsy. Transpl Int 2022; 35:10122. [PMID: 35387397 PMCID: PMC8977404 DOI: 10.3389/ti.2022.10122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/16/2022] [Indexed: 11/13/2022]
Abstract
Background: In heart transplant recipients, donor-derived cell-free DNA (ddcfDNA) is a potential biomarker for acute rejection (AR), in that increased values may indicate rejection. For the assessment of ddcfDNA as new biomarker for rejection, blood plasma sampling around the endomyocardial biopsy (EMB) seems a practical approach. To evaluate the effect of the EMB procedure on ddcfDNA values, ddcfDNA values before the EMB were pairwise compared to ddcfDNA values after the EMB. We aimed at evaluating whether it matters whether the ddcfDNA sampling is done before or after the EMB-procedure. Methods: Plasma samples from heart transplant recipients were obtained pre-EMB and post-EMB. A droplet digital PCR method was used for measuring ddcfDNA, making use of single-nucleotide polymorphisms that allowed both relative quantification, as well as absolute quantification of ddcfDNA. Results: Pairwise comparison of ddcfDNA values pre-EMB with post-EMB samples (n = 113) showed significantly increased ddcfDNA concentrations and ddcfDNA% in post-EMB samples: an average 1.28-fold increase in ddcfDNA concentrations and a 1.31-fold increase in ddcfDNA% was observed (p = 0.007 and p = 0.03, respectively). Conclusion: The EMB procedure causes iatrogenic injury to the allograft that results in an increase in ddcfDNA% and ddcfDNA concentrations. For the assessment of ddcfDNA as marker for AR, collection of plasma samples before the EMB procedure is therefore essential.
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Affiliation(s)
- Jeroen G H P Verhoeven
- Division of Nephrology and Transplantation, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Annemiek M A Peeters
- Division of Nephrology and Transplantation, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Evert de Jonge
- Department of Clinical Chemistry, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jan H von der Thüsen
- Department of Pathology, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Carla C Baan
- Division of Nephrology and Transplantation, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - O C Manintveld
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Karin Boer
- Division of Nephrology and Transplantation, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
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23
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Akin S, Schriek P, van Nieuwkoop C, Neuman RI, Meynaar I, van Helden EJ, Bouazzaoui HE, Baak R, Veuger M, Mairuhu RA, van den Berg L, van Driel V, Visser LE, de Jonge E, Garrelds IM, Duynstee JF, van Rooden JK, Ludikhuize J, Verdonk K, Caliskan K, Jansen T, van Schaik RH, Danser AJ. A low aldosterone/renin ratio and high soluble ACE2 associate with COVID-19 severity. J Hypertens 2022; 40:606-614. [PMID: 34862332 PMCID: PMC8815849 DOI: 10.1097/hjh.0000000000003054] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/01/2021] [Accepted: 10/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The severity of COVID-19 after SARS-CoV-2 infection is unpredictable. Angiotensin-converting enzyme-2 (ACE2) is the receptor responsible for coronavirus binding, while subsequent cell entry relies on priming by the serine protease TMPRSS2 (transmembrane protease, serine 2). Although renin-angiotensin-aldosterone-system (RAAS) blockers have been suggested to upregulate ACE2, their use in COVID-19 patients is now considered well tolerated. The aim of our study was to investigate parameters that determine COVID-19 severity, focusing on RAAS-components and variation in the genes encoding for ACE2 and TMPRSS2. METHODS Adult patients hospitalized due to SARS-CoV-2 infection between May 2020 and October 2020 in the Haga Teaching Hospital were included, and soluble ACE2 (sACE2), renin, aldosterone (in heparin plasma) and polymorphisms in the ACE2 and TMPRSS2 genes (in DNA obtained from EDTA blood) were determined. MEASUREMENTS AND MAIN RESULTS Out of the 188 patients who were included, 60 were defined as severe COVID-19 (ICU and/or death). These patients more often used antidiabetic drugs, were older, had higher renin and sACE2 levels, lower aldosterone levels and a lower aldosterone/renin ratio. In addition, they displayed the TMPRSS2-rs2070788 AA genotype less frequently. No ACE2 polymorphism-related differences were observed. Multivariate regression analysis revealed independent significance for age, sACE2, the aldosterone/renin ratio, and the TMPRSS2 rs2070788 non-AA genotype as predictors of COVID-19 severity, together yielding a C-index of 0.79. Findings were independent of the use of RAAS blockers. CONCLUSION High sACE2, a low aldosterone/renin ratio and having the TMPRSS2 rs2070788 non-AA genotype are novel independent determinants that may help to predict COVID-19 disease severity. TRIAL REGISTRATION retrospectively registered.
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Affiliation(s)
- Sakir Akin
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
- Department of Cardiology, Unit Heart Failure and Transplant Unit, Erasmus MC University Medical Center, Rotterdam
| | | | | | - Rugina I. Neuman
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology Erasmus MC University Medical Center, Rotterdam
| | - Iwan Meynaar
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | | | | | - Remon Baak
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | | | | | - Lettie van den Berg
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | | | - Loes E. Visser
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague
| | - Evert de Jonge
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam
| | - Ingrid M. Garrelds
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology Erasmus MC University Medical Center, Rotterdam
| | | | | | - Jeroen Ludikhuize
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Koen Verdonk
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology Erasmus MC University Medical Center, Rotterdam
| | - Kadir Caliskan
- Department of Cardiology, Unit Heart Failure and Transplant Unit, Erasmus MC University Medical Center, Rotterdam
| | - Tim Jansen
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Ron H.N. van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam
| | - A.H. Jan Danser
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology Erasmus MC University Medical Center, Rotterdam
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24
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Raven W, van den Hoven EMP, Gaakeer MI, Ter Avest E, Sir O, Lameijer H, Hessels RAPA, Reijnen R, van Zwet E, de Jonge E, Nickel CH, de Groot B. The association between presenting complaints and clinical outcomes in emergency department patients of different age categories. Eur J Emerg Med 2022; 29:33-41. [PMID: 34406137 DOI: 10.1097/mej.0000000000000860] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND IMPORTANCE Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent. OBJECTIVE To assess the frequency and association of PCs with hospitalization and mortality across age categories. METHODS An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs). RESULTS We included 172 104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and 'palpitations' [0.64 (0.58-0.71)]. CONCLUSIONS Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality.
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Affiliation(s)
- Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
| | | | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Centre Groningen, Groningen
| | - Ozcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden
| | | | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague
| | - Erik van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
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25
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Candel BGJ, Khoudja J, Gaakeer MI, Ter Avest E, Sir Ö, Lameijer H, Hessels RAPA, Reijnen R, van Zwet E, de Jonge E, de Groot B. Age-adjusted interpretation of biomarkers of renal function and homeostasis, inflammation, and circulation in Emergency Department patients. Sci Rep 2022; 12:1556. [PMID: 35091652 PMCID: PMC8799641 DOI: 10.1038/s41598-022-05485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/12/2022] [Indexed: 12/03/2022] Open
Abstract
Appropriate interpretation of blood tests is important for risk stratification and guidelines used in the Emergency Department (ED) (such as SIRS or CURB-65). The impact of abnormal blood test values on mortality may change with increasing age due to (patho)-physiologic changes. The aim of this study was therefore to assess the effect of age on the case-mix adjusted association between biomarkers of renal function and homeostasis, inflammation and circulation and in-hospital mortality. This observational multi-center cohort study has used the Netherlands Emergency department Evaluation Database (NEED), including all consecutive ED patients ≥ 18 years of three hospitals. A generalized additive logistic regression model was used to visualize the association between in-hospital mortality, age and five blood tests (creatinine, sodium, leukocytes, C-reactive Protein, and hemoglobin). Multivariable logistic regression analyses were used to assess the association between the number of abnormal blood test values and mortality per age category (18-50; 51-65; 66-80; > 80 years). Of the 94,974 included patients, 2550 (2.7%) patients died in-hospital. Mortality increased gradually for C-reactive Protein (CRP), and had a U-shaped association for creatinine, sodium, leukocytes, and hemoglobin. Age significantly affected the associations of all studied blood tests except in leukocytes. In addition, with increasing age categories, case-mix adjusted mortality increased with the number of abnormal blood tests. In summary, the association between blood tests and (adjusted) mortality depends on age. Mortality increases gradually or in a U-shaped manner with increasing blood test values. Age-adjusted numerical scores may improve risk stratification. Our results have implications for interpretation of blood tests and their use in risk stratification tools and acute care guidelines.Trial registration number Netherlands Trial Register (NTR) NL8422, 03/2020.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | - Jamèl Khoudja
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Admiraal de Ruyter Hospital, 's-Gravenpolderseweg 114, 4462 RA, Goes, The Netherlands
| | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Center Groningen, Hanzeplein1, 9713 GZ, Groningen, The Netherlands
| | - Özcan Sir
- Department of Emergency Medicine, Radboud University Medical Center, Houtlaan 4, 6525 XZ, Nijmegen, The Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Roger A P A Hessels
- Department of Emergency Medicine, Elisabeth-TweeSteden Hospital, Doctor Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - Erik van Zwet
- Department of Biostatistics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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26
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Candel BG, Duijzer R, Gaakeer MI, Ter Avest E, Sir Ö, Lameijer H, Hessels R, Reijnen R, van Zwet EW, de Jonge E, de Groot B. The association between vital signs and clinical outcomes in emergency department patients of different age categories. Emerg Med J 2022; 39:903-911. [PMID: 35017189 DOI: 10.1136/emermed-2020-210628] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/07/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category. AIMS To assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories. METHODS Observational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81-100, 101-120, 121-140, >140 mm Hg). RESULTS We included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO2). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients. CONCLUSION For SBP, DBP, SpO2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines.
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Affiliation(s)
- Bart Gj Candel
- Emergency Department, Maxima Medical Centre, Veldhoven, Noord-Brabant, The Netherlands .,Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Renée Duijzer
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Menno I Gaakeer
- Emergency Department, Admiraal De Ruyter Hospital, Goes, Zeeland, The Netherlands
| | - Ewoud Ter Avest
- Emergency Department, University Medical Centre Groningen, Groningen, The Netherlands
| | - Özcan Sir
- Emergency Department, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Heleen Lameijer
- Emergency Department, Medical Centre Leeuwarden, Leeuwarden, Friesland, The Netherlands
| | - Roger Hessels
- Emergency Department, Elisabeth-TweeSteden Hospital, Tilburg, Noord-Brabant, The Netherlands
| | - Resi Reijnen
- Emergency Department, Medical Centre Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Erik W van Zwet
- Department of Biostatistics, Leiden Universitair Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Evert de Jonge
- Intensive Care, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands
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27
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Candel BG, Dap S, Raven W, Lameijer H, Gaakeer MI, de Jonge E, de Groot B. Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study. Eur J Intern Med 2022; 95:74-79. [PMID: 34521584 DOI: 10.1016/j.ejim.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). METHODS Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. RESULTS Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. CONCLUSIONS Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.
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Affiliation(s)
- Bart Gj Candel
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands; Department of Emergency Medicine, Máxima Medical Center, De Run 4600, Veldhoven, DB 5504, the Netherlands.
| | - Saimi Dap
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden, AD 8934, the Netherlands
| | - Menno I Gaakeer
- Department of Emergency Medicine, Adrz Hospital, 's-Gravenpolderseweg 114, Goes, RA 4462, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, RC 2300, the Netherlands
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28
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Candel BGJ, van Ingen IB, van Doormalen IPH, Raven W, Mignot-Evers LAA, de Jonge E, de Groot B. The difference between the patients' initial and previously measured systolic blood pressure as predictor of mortality in older emergency department patients. Eur Geriatr Med 2021; 13:359-365. [PMID: 34826112 DOI: 10.1007/s41999-021-00588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess how often baseline systolic blood pressure (SBP) could be retrieved from the Electronic Health Record (EHR) in older Emergency Department (ED) patients. Second, to assess whether the difference between baseline SBP and initial SBP in the ED (ΔSBP) was associated with 30-day mortality. METHODS A multicenter hypothesis-generating cohort study including patients ≥ 70 years. EHRs were searched for baseline SBPs. The association between ΔSBP and 30-day mortality was investigated. RESULTS Baseline SBP was found in 220 out of 300 patients (73.3%; 95%CI 68.1-78.0%). In 72 patients with normal initial SBPs (133-166 mmHg) in the ED, fifteen (20.8%) had a negative ΔSBP with 20.0% mortality. A negative ΔSBP was associated with 30-day mortality (AHR 4.7; 1.7-12.7). CONCLUSION Baseline SBPs are often available in older ED patients. The ΔSBP has prognostic value and could be used as an extra variable to recognize hypotension in older ED patients. Future studies should clarify whether the ΔSBP improves risk stratification in the ED.
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Affiliation(s)
- Bart G J Candel
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504DB, Veldhoven, The Netherlands. .,Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - Iris B van Ingen
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris P H van Doormalen
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504DB, Veldhoven, The Netherlands
| | - Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisette A A Mignot-Evers
- Department of Emergency Medicine, Máxima Medical Center, De Run 4600, 5504DB, Veldhoven, The Netherlands.,Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
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29
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Stals MAM, Grootenboers MJJH, van Guldener C, Kaptein FHJ, Braken SJE, Chen Q, Chu G, van Driel EM, Iglesias del Sol A, de Jonge E, Kant KM, Pals F, Toorop MMA, Cannegieter SC, Klok FA, Huisman MV. Risk of thrombotic complications in influenza versus COVID-19 hospitalized patients. Res Pract Thromb Haemost 2021; 5:412-420. [PMID: 33821230 PMCID: PMC8014477 DOI: 10.1002/rth2.12496] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/16/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022] Open
Abstract
Background Whereas accumulating studies on patients with coronavirus disease 2019 (COVID-19) report high incidences of thrombotic complications, large studies on clinically relevant thrombosis in patients with other respiratory tract infections are lacking. How this high risk in COVID-19 patients compares to those observed in hospitalized patients with other viral pneumonias such as influenza is unknown. Objectives To assess the incidence of venous and arterial thrombotic complications in hospitalized patients with influenza as opposed to that observed in hospitalized patients with COVID-19. Methods This was a retrospective cohort study; we used data from Statistics Netherlands (study period: 2018) on thrombotic complications in hospitalized patients with influenza. In parallel, we assessed the cumulative incidence of thrombotic complications-adjusted for competing risk of death-in patients with COVID-19 in three Dutch hospitals (February 24 to April 26, 2020). Results Of the 13 217 hospitalized patients with influenza, 437 (3.3%) were diagnosed with thrombotic complications, versus 66 (11%) of the 579 hospitalized patients with COVID-19. The 30-day cumulative incidence of any thrombotic complication in influenza was 11% (95% confidence interval [CI], 9.4-12) versus 25% (95% CI, 18-32) in COVID-19. For venous thrombotic (VTC) complications and arterial thrombotic complications alone, these numbers were, respectively, 3.6% (95% CI, 2.7-4.6) and 7.5% (95% CI, 6.3-8.8) in influenza versus 23% (95% CI, 16-29) and 4.4% (95% CI, 1.9-8.8) in COVID-19. Conclusions The incidence of thrombotic complications in hospitalized patients with influenza was lower than in hospitalized patients with COVID-19. This difference was mainly driven by a high risk of VTC complications in the patients with COVID-19 admitted to the Intensive Care Unit. Remarkably, patients with influenza were more often diagnosed with arterial thrombotic complications.
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Affiliation(s)
- Milou A. M. Stals
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | | | | | - Fleur H. J. Kaptein
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Sander J. E. Braken
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Qingui Chen
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gordon Chu
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Erik M. van Driel
- Department of Intensive Care MedicineAlrijne HospitalLeiderdorpThe Netherlands
| | | | - Evert de Jonge
- Department of Intensive Care MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - K. Merijn Kant
- Department of Intensive Care MedicineAmphia HospitalBredaThe Netherlands
| | - Fleur Pals
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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30
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Heldeweg MLA, Lopez Matta JE, Haaksma ME, Smit JM, Elzo Kraemer CV, de Grooth HJ, de Jonge E, Meijboom LJ, Heunks LMA, van Westerloo DJ, Tuinman PR. Lung ultrasound and computed tomography to monitor COVID-19 pneumonia in critically ill patients: a two-center prospective cohort study. Intensive Care Med Exp 2021; 9:1. [PMID: 33491147 PMCID: PMC7829056 DOI: 10.1186/s40635-020-00367-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/21/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Lung ultrasound can adequately monitor disease severity in pneumonia and acute respiratory distress syndrome. We hypothesize lung ultrasound can adequately monitor COVID-19 pneumonia in critically ill patients. METHODS Adult patients with COVID-19 pneumonia admitted to the intensive care unit of two academic hospitals who underwent a 12-zone lung ultrasound and a chest CT examination were included. Baseline characteristics, and outcomes including composite endpoint death or ICU stay > 30 days were recorded. Lung ultrasound and CT images were quantified as a lung ultrasound score involvement index (LUSI) and CT severity involvement index (CTSI). Primary outcome was the correlation, agreement, and concordance between LUSI and CTSI. Secondary outcome was the association of LUSI and CTSI with the composite endpoints. RESULTS We included 55 ultrasound examinations in 34 patients, which were 88% were male, with a mean age of 63 years and mean P/F ratio of 151. The correlation between LUSI and CTSI was strong (r = 0.795), with an overall 15% bias, and limits of agreement ranging - 40 to 9.7. Concordance between changes in sequentially measured LUSI and CTSI was 81%. In the univariate model, high involvement on LUSI and CTSI were associated with a composite endpoint. In the multivariate model, LUSI was the only remaining independent predictor. CONCLUSIONS Lung ultrasound can be used as an alternative for chest CT in monitoring COVID-19 pneumonia in critically ill patients as it can quantify pulmonary involvement, register changes over the course of the disease, and predict death or ICU stay > 30 days. TRIAL REGISTRATION NTR, NL8584. Registered 01 May 2020-retrospectively registered, https://www.trialregister.nl/trial/8584.
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Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands.
- VU University Medical Center Amsterdam, Postbox 7507, 1007 MB, Amsterdam, The Netherlands.
| | - Jorge E Lopez Matta
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
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31
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Bos MK, Nasserinejad K, Jansen MPHM, Angus L, Atmodimedjo PN, de Jonge E, Dinjens WNM, van Schaik RHN, Del Re M, Dubbink HJ, Sleijfer S, Martens JWM. Comparison of variant allele frequency and number of mutant molecules as units of measurement for circulating tumor DNA. Mol Oncol 2021; 15:57-66. [PMID: 33070443 PMCID: PMC7782075 DOI: 10.1002/1878-0261.12827] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/10/2020] [Accepted: 10/15/2020] [Indexed: 12/26/2022] Open
Abstract
Quantification of tumor-specific variants (TSVs) in cell-free DNA is rapidly evolving as a prognostic and predictive tool in patients with cancer. Currently, both variant allele frequency (VAF) and number of mutant molecules per mL plasma are used as units of measurement to report those TSVs. However, it is unknown to what extent both units of measurement agree and what are the factors underlying an existing disagreement. To study the agreement between VAF and mutant molecules in current clinical studies, we analyzed 1116 TSVs from 338 patients identified with next-generation sequencing (NGS) or digital droplet PCR (ddPCR). On different study cohorts, a Deming regression analysis was performed and its 95% prediction interval was used as surrogate for the limits of agreement between VAF and number of mutant molecules per mL and to identify outliers. VAF and number of mutant molecules per mL plasma yielded greater agreement when using ddPCR than NGS. In case of discordance between VAF and number of mutant molecules per mL, insufficient molecular coverage in NGS and high cell-free DNA concentration were the main responsible factors. We propose several optimization steps needed to bring monitoring of TSVs in cell-free DNA to its full potential.
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Affiliation(s)
- Manouk K. Bos
- Department of Medical OncologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Kazem Nasserinejad
- Department of HematologyHOVON Data CenterErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Maurice P. H. M. Jansen
- Department of Medical OncologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Lindsay Angus
- Department of Medical OncologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Peggy N. Atmodimedjo
- Department of PathologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Evert de Jonge
- Department of Clinical ChemistryErasmus University Medical CenterRotterdamThe Netherlands
| | - Winand N. M. Dinjens
- Department of PathologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Ron H. N. van Schaik
- Department of Clinical ChemistryErasmus University Medical CenterRotterdamThe Netherlands
| | - Marzia Del Re
- Department of Clinical ChemistryErasmus University Medical CenterRotterdamThe Netherlands
- Unit of Clinical Pharmacology and PharmacogeneticsDepartment of Clinical and Experimental MedicineUniversity Hospital of PisaItaly
| | - Hendrikus J. Dubbink
- Department of PathologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - Stefan Sleijfer
- Department of Medical OncologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
| | - John W. M. Martens
- Department of Medical OncologyErasmus MC Cancer Institute, University Medical CenterRotterdamThe Netherlands
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32
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Robba C, Siwicka-Gieroba D, Sikter A, Battaglini D, Dąbrowski W, Schultz MJ, de Jonge E, Grim C, Rocco PR, Pelosi P. Pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. Intensive Care Med Exp 2020; 8:19. [PMID: 33336311 PMCID: PMC7746422 DOI: 10.1186/s40635-020-00307-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
Post cardiac arrest syndrome is associated with high morbidity and mortality, which is related not only to a poor neurological outcome but also to respiratory and cardiovascular dysfunctions. The control of gas exchange, and in particular oxygenation and carbon dioxide levels, is fundamental in mechanically ventilated patients after resuscitation, as arterial blood gases derangement might have important effects on the cerebral blood flow and systemic physiology. In particular, the pathophysiological role of carbon dioxide (CO2) levels is strongly underestimated, as its alterations quickly affect also the changes of intracellular pH, and consequently influence metabolic energy and oxygen demand. Hypo/hypercapnia, as well as mechanical ventilation during and after resuscitation, can affect CO2 levels and trigger a dangerous pathophysiological vicious circle related to the relationship between pH, cellular demand, and catecholamine levels. The developing hypocapnia can nullify the beneficial effects of the hypothermia. The aim of this review was to describe the pathophysiology and clinical consequences of arterial blood gases and pH after cardiac arrest. According to our findings, the optimal ventilator strategies in post cardiac arrest patients are not fully understood, and oxygen and carbon dioxide targets should take in consideration a complex pattern of pathophysiological factors. Further studies are warranted to define the optimal settings of mechanical ventilation in patients after cardiac arrest.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Andras Sikter
- Internal Medicine, Municipal Clinic of Szentendre, Szentendre, Hungary
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Chloe Grim
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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33
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Grim CC, Helmerhorst HJ, Schultz MJ, Winters T, van der Voort PH, van Westerloo DJ, de Jonge E. Changes in Attitudes and Actual Practice of Oxygen Therapy in ICUs after Implementation of a Conservative Oxygenation Guideline. Respir Care 2020; 65:1502-1510. [PMID: 32209714 DOI: 10.4187/respcare.07527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Little is known to what extent attitudes of ICU clinicians are influenced by new insights and recommendations to be more conservative with oxygen therapy. Our aim was to investigate whether implementation of a conservative oxygenation guideline structurally changed self-reported attitudes and actual clinical practice. METHODS After the implementation of a conservative oxygen therapy guideline in 3 teaching hospitals in the Netherlands, ICU clinicians were surveyed regarding their attitudes toward oxygen therapy. The survey results were compared with survey results taken before the introduction of the new guideline. Arterial blood gas analysis data and ventilator settings were retrieved from all patients admitted to the participating ICUs in the studied period, and changes after implementing the guideline were assessed. RESULTS In total, 180 ICU clinicians returned the survey. Compared to before implementation of a conservative oxygen guideline, more clinicians chose a preferred [Formula: see text] and an oxygen saturation measured from an arterial sample ([Formula: see text]) limit after implementation of the guideline. In general, clinicians reported a more conservative approach toward management of [Formula: see text] and less frequently increased the [Formula: see text]. In the period after the active implementation of the guideline, 5,840 subjects were admitted to the participating ICUs and 101,869 arterial blood gas analyses were retrieved. Actual practice changed with overall lower oxygenation levels (median [Formula: see text] 77.93 mm Hg, compared to 86.93 mm Hg before implementation) of arterial blood and a decrease of PEEP and [Formula: see text]. CONCLUSIONS Implementing a conservative oxygenation guideline was an effective method that changed self-reported attitudes and actual clinical practice and improved adherence to conservative oxygenation targets in a short period of time.
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Affiliation(s)
- Chloe Ca Grim
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - Hendrik Jf Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Tineke Winters
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Schoe A, Bakhshi-Raiez F, de Keizer N, van Dissel JT, de Jonge E. Mortality prediction by SOFA score in ICU-patients after cardiac surgery; comparison with traditional prognostic-models. BMC Anesthesiol 2020; 20:65. [PMID: 32169047 PMCID: PMC7068937 DOI: 10.1186/s12871-020-00975-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 03/02/2020] [Indexed: 01/09/2023] Open
Abstract
Background There are many prognostic models and scoring systems in use to predict mortality in ICU patients. The only general ICU scoring system developed and validated for patients after cardiac surgery is the APACHE-IV model. This is, however, a labor-intensive scoring system requiring a lot of data and could therefore be prone to error. The SOFA score on the other hand is a simpler system, has been widely used in ICUs and could be a good alternative. The goal of the study was to compare the SOFA score with the APACHE-IV and other ICU prediction models. Methods We investigated, in a large cohort of cardiac surgery patients admitted to Dutch ICUs, how well the SOFA score from the first 24 h after admission, predict hospital and ICU mortality in comparison with other recalibrated general ICU scoring systems. Measures of discrimination, accuracy, and calibration (area under the receiver operating characteristic curve (AUC), Brier score, R2, and Ĉ-statistic) were calculated using bootstrapping. The cohort consisted of 36,632 Patients from the Dutch National Intensive Care Evaluation (NICE) registry having had a cardiac surgery procedure for which ICU admission was necessary between January 1st, 2006 and June 31st, 2018. Results Discrimination of the SOFA-, APACHE-IV-, APACHE-II-, SAPS-II-, MPM24-II - models to predict hospital mortality was good with an AUC of respectively: 0.809, 0.851, 0.830, 0.850, 0.801. Discrimination of the SOFA-, APACHE-IV-, APACHE-II-, SAPS-II-, MPM24-II - models to predict ICU mortality was slightly better with AUCs of respectively: 0.809, 0.906, 0.892, 0.919, 0.862. Calibration of the models was generally poor. Conclusion Although the SOFA score had a good discriminatory power for hospital- and ICU mortality the discriminatory power of the APACHE-IV and SAPS-II was better. The SOFA score should not be preferred as mortality prediction model above traditional prognostic ICU-models.
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Affiliation(s)
- Abraham Schoe
- Department of Intensive Care, Leiden University Medical Center, University of Leiden, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Ferishta Bakhshi-Raiez
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands
| | - Nicolette de Keizer
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands
| | - Jaap T van Dissel
- Department of infectious diseases, Leiden University Medical Centre, University of Leiden, Leiden, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, University of Leiden, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
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35
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Steendam CM, Atmodimedjo P, de Jonge E, Paats MS, van der Leest C, Oomen-de Hoop E, Jansen MP, Del Re M, von der Thüsen JH, Dinjens WN, van Schaik RH, Aerts JG, Dubbink HJ. Plasma Cell-Free DNA Testing of Patients With EGFR Mutant Non–Small-Cell Lung Cancer: Droplet Digital PCR Versus Next-Generation Sequencing Compared With Tissue-Based Results. JCO Precis Oncol 2019; 3:1-9. [DOI: 10.1200/po.18.00401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
PURPOSE To compare the results of plasma cell-free DNA (cfDNA) droplet digital PCR (ddPCR) and next-generation sequencing (NGS) on detection of epidermal growth factor receptor ( EGFR) primary activating mutations and p.T790M with results of tissue analysis in patients with EGFR mutated non–small-cell lung cancer. METHODS All patients with EGFR mutated non–small cell lung cancer for which a pathology and a plasma specimen were available upon progression between November 2016 and July 2018 were selected. Concordance, Cohen’s κ, and intraclass correlation coefficients were calculated. RESULTS Plasma cfDNA and pathology specimens of 36 patients were analyzed. Agreement between ddPCR and NGS was 86% (κ = 0.63) for the primary activating mutation and 94% (κ = 0.89) for the p.T790M detection. Allele ratios were comparable, with an intraclass correlation coefficient of 0.992 and 0.997, respectively. Discrepancies of some degree were found in 15 patients (41.7%). In six patients (16.7%), no mutations were detected in cfDNA. In three patients (8.3%), p.T790M was detected in plasma but not in the pathology specimen, whereas in three other patients (8.3%), p.T790M was demonstrated in the pathology specimen but not in plasma. Concordance of cfDNA and pathology for the primary activating mutation was 69% for ddPCR and 83% for NGS. For the detection of p.T790M, this was 75% (κ = 0.49) for ddPCR as well as for NGS. CONCLUSION Mutual agreement is high between NGS and ddPCR in cfDNA on the level of a specific mutation, with comparable ratio results. Plasma testing of EGFR primary activating mutations and p.T790M shows high concordance with pathology results, for NGS as well as for ddPCR, depending on the extent of the panel used. In NGS, more genetic aberrations can be investigated at once.
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Affiliation(s)
- Christi M.J. Steendam
- Erasmus MC Rotterdam, Rotterdam, the Netherlands
- Amphia Hospital, Breda, the Netherlands
| | | | | | | | | | | | | | - Marzia Del Re
- University Hospital of Pisa, University of Pisa, Pisa, Italy
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36
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van Vessem ME, Beeres SLMA, de Wilde RBP, de Vries R, Berendsen RR, de Jonge E, Danser AHJ, Klautz RJM, Schalij MJ, Palmen M. Vasoresponsiveness in patients with heart failure (VASOR): protocol for a prospective observational study. J Cardiothorac Surg 2019; 14:200. [PMID: 31752946 PMCID: PMC6868831 DOI: 10.1186/s13019-019-1014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/21/2019] [Indexed: 11/22/2022] Open
Abstract
Background Vasoplegia is a severe complication which may occur after cardiac surgery, particularly in patients with heart failure. It is a result of activation of vasodilator pathways, inactivation of vasoconstrictor pathways and the resistance to vasopressors. However, the precise etiology remains unclear. The aim of the Vasoresponsiveness in patients with heart failure (VASOR) study is to objectify and characterize the altered vasoresponsiveness in patients with heart failure, before, during and after heart failure surgery and to identify the etiological factors involved. Methods This is a prospective, observational study conducted at Leiden University Medical Center. Patients with and patients without heart failure undergoing cardiac surgery on cardiopulmonary bypass are enrolled. The study is divided in two inclusion phases. During phase 1, 18 patients with and 18 patients without heart failure are enrolled. The vascular reactivity in response to a vasoconstrictor (phenylephrine) and a vasodilator (nitroglycerin) is assessed in vivo on different timepoints. The response to phenylephrine is assessed on t1 (before induction), t2 (before induction, after start of cardiotropic drugs and/or vasopressors), t3 (after induction), t4 (15 min after cessation of cardiopulmonary bypass) and t5 (1 day post-operatively). The response to nitroglycerin is assessed on t1 and t5. Furthermore, a sample of pre-pericardial fat tissue, containing resistance arteries, is collected intraoperatively. The ex vivo vascular reactivity is assessed by constructing concentrations response curves to various vasoactive substances using isolated resistance arteries. Next, expression of signaling proteins and receptors is assessed using immunohistochemistry and mRNA analysis. Furthermore, the groups are compared with respect to levels of organic compounds that can influence the cardiovascular system (e.g. copeptin, (nor)epinephrine, ANP, BNP, NTproBNP, angiotensin II, cortisol, aldosterone, renin and VMA levels). During inclusion phase 2, only the ex vivo vascular reactivity test is performed in patients with (N = 12) and without heart failure (N = 12). Discussion Understanding the difference in vascular responsiveness between patients with and without heart failure in detail, might yield therapeutic options or development of preventive strategies for vasoplegia, leading to safer surgical interventions and improvement in outcome. Trial registration The Netherlands Trial Register (NTR), NTR5647. Registered 26 January 2016.
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Affiliation(s)
- Marieke E van Vessem
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands. .,Department of Cardiothoracic Surgery, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands.
| | - Saskia L M A Beeres
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Rob B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - René de Vries
- Department of Internal medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Remco R Berendsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A H Jan Danser
- Department of Internal medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
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37
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Roos-Blom MJ, Dongelmans D, Stilma W, Spijkstra JJ, de Jonge E, de Keizer N. Association between organizational characteristics and adequate pain management at the intensive care unit. J Crit Care 2019; 56:1-5. [PMID: 31765909 DOI: 10.1016/j.jcrc.2019.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/25/2019] [Accepted: 11/15/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Half of the patients experience pain during their ICU stay which is known to influence their outcomes. Nurses and physicians encounter organizational barriers towards pain assessment and treatment. We aimed to evaluate the association between adequate pain management and nurse to patient ratio, bed occupancy rate, and fulltime presence of an intensivist. MATERIALS AND METHODS We performed unadjusted and case-mix adjusted mixed-effect logistic regression modeling on data from thirteen Dutch ICUs to investigate the association between ICU organizational characteristics and adequate pain management, i.e. patient-shift observations in which patients' pain was measured and acceptable, or unacceptable and normalized within 1 h. All ICU patients admitted between December 2017 and June 2018 were included, excluding patients who were delirious, comatose or had a Glasgow coma score < 8 at the first day of ICU admission. RESULTS Case-mix adjusted nurse to patient ratios of 0.70 to 0.80 and over 0.80 were significantly associated with adequate pain management (OR [95% confidence interval] of respectively 1.14 [1.07-1.21] and 1.16 [1.08-1.24]). Bed occupancy rate and intensivist presence showed no association. CONCLUSION Higher nurse to patient ratios increase the percentage of patients with adequate pain management especially in medical and mechanically ventilated patients.
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Affiliation(s)
- Marie-José Roos-Blom
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands; National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands.
| | - Dave Dongelmans
- National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands; Amsterdam UMC, location AMC, University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
| | - Willemke Stilma
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands; ACHIEVE, Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Jan Jaap Spijkstra
- National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands; Amsterdam UMC, location VUmc, Vrije Universiteit Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
| | - Evert de Jonge
- Leiden University Medical Center, Department of Intensive Care Medicine, Leiden, The Netherlands
| | - Nicolette de Keizer
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands; National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands
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38
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van Paassen J, van Dissel JT, Hiemstra PS, Zwaginga JJ, Cobbaert CM, Juffermans NP, de Wilde RB, Stijnen T, de Jonge E, Klautz RJ, Arbous MS. Perioperative proADM-change is associated with the development of acute respiratory distress syndrome in critically ill cardiac surgery patients: a prospective cohort study. Biomark Med 2019; 13:1081-1091. [PMID: 31544475 DOI: 10.2217/bmm-2019-0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Biomarkers of acute respiratory distress syndrome (ARDS) after cardiac-surgery may help risk-stratification and management. Preoperative single-value proADM increases predictive capacity of scoring-system EuroSCORE. To include the impact of surgery, we aim to assess the predictive value of the perioperative proADM-change on development of ARDS in 40 cardiac-surgery patients. Materials & methods: ProADM was measured in nine sequential blood samples. The Berlin definition of ARDS was used. For data-analyses, a multivariate model of EuroSCORE and perioperative proADM-change, linear mixed models and logistic regression were used. Results: Perioperative proADM-change was associated with ARDS after cardiac-surgery, and it was superior to EuroSCORE. A perioperative proADM-change >1.5 nmol/l could predict ARDS. Conclusion: Predicting post-surgery ARDS with perioperative proADM-change enables clinicians to intensify lung-protective interventions and individualized fluid therapy to minimize secondary injury.
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Affiliation(s)
- Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap T van Dissel
- Department of Infectious Disease, Leiden University Medical Center, Leiden, The Netherlands.,Center for Infectious Disease Control, National Institute of Public Health & the Environment, Bilthoven, The Netherlands
| | - Pieter S Hiemstra
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Jan Zwaginga
- Department of Immunohematology & Blood transfusion, Leiden University Medical Center, Leiden, The Netherlands.,Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry & Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care & Anesthesiology (L.E.I.C.A.), Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Rob B de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Gude WT, Roos-Blom MJ, van der Veer SN, Dongelmans DA, de Jonge E, Peek N, de Keizer NF. Facilitating action planning within audit and feedback interventions: a mixed-methods process evaluation of an action implementation toolbox in intensive care. Implement Sci 2019; 14:90. [PMID: 31533841 PMCID: PMC6751678 DOI: 10.1186/s13012-019-0937-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/27/2019] [Indexed: 01/20/2023] Open
Abstract
Background Audit and feedback (A&F) is more effective if it facilitates action planning, but little is known about how best to do this. We developed an electronic A&F intervention with an action implementation toolbox to improve pain management in intensive care units (ICUs); the toolbox contained suggested actions for improvement. A head-to-head randomised trial demonstrated that the toolbox moderately increased the intervention’s effectiveness when compared with A&F only. Objective To understand the mechanisms through which A&F with action implementation toolbox facilitates action planning by ICUs to increase A&F effectiveness. Methods We extracted all individual actions from action plans developed by ICUs that received A&F with (n = 10) and without (n = 11) toolbox for 6 months and classified them using Clinical Performance Feedback Intervention Theory. We held semi-structured interviews with participants during the trial. We compared the number and type of planned and completed actions between study groups and explored barriers and facilitators to effective action planning. Results ICUs with toolbox planned more actions directly aimed at improving practice (p = 0.037) and targeted a wider range of practice determinants compared to ICUs without toolbox. ICUs with toolbox also completed more actions during the study period, but not significantly (p = 0.142). ICUs without toolbox reported more difficulties in identifying what actions they could take. Regardless of the toolbox, all ICUs still experienced barriers relating to the feedback (low controllability, accuracy) and organisational context (competing priorities, resources, cost). Conclusions The toolbox helped health professionals to broaden their mindset about actions they could take to change clinical practice. Without the toolbox, professionals tended to focus more on feedback verification and exploring solutions without developing intentions for actual change. All feedback recipients experienced organisational barriers that inhibited eventual completion of actions. Trial registration ClinicalTrials.gov, NCT02922101. Registered on 26 September 2016. Electronic supplementary material The online version of this article (10.1186/s13012-019-0937-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wouter T Gude
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.
| | - Marie-José Roos-Blom
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Dave A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Niels Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
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40
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Roos-Blom MJ, Gude WT, de Jonge E, Spijkstra JJ, van der Veer SN, Peek N, Dongelmans DA, de Keizer NF. Impact of audit and feedback with action implementation toolbox on improving ICU pain management: cluster-randomised controlled trial. BMJ Qual Saf 2019; 28:1007-1015. [PMID: 31263017 PMCID: PMC6934240 DOI: 10.1136/bmjqs-2019-009588] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/30/2019] [Accepted: 06/08/2019] [Indexed: 11/21/2022]
Abstract
Background Audit and feedback (A&F) enjoys widespread use, but often achieves only marginal improvements in care. Providing recipients of A&F with suggested actions to overcome barriers (action implementation toolbox) may increase effectiveness. Objective To assess the impact of adding an action implementation toolbox to an electronic A&F intervention targeting quality of pain management in intensive care units (ICUs). Trial design Two-armed cluster-randomised controlled trial. Randomisation was computer generated, with allocation concealment by a researcher, unaffiliated with the study. Investigators were not blinded to the group assignment of an ICU. Participants Twenty-one Dutch ICUs and patients eligible for pain measurement. Interventions Feedback-only versus feedback with action implementation toolbox. Outcome Proportion of patient-shift observations where pain management was adequate; composed by two process (measuring pain at least once per patient in each shift; re-measuring unacceptable pain scores within 1 hour) and two outcome indicators (acceptable pain scores; unacceptable pain scores normalised within 1 hour). Results 21 ICUs (feedback-only n=11; feedback-with-toolbox n=10) with a total of 253 530 patient-shift observations were analysed. We found absolute improvement on adequate pain management in the feedback-with-toolbox group (14.8%; 95% CI 14.0% to 15.5%) and the feedback-only group (4.8%; 95% CI 4.2% to 5.5%). Improvement was limited to the two process indicators. The feedback-with-toolbox group achieved larger effects than the feedback-only group both on the composite adequate pain management (p<0.05) and on measuring pain each shift (p<0.001). No important adverse effects have occurred. Conclusion Feedback with toolbox improved the number of shifts where patients received adequate pain management compared with feedback alone, but only in process and not outcome indicators. Trial registration number NCT02922101.
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Affiliation(s)
- Marie-José Roos-Blom
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands .,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Wouter T Gude
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Evert de Jonge
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Jaap Spijkstra
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Niels Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Dave A Dongelmans
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
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Roos-Blom MJ, Gude WT, Spijkstra JJ, de Jonge E, Dongelmans D, de Keizer NF. Measuring quality indicators to improve pain management in critically ill patients. J Crit Care 2019; 49:136-142. [DOI: 10.1016/j.jcrc.2018.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/12/2018] [Accepted: 10/29/2018] [Indexed: 12/14/2022]
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van Asten L, Luna Pinzon A, de Lange DW, de Jonge E, Dijkstra F, Marbus S, Donker GA, van der Hoek W, de Keizer NF. Estimating severity of influenza epidemics from severe acute respiratory infections (SARI) in intensive care units. Crit Care 2018; 22:351. [PMID: 30567568 PMCID: PMC6299979 DOI: 10.1186/s13054-018-2274-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/22/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND While influenza-like-illness (ILI) surveillance is well-organized at primary care level in Europe, few data are available on more severe cases. With retrospective data from intensive care units (ICU) we aim to fill this current knowledge gap. Using multiple parameters proposed by the World Health Organization we estimate the burden of severe acute respiratory infections (SARI) in the ICU and how this varies between influenza epidemics. METHODS We analyzed weekly ICU admissions in the Netherlands (2007-2016) from the National Intensive Care Evaluation (NICE) quality registry (100% coverage of adult ICUs in 2016; population size 14 million) to calculate SARI incidence, SARI peak levels, ICU SARI mortality, SARI mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score, and the ICU SARI/ILI ratio. These parameters were calculated both yearly and per separate influenza epidemic (defined epidemic weeks). A SARI syndrome was defined as admission diagnosis being any of six pneumonia or pulmonary sepsis codes in the APACHE IV prognostic model. Influenza epidemic periods were retrieved from primary care sentinel influenza surveillance data. RESULTS Annually, an average of 13% of medical admissions to adult ICUs were for a SARI but varied widely between weeks (minimum 5% to maximum 25% per week). Admissions for bacterial pneumonia (59%) and pulmonary sepsis (25%) contributed most to ICU SARI. Between the eight different influenza epidemics under study, the value of each of the severity parameters varied. Per parameter the minimum and maximum of those eight values were as follows: ICU SARI incidence 558-2400 cumulated admissions nationwide, rate 0.40-1.71/10,000 inhabitants; average APACHE score 71-78; ICU SARI mortality 13-20%; ICU SARI/ILI ratio 8-17 cases per 1000 expected medically attended ILI in primary care); peak-incidence 101-188 ICU SARI admissions in highest-incidence week, rate 0.07-0.13/10,000 population). CONCLUSIONS In the ICU there is great variation between the yearly influenza epidemic periods in terms of different influenza severity parameters. The parameters also complement each other by reflecting different aspects of severity. Prospective syndromic ICU SARI surveillance, as proposed by the World Health Organization, thereby would provide insight into the severity of ongoing influenza epidemics, which differ from season to season.
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Affiliation(s)
- Liselotte van Asten
- Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
| | - Angie Luna Pinzon
- Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Dylan W de Lange
- National Intensive Care Evaluation, Amsterdam, the Netherlands
- Department of Intensive Care Medicine, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Evert de Jonge
- National Intensive Care Evaluation, Amsterdam, the Netherlands
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederika Dijkstra
- Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Sierk Marbus
- Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Gé A Donker
- Nivel Primary Care Database - Sentinel Practices, Utrecht, the Netherlands
| | - Wim van der Hoek
- Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Nicolette F de Keizer
- National Intensive Care Evaluation, Amsterdam, the Netherlands
- Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Oerlemans AJM, de Jonge E, van der Hoeven JG, Zegers M. A systematic approach to develop a core set of parameters for boards of directors to govern quality of care in the ICU. Int J Qual Health Care 2018; 30:545-550. [PMID: 29635336 PMCID: PMC6094796 DOI: 10.1093/intqhc/mzy048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 03/08/2018] [Indexed: 11/14/2022] Open
Abstract
Objective Hospital boards are legally responsible for the quality of care delivered by healthcare professionals in their hospitals, but experience difficulties in overseeing quality and safety risks. This study aimed to select a core set of parameters for boards to govern quality of care in the intensive care unit (ICU). Design Two-round Delphi study. Setting Two university hospitals in the Netherlands. Participants An expert panel of 12 former ICU patients or their family members, 12 ICU nurses, 12 ICU physicians and 12 members of boards of directors and quality managers. Main outcome measures Participants indicated the relevance of existing parameters for assessing the quality of ICU care for governance purposes (round 1) and selected 10 quality parameters that together provide boards of directors with a good representation of quality of care in their ICU (round 2). Results We identified 122 quality parameters related to care in the ICU, which we limited to a short list to present to participants in round 1. The response rate was 94% in round 1 and 85% in round 2. The final set consisted of the 10 most frequently selected quality parameters per hospital. Five parameters were included in both sets; all related to patient safety and continuous quality improvement. Conclusions Parameters in the core set were mostly qualitative and generic, rather than quantitative and ICU-specific in nature. To engage in a true dialog about quality of care, boards are more interested in the story behind the numbers than in just the numbers themselves.
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Affiliation(s)
- Anke J M Oerlemans
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Marieke Zegers
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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44
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Kallen MC, Roos-Blom MJ, Dongelmans DA, Schouten JA, Gude WT, de Jonge E, Prins JM, de Keizer NF. Development of actionable quality indicators and an action implementation toolbox for appropriate antibiotic use at intensive care units: A modified-RAND Delphi study. PLoS One 2018; 13:e0207991. [PMID: 30496227 PMCID: PMC6264509 DOI: 10.1371/journal.pone.0207991] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 11/10/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Extensive antibiotic use makes the intensive care unit (ICU) an important focus for antibiotic stewardship programs. The aim of this study was to develop a set of actionable quality indicators for appropriate antibiotic use at ICUs and an implementation toolbox, which can be used to assess and improve the appropriateness of antibiotic use in the treatment of adult patients at an ICU. Methods A four round modified-RAND Delphi procedure was used. Potential indicators were identified by a multidisciplinary panel of 15 Dutch experts, from international literature and guidelines. Using an online survey, the identified indicators were rated on three criteria: relevance, actionability and feasibility. Experts discussed and rated the indicators for the second time during a face-to-face consensus meeting. During a final consensus meeting the toolbox was developed, containing potential barriers and improvement strategies which were identified using a validated checklist by Flottorp et al., and if available also containing supporting material. Results The first round resulted in 24 potential indicators. After the final meeting a set of three process indicators, one structure indicator and one quantity metric remained: 1) perform at least two sets of blood cultures before start of empirical systemic therapy; 2) perform therapeutic drug monitoring in patients treated with vancomycin or aminoglycosides; 3) perform surveillance cultures if selective digestive or oropharyngeal decontamination is applied at the ICU; 4) biannual face-to-face meetings between ICU and microbiology staff in which local resistance rates are discussed; and 5) quantitative antibiotic use at the ICU expressed in days of therapy (DOT). The toolbox contains 24 unique barriers and 37 improvement strategies. Conclusions Our study identified a set of four actionable quality indicators and one quantity metric, together with an implementation toolbox, to improve appropriate antibiotic use at ICUs.
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Affiliation(s)
- Marlot C. Kallen
- Amsterdam UMC, University of Amsterdam, Department of Infectious Diseases, Amsterdam, The Netherlands
- * E-mail: (MCK); (MJRB)
| | - Marie-Jose Roos-Blom
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
- * E-mail: (MCK); (MJRB)
| | - Dave A. Dongelmans
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
| | - Jeroen A. Schouten
- Canisius Wilhelmina Hospital, Department of Intensive Care Medicine, Nijmegen, The Netherlands
- Radboud University Medical Center, Department of Scientific Institute for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - Wouter T. Gude
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Evert de Jonge
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
- Leiden University Medical Center, Department of Intensive Care Medicine, Leiden, The Netherlands
| | - Jan M. Prins
- Amsterdam UMC, University of Amsterdam, Department of Infectious Diseases, Amsterdam, The Netherlands
| | - Nicolette F. de Keizer
- Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
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Simonis FD, Serpa Neto A, Binnekade JM, Braber A, Bruin KCM, Determann RM, Goekoop GJ, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, de Wilde RBP, Vriends M, Gama de Abreu M, Pelosi P, Schultz MJ. Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial. JAMA 2018; 320:1872-1880. [PMID: 30357256 PMCID: PMC6248136 DOI: 10.1001/jama.2018.14280] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS). OBJECTIVE To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands. INTERVENTIONS Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax. RESULTS In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55). CONCLUSIONS AND RELEVANCE In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02153294.
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Affiliation(s)
| | - Fabienne D Simonis
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jan M Binnekade
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Annemarije Braber
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Karina C M Bruin
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | - Rogier M Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Geert-Jan Goekoop
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | - Jeroen Heidt
- Department of Intensive Care Tergooi, Hilversum, the Netherlands
| | - Janneke Horn
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Gerard Innemee
- Department of Intensive Care Tergooi, Hilversum, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, the Netherlands
| | - Rob B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marijn Vriends
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, the Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
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Gude WT, Roos-Blom MJ, van der Veer SN, Dongelmans DA, de Jonge E, Francis JJ, Peek N, de Keizer NF. Health professionals' perceptions about their clinical performance and the influence of audit and feedback on their intentions to improve practice: a theory-based study in Dutch intensive care units. Implement Sci 2018; 13:33. [PMID: 29454393 PMCID: PMC5816547 DOI: 10.1186/s13012-018-0727-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/06/2018] [Indexed: 11/18/2022] Open
Abstract
Background Audit and feedback aims to guide health professionals in improving aspects of their practice that need it most. Evidence suggests that feedback fails to increase accuracy of professional perceptions about clinical performance, which likely reduces audit and feedback effectiveness. This study investigates health professionals’ perceptions about their clinical performance and the influence of feedback on their intentions to change practice. Methods We conducted an online laboratory experiment guided by Control Theory with 72 intensive care professionals from 21 units. For each of four new pain management indicators, we collected professionals’ perceptions about their clinical performance; peer performance; targets; and improvement intentions before and after receiving first-time feedback. An electronic audit and feedback dashboard provided ICU’s own performance, median and top 10% peer performance, and improvement recommendations. The experiment took place approximately 1 month before units enrolled into a cluster-randomised trial assessing the impact of adding a toolbox with suggested actions and materials to improve intensive care pain management. During the experiment, the toolbox was inaccessible; all participants accessed the same version of the dashboard. Results We analysed 288 observations. In 53.8%, intensive care professionals overestimated their clinical performance; but in only 13.5%, they underestimated it. On average, performance was overestimated by 22.9% (on a 0–100% scale). Professionals similarly overestimated peer performance, and set targets 20.3% higher than the top performance benchmarks. In 68.4% of cases, intentions to improve practice were consistent with actual gaps in performance, even before professionals had received feedback; which increased to 79.9% after receiving feedback (odds ratio, 2.41; 95% CI, 1.53 to 3.78). However, in 56.3% of cases, professionals still wanted to improve care aspects at which they were already top performers. Alternatively, in 8.3% of cases, they lacked improvement intentions because they did not consider indicators important; did not trust the data; or deemed benchmarks unrealistic. Conclusions Audit and feedback helps health professionals to work on aspects for which improvement is recommended. Given the abundance of professionals’ prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice. Trial registration ClinicalTrials.govNCT02922101. Registered 26 September 2016. Electronic supplementary material The online version of this article (10.1186/s13012-018-0727-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wouter T Gude
- Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.
| | - Marie-José Roos-Blom
- Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Dave A Dongelmans
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Evert de Jonge
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jill J Francis
- Centre for Health Services Research, City University of London, London, UK
| | - Niels Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Nicolette F de Keizer
- Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
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Atashi A, Verburg IW, Karim H, Miri M, Abu-Hanna A, de Jonge E, de Keizer NF, Eslami S. Models to predict length of stay in the Intensive Care Unit after coronary artery bypass grafting: a systematic review. J Cardiovasc Surg (Torino) 2018; 59:471-482. [PMID: 29430883 DOI: 10.23736/s0021-9509.18.09847-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Intensive Care Units (ICU) length of stay (LoS) prediction models are used to compare different institutions and surgeons on their performance, and is useful as an efficiency indicator for quality control. There is little consensus about which prediction methods are most suitable to predict (ICU) length of stay. The aim of this study is to systematically review models for predicting ICU LoS after coronary artery bypass grafting and to assess the reporting and methodological quality of these models to apply them for benchmarking. EVIDENCE ACQUISITION A general search was conducted in Medline and Embase up to 31-12-2016. Three authors classified the papers for inclusion by reading their title, abstract and full text. All original papers describing development and/or validation of a prediction model for LoS in the ICU after CABG surgery were included. We used a checklist developed for critical appraisal and data extraction for systematic reviews of prediction modeling and extended it on handling specific patients subgroups. We also defined other items and scores to assess the methodological and reporting quality of the models. EVIDENCE SYNTHESIS Of 5181 uniquely identified articles, fifteen studies were included of which twelve on development of new models and three on validation of existing models. All studies used linear or logistic regression as method for model development, and reported various performance measures based on the difference between predicted and observed ICU LoS. Most used a prospective (46.6%) or retrospective study design (40%). We found heterogeneity in patient inclusion/exclusion criteria; sample size; reported accuracy rates; and methods of candidate predictor selection. Most (60%) studies have not mentioned the handling of missing values and none compared the model outcome measure of survivors with non-survivors. For model development and validation studies respectively, the maximum reporting (methodological) scores were 66/78 and 62/62 (14/22 and 12/22). CONCLUSIONS There are relatively few models for predicting ICU length of stay after CABG. Several aspects of methodological and reporting quality of studies in this field should be improved. There is a need for standardizing outcome and risk factor definitions in order to develop/validate a multi-institutional and international risk scoring system.
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Affiliation(s)
- Alireza Atashi
- E-health Department, Virtual School, Tehran University of Medical Sciences, Tehran, Iran.,Department of Medical Informatics, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Ilona W Verburg
- Academic Medical Center, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Hesam Karim
- Department of Health Information Management, Faculty of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mirmohammad Miri
- Department of Anesthesiology and Critical Care, Emam Hossein Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Ameen Abu-Hanna
- Academic Medical Center, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicolette F de Keizer
- Academic Medical Center, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Saeid Eslami
- Academic Medical Center, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands - .,Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Verburg IW, Holman R, Dongelmans D, de Jonge E, de Keizer NF. Is patient length of stay associated with intensive care unit characteristics? J Crit Care 2018; 43:114-121. [DOI: 10.1016/j.jcrc.2017.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/24/2017] [Accepted: 08/08/2017] [Indexed: 11/15/2022]
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Schoe A, de Jonge E, Klautz RJM, van Dissel JT, van de Vosse E. Single-Nucleotide Polymorphisms in the CALCA Gene Are Associated with Variation of Procalcitonin Concentration in Patients Undergoing Cardiac Surgery. Am J Respir Crit Care Med 2017; 194:767-9. [PMID: 27628079 DOI: 10.1164/rccm.201604-0772le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Abraham Schoe
- 1 Leiden University Medical Center Leiden, the Netherlands
| | - Evert de Jonge
- 1 Leiden University Medical Center Leiden, the Netherlands
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Folman C, Linthorst G, van Mourik J, van Willigen G, de Jonge E, Levi M, de Haas M, von dem Borne A. Platelets Release Thrombopoietin (Tpo) upon Activation: another Regulatory Loop in Thrombocytopoiesis? Thromb Haemost 2017. [DOI: 10.1055/s-0037-1613944] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryThrombopoietin is produced at a constant rate by the liver and kidney and is removed from the circulation upon binding and subsequent uptake via the Tpo receptor, c-Mpl, expressed by platelets and megakaryocytes. Apart from uptake, this study shows that platelets can also function as a storage pool for Tpo.Upon stimulation with various platelet agonists, full-length biologically active Tpo was released by platelets. Platelet fractionation experiments indicated that this Tpo most likely is contained in the granules. When platelets were preincubated with Tpo-peptide mimetic or truncated Tpo prior to maximal activation, a three- to fivefold increment in Tpo release was seen, whereas, the release of other granule proteins such as vWF-propeptide or serotonin remained unchanged. Therefore, the Mpl agonists might compete with Mpl-bound Tpo, thereby releasing Tpo into the platelet supernatant.Intravascular release of Tpo by platelets might occur in patients with massive platelet activation, as occurs in patients with disseminated intravascular coagulation. The Tpo concentration in these patients is elevated (p <0.01) and correlates with markers for thrombin generation, TAT complexes and Fl+2 (rp =0.8 and 0.9; p <0.01). This suggests that the increment in Tpo concentration was attributed to Tpo release by activated platelets in vivo, which might be instrumental in subsequent stimulation of thrombocytopoiesis.
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