Effectiveness of Proadrenomedullin Enhanced CURB65 Score Algorithm in Patients with Community-Acquired Pneumonia in "Real Life", an Observational Quality Control Survey

BACKGROUND

An intervention trial found a trend for shorter length of stay (LOS) in patients with community-acquired pneumonia (CAP) when the CURB65 score was combined with the prognostic biomarker proadrenomedullin (ProADM) (CURB65-A). However, the efficacy and safety of CURB65-A in real life situations remains unclear.

METHODS

From September, 2011, until April, 2012, we performed a post-study prospective observational quality control survey at the cantonal Hospital of Aarau, Switzerland of consecutive adults with CAP. The primary endpoint was length of stay (LOS) during the index hospitalization and within 30 days. We compared the results with two well-defined historic cohorts of CAP patients hospitalized in the same hospital with the use of multivariate regression, namely 83 patients in the observation study without ProADM (OPTIMA I) and the 169 patients in the intervention study (OPTIMA II RCT).

RESULTS

A total of 89 patients with confirmed CAP were included. As compared to patients with CURB65 only observed in the OPTIMA I study, adjusted regression analysis showed a significant shorter initial LOS (7.5 vs. 10.4 days; -2.32; 95% CI, -4.51 to -0.13; p = 0.04) when CURB65-A was used in clinical routine. No significant differences were found for LOS within 30 days. There were no significant differences in safety outcomes in regard to mortality and ICU admission between the cohorts.

CONCLUSION

This post-study survey provides evidence that the use of ProADM in combination with CURB65 (CURB65-A) in "real life" situations reduces initial LOS compared to the CURB65 score alone without apparent negative effects on patient safety.

Procalcitonin, pyuria and proadrenomedullin in the management of urinary tract infections--'triple p in uti': study protocol for a randomized controlled trial

Background

Urinary tract infections (UTIs) are among the most common infectious diseases and drivers of antibiotic use and in-hospital days. A reduction of antibiotic use potentially lowers the risk of antibiotic resistance. An early and adequate risk assessment combining medical, biopsychosocial and functional risk scores has the potential to optimize site-of-care decisions and thus allocation of limited health-care resources. The aim of this factorial design study is twofold: first, for Intervention A, it investigates antibiotic exposure of patients treated with a protocol based on the type of UTI, procalcitonin (PCT) and pyuria. Second, for Intervention B, it investigates the usefulness of the prognostic biomarker proadrenomedullin (ProADM) integrated into an interdisciplinary assessment bundle for site-of-care decisions.

Methods and design

This randomized controlled open-label trial has a factorial design (2 × 2). Randomization of patients will be based on a pre-specified computer-generated randomization list and independent for the two interventions. Adults with UTI presenting to the emergency department (ED) will be screened and enrolled after providing informed consent.

For our first Intervention (A), we developed a protocol based on previous observational research to recommend initiation and duration of antibiotic use based on the clinical presentation of UTI, pyuria and PCT levels. For our second intervention (B), an algorithm was developed to support site-of care decisions based on the prognostic marker ProADM and distinct nursing factors on days 1 and 3. Both interventions will be compared with a control group conforming to the guidelines.

The primary endpoints for the two interventions will be: (A) overall exposure to antibiotics and (B) length of physician-led hospitalization within a follow-up of 30 days. Endpoints are assessed at discharge from hospital, and 30 and 90 days after admission. We plan to screen 300 patients and enroll 250 for an anticipated estimated loss of follow-up of 20%. This will provide adequate power for the two interventions.

Discussion

This trial investigates two strategies for improved individualized medical care in patients with UTI. The minimally effective duration of antibiotic therapy is not known for UTIs, which is important for reducing the selection pressure for antibiotic resistance, costs and drug-related side effects. Triage decisions must be improved to reflect the true medical, biopsychosocial and functional risks in order to allocate patients to the most appropriate care setting and reduce hospital-acquired disability.

Trial registration

Trial registration number: ISRCTN13663741

The potential impact of biomarker-guided triage decisions for patients with urinary tract infections

OBJECTIVES

Current guidelines provide limited evidence as to which patients with urinary tract infection (UTI) require hospitalisation. We evaluated the currently used triage routine and tested whether a set of criteria including biomarkers like proadrenomedullin (proADM) and urea have the potential to improve triage decisions.

METHODS

Consecutive adults with UTI presenting to our emergency department (ED) were recruited and followed for 30 days. We defined three virtual triage algorithms, which included either guideline-based clinical criteria, optimised admission proADM or urea levels in addition to a set of clinical criteria. We compared actual treatment sites and observed adverse events based on the physician judgment with the proportion of patients assigned to treatment sites according to the three virtual algorithms. Adverse outcome was defined as transfer to the intensive care unit (ICU), death, recurrence of UTI or rehospitalisation for any reason.

RESULTS

We recruited 127 patients (age 61.8 ± 20.8 years; 73.2 % females) and analysed the data of 123 patients with a final diagnosis of UTI. Of these 123 patients, 27 (22.0 %) were treated as outpatients. Virtual triage based only on clinical signs would have treated only 22 (17.9 %) patients as outpatients, with higher proportions of outpatients equally in both biomarker groups (29.3 %; p = 0.02). There were no significant differences in adverse events between outpatients according to the clinical (4.5 %), proADM (2.8 %) or urea groups (2.8 %). The mean length of stay was 6.6 days, including 2.2 days after reaching medical stability.

CONCLUSIONS

Adding biomarkers to clinical criteria has the potential to improve risk-based triage without impairing safety. Current rates of admission and length of stay could be shortened in patients with UTI.

Biomarker-enhanced triage in respiratory infections: a proof-of-concept feasibility trial

Concerns about inadequate performance and complexity limit routine use of clinical risk scores in lower respiratory tract infections. Our aim was to study feasibility and effects of adding the biomarker proadrenomedullin (proADM) to the confusion, urea >7 mmol·L⁻¹, respiratory rate ≥30 breaths·min⁻¹, blood pressure <90 mmHg (systolic) or ≤60 mmHg (diastolic), age ≥65 years (CURB-65) score on triage decisions and length of stay.

In a randomised controlled proof-of-concept intervention trial, triage and discharge decisions were made for adults with lower respiratory tract infection according to interprofessional assessment using medical and nursing risk scores either without (control group) or with (proADM group) knowledge of proADM values, measured on admission, and on days 3 and 6. An adjusted generalised linear model was calculated to investigate the effect of our intervention.

On initial presentation the algorithms were overruled in 123 (39.3%) of the cases. Mean length of stay tended to be shorter in the proADM (n=154, 6.3 days) compared with the control group (n=159, 6.8 days; adjusted regression coefficient -0.19, 95% CI -0.41–0.04; p=0.1). This trend was robust in subgroup analyses and for overall length of stay within 90 days (7.2 versus 7.9 days; adjusted regression coefficient -0.18, 95% CI -0.40–0.05; p=0.13). There were no differences in adverse outcomes or readmission.

Logistic obstacles and overruling are major challenges to implement biomarker-enhanced algorithms in clinical settings and need to be addressed to shorten length of stay.

Proof-of-concept trial: how to shorten LOS in patients with LRTIs by reducing medically unnecessary days in the hospitalhttp://ow.ly/nI7z4

Do specialized oncology units improve the detection and management of pain?

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Background: Pain is a common complaint of cancer patients and has a significant impact on quality of life. The objective of this study was to compare pain management for cancer patients admitted to dedicated oncology vs. general medicine/surgery units. Methods: Design: Secondary analysis of data obtained from a controlled clinical trial evaluating a series of interventions to improve pain outcomes conducted from 4/2002–2/2003. Setting: 1,171 bed hospital. Patients: 445 hospitalized adult oncology patients; 239 patients admitted to a specialized oncology unit, 206 patients admitted to general medicine/surgery units. Main outcome measures: Pain assessment and severity, analgesic prescribing. Analysis: T tests and chi square were used to compare patient characteristics. Hierarchical linear modeling (HLM) was used to explore the effect of a specialized oncology unit on pain assessment, severity, and analgesic and laxative prescribing. Results: The two groups did not differ significantly in patient characteristics. Mean age was 59 years, 56% were men, 61% were white, 79% had solid tumors. In multivariate analysis, patients admitted to a specialized oncology unit had significantly less pain (mean pain score for patients on oncology unit was 1.24 vs 1.68 for non-oncology unit; parameter estimate = −0.42; p<0.01). There were no significant differences in the frequency of nursing assessment of pain, opiate prescribing, or laxative prescribing for those patients receiving opioids. Conclusion: In multivariate analysis, admission to a specialized oncology unit was associated with significantly less reported pain. These findings have implications for structuring medical units for patients at high risk for pain.

No significant financial relationships to disclose.

Amplitude of visual P3 event-related potential as a phenotypic marker for a predisposition to alcoholism: preliminary results from the COGA Project. Collaborative Study on the Genetics of Alcoholism

Recent data collected at six identical electrophysiological laboratories from the large national multisite Collaborative Study on the Genetics of Alcoholism provide evidence for considering the P3 amplitude of the event-related potential as a phenotypic marker for the risk of alcoholism. The distribution of P3 amplitude to target stimuli at the Pz electrode in individuals 16 years of age and over from 163 randomly ascertained control families (n = 687) was compared with those from 219 densely affected alcoholic families (n = 1276) in which three directly interviewed first-degree relatives met both DSM-III-R and Feighner criteria at the definite level for alcohol dependence (stage II). The control sample did not exclude individuals with psychiatric illness or alcoholism to obtain incidence rates of psychiatric disorders similar to those of the general population. P3 amplitude data from control families was converted to Z-scores, and a P3 amplitude beyond 2 SD's below the mean was considered an "abnormal trait." When age- and sex-matched distributions of P3 amplitude were compared, members of densely affected stage II families were more likely to manifest low P3 amplitudes (2 SD below the mean) than members of control families, comparing affected and unaffected offspring, and all individuals; all comparisons of these distributions between groups were significant (p < 0.00001). P3 amplitude means were also significantly lower in stage II family members, compared with control family members for all comparisons, namely probands, affected and unaffected individuals (p < 0.0001), and offspring (p < 0.01). Furthermore, affected individuals from stage II families, but not control families, had significantly lower P3 amplitudes than unaffected individuals (p < 0.001). Affected males from stage II families had significantly lower P3 amplitudes than affected females (p < 0.001). Recent linkage analyses indicate that visual P3 amplitude provides a biological phenotypic marker that has genetic underpinnings.

Electrophysiological evidence of memory impairment in alcoholic patients

In a series of event-related potential (ERP) studies, we have consistently demonstrated an ERP component correlate of visual short-term memory. There have been frequent reports on the deficits of information encoding, retention, and retrieval in chronic alcoholics. In the present study, we investigated that the ERP mnemonic effects could be influenced by long-term alcohol abuse. ERP data were recorded from 48 controls and 77 alcoholics while the subjects performed a modified delayed matching to sample paradigm using a series of object pictures as stimuli. The alcoholics completed the task with more errors and longer response times than the controls. The major differences in the evoked potentials between the two groups are found at the temporo-occipital and frontal regions in the sample and nonmatching trials, and mostly prominent in the right hemisphere. The current study indicates that the ERP technique can be a useful tool to index short-term memory. The ERP mnemonic effect difference between the two groups may be a reflection of a working memory deficit caused by long-term alcohol abuse. Our data also suggest right hemisphere dysfunction in alcoholics, with deficits in information encoding.

Reflection of working memory: ERP mnemonic effects

The study of working memory often utilizes a delayed matching to sample paradigm (DMS). Typically in the matching condition, the test and sample stimuli are identical, raising the possible confound of retinotopic projections for the matching stimuli in contrast to the non-matching stimuli. In the present study, 65 healthy subjects performed a modified delayed matching to sample task while monitoring their ERP waveforms. The stimuli consisted of 60 different sample stimuli (S1) and 60 different test stimuli (S2). Half of the S2s were complementary to the sample stimuli (Fit), the other half of the S2s were not complementary (Nonfit). After S2, the subjects pressed one of the buttons to indicate whether the test stimulus fits the sample stimulus. Our statistical results indicated that the ERPs to sample stimuli differed from the ERPs to test stimuli from 200 ms poststimulus to the end of the recording epoch. The ERPs to fitting stimuli were significantly different from those to non-fitting stimuli from 200 to 400 ms poststimulus. The ERP patterns in the present study may reflect ERP mnemonic effect for working memory. Our results ruled out the retinotopic confound as a potential mediator variable, and are in agreement with other animal or human neurophysiological studies on memory.

Visual object priming differs from visual word priming: an ERP study

Implicit memory is inferred from repetition priming effects in tasks such as word identification, word fragment completion, and perceptual recognition with masking or brief exposures. In this experiment, we explored whether the visual word and object repetition priming effects can be reflected by features of ERP and whether visual word repetition priming differs from visual object repetition priming. We have observed that (1) pre-exposure to recognizable stimuli (both word and object picture) shortened the response time in identifying their repetitions; (2) repetition of unrecognized scrambles of words or object pictures did not show any effects on ERP patterns; (3) ERPs distinguished recognizable from unrecognizable stimuli; and, (4) repetitions of both words and pictures strongly influenced the patterns of ERPs, though the ERPs to word stimuli differed from the ERPs to picture stimuli.

A simple auditory oddball task in young adult males at high risk for alcoholism

The reduction in the amplitude of the auditory P300 in young adult males at high risk for alcoholism has not been as consistently replicated as has been the reduction in the visual P300 amplitude in the same group. The easier nature of the auditory task was thought to be responsible for the inconsistency. We examined the auditory P300 amplitude in a group that has not yet been studied, young adult sons of alcoholics (mean age = 24.9 years, n = 48), and compared them with age and sex-matched controls (mean age = 27.8 years, n = 23). We found the auditory P300 amplitude to be reduced in the high-risk group and this reduction to be the greatest over the posterior centroparietal and occipital areas when individual leads were examined. We further analyzed the data using current source density, a mathematical transformation that circumvents some of the errors inherent in measuring scalp-evoked potentials, and found reduced current source density in the high-risk group in the posterior central and parietal areas. Thus, we found that a simple auditory oddball task was effective in eliciting P300 differences in groups at high and low risk for alcoholism. The clinical significance of the P300 is discussed, as well as the relevance of task difficulty in eliciting auditory P300 differences in young males at high risk for alcoholism.

Event related potentials during object recognition tasks

In our previous studies, we have demonstrated an ERP correlate of visual memory with a modified delayed matching-to-sample paradigm using a series of nonsense line drawings or faces as stimuli. In this experiment, we employed pictures of objects to determine whether the ERP can reflect the object recognition process and whether visual stimuli with a verbal label would result in a different topographic distribution from past topography obtained with visual stimuli without a verbal label. The results of this study suggest that the amplitude of the ERP component (c247) to repeated (primed) pictures of common objects was significantly decreased as compared to the unrepeated (unprimed) pictures; the latency for the peak of c247 was decreased for the repeated compared to the unrepeated, and the response time was also significantly shorter to the repeated picture stimuli than to the unrepeated; the topographical distribution of c247 was mainly located in the occipitotemporal areas of the brain. However, the source energy density map showed that the topographic involvement of the brain regions to the c247 was different in the matching and nonmatching trials.