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Titeca-Beauport D, Diouf M, Daubin D, Vong LV, Belliard G, Bruel C, Zerbib Y, Vinsonneau C, Klouche K, Maizel J. The combination of kidney function variables with cell cycle arrest biomarkers identifies distinct subphenotypes of sepsis-associated acute kidney injury: a post-hoc analysis (the PHENAKI study). Ren Fail 2024; 46:2325640. [PMID: 38445412 PMCID: PMC10919311 DOI: 10.1080/0886022x.2024.2325640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The severity and course of sepsis-associated acute kidney injury (SA-AKI) are correlated with the mortality rate. Early detection of SA-AKI subphenotypes might facilitate the rapid provision of individualized care. PATIENTS AND METHODS In this post-hoc analysis of a multicenter prospective study, we combined conventional kidney function variables with serial measurements of urine (tissue inhibitor of metalloproteinase-2 [TIMP-2])* (insulin-like growth factor-binding protein [IGFBP7]) at 0, 6, 12, and 24 h) and then using an unsupervised hierarchical clustering of principal components (HCPC) approach to identify different phenotypes of SA-AKI. We then compared the subphenotypes with regard to a composite outcome of in-hospital death or the initiation of renal replacement therapy (RRT). RESULTS We included 184 patients presenting SA-AKI within 6 h of the initiation of catecholamines. Three distinct subphenotypes were identified: subphenotype A (99 patients) was characterized by a normal urine output (UO), a low SCr and a low [TIMP-2]*[IGFBP7] level; subphenotype B (74 patients) was characterized by existing chronic kidney disease (CKD), a higher SCr, a low UO, and an intermediate [TIMP-2]*[IGFBP7] level; and subphenotype C was characterized by very low UO, a very high [TIMP-2]*[IGFBP7] level, and an intermediate SCr level. With subphenotype A as the reference, the adjusted hazard ratio (aHR) [95%CI] for the composite outcome was 3.77 [1.92-7.42] (p < 0.001) for subphenotype B and 4.80 [1.67-13.82] (p = 0.004) for subphenotype C. CONCLUSIONS Combining conventional kidney function variables with urine measurements of [TIMP-2]*[IGFBP7] might help to identify distinct SA-AKI subphenotypes with different short-term courses and survival rates.
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Affiliation(s)
- Dimitri Titeca-Beauport
- Medical Intensive Care Unit and EA7517, Boreal Study Group, Amiens University Hospital, Amiens, France
| | - Momar Diouf
- Department of Statistics, Amiens University Hospital, Amiens, France
| | - Delphine Daubin
- Department of Intensive Care Medicine, Lapeyronie University Hospital, PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Ly Van Vong
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Guillaume Belliard
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Bretagne Sud, Lorient, France
| | - Cédric Bruel
- Medical and Surgical Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Yoann Zerbib
- Medical Intensive Care Unit and EA7517, Boreal Study Group, Amiens University Hospital, Amiens, France
| | | | - Kada Klouche
- Department of Intensive Care Medicine, Lapeyronie University Hospital, PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Julien Maizel
- Medical Intensive Care Unit and EA7517, Boreal Study Group, Amiens University Hospital, Amiens, France
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Xiao W, Huang L, Guo H, Liu W, Zhang J, Liu Y, Hua T, Yang M. Development and validation of potential phenotypes of serum electrolyte disturbances in critically ill patients and a Web-based application. J Crit Care 2024; 82:154793. [PMID: 38548515 DOI: 10.1016/j.jcrc.2024.154793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 06/01/2024]
Abstract
BACKGROUND Electrolyte disturbances are highly heterogeneous and severely affect the prognosis of critically ill patients. Our study was to determine whether data-driven phenotypes of seven electrolytes have prognostic relevance in critically ill patients. METHODS We extracted patient information from three large independent public databases, and clustered the electrolyte distribution of ICU patients based on the extreme value, median value and coefficient of variation of electrolytes. Three plausible clinical phenotypes were calculated using K-means clustering algorithm as the basic clustering method. MIMIC-IV was considered a training set, and two others have been designated as verification set. The robustness of the model was then validated from different angles, providing dynamic and interactive visual charts for more detailed characterization of phenotypes. RESULTS 15,340, 12,445 and 2147 ICU patients with electrolyte records during early ICU stay in MIMIC-IV, eICU-CRD and AmsterdamUMCdb were enrolled. After clustering, three reasonable and interpretable phenotypes are defined as α, β and γ according to the order of clusters. The α and γ phenotype, with significant differences in electrolyte distribution and clinical variables, higher 28-day mortality and longer length of ICU stay (p < 0.001), was further demonstrated by robustness analysis. The α phenotype has significant kidney injury, while the β phenotype has the best prognosis. In addition, the assignment methods of the three phenotypes were developed into a web-based tool for further verification and application. CONCLUSIONS Three different clinical phenotypes were identified that correlated with electrolyte distribution and clinical outcomes. Further validation and characterization of these phenotypes is warranted.
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Affiliation(s)
- Wenyan Xiao
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Lisha Huang
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Heng Guo
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Wanjun Liu
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Jin Zhang
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Yu Liu
- Key Laboratory of Intelligent Computing and Signal Processing, Anhui University, Ministry of Education, Hefei, Anhui 230601, PR China; School of Integrated Circuits, Anhui University, Anhui, Hefei 230601, PR China
| | - Tianfeng Hua
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China
| | - Min Yang
- The Second Department of Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China; The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, the Second Affiliated Hospital of Anhui Medical University, Anhui, Hefei 230601, PR China.
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3
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Zhang C, Singla RK, Tang M, Shen B. Natural products act as game-changer potentially in treatment and management of sepsis-mediated inflammation: A clinical perspective. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 130:155710. [PMID: 38759311 DOI: 10.1016/j.phymed.2024.155710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/19/2024] [Accepted: 05/02/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Sepsis, a life-threatening condition resulting from uncontrolled host responses to infection, poses a global health challenge with limited therapeutic options. Due to high heterogeneity, sepsis lacks specific therapeutic drugs. Additionally, there remains a significant gap in the clinical management of sepsis regarding personalized and precise medicine. PURPOSE This review critically examines the scientific landscape surrounding natural products in sepsis and sepsis-mediated inflammation, highlighting their clinical potential. METHODS Following the PRISMA guidelines, we retrieved articles from PubMed to explore potential natural products with therapeutic effects in sepsis-mediated inflammation. RESULTS 434 relevant in vitro and in vivo studies were identified and screened. Ultimately, 55 studies were obtained as the supporting resources for the present review. We divided the 55 natural products into three categories: those influencing the synthesis of inflammatory factors, those affecting surface receptors and modulatory factors, and those influencing signaling pathways and the inflammatory cascade. CONCLUSION Natural products' potential as game-changers in sepsis-mediated inflammation management lies in their ability to modulate hallmarks in sepsis, including inflammation, immunity, and coagulopathy, which provides new therapeutic avenues that are readily accessible and capable of undergoing rapid clinical validation and deployment, offering a gift from nature to humanity. Innovative techniques like bioinformatics, metabolomics, and systems biology offer promising solutions to overcome these obstacles and facilitate the development of natural product-based therapeutics, holding promise for personalized and precise sepsis management and improving patient outcomes. However, standardization, bioavailability, and safety challenges arise during experimental validation and clinical trials of natural products.
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Affiliation(s)
- Chi Zhang
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, 610212, PR China
| | - Rajeev K Singla
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, 610212, PR China; School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab-144411, India
| | - Min Tang
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, 610212, PR China; West China School of Nursing, Sichuan University, Chengdu, PR China
| | - Bairong Shen
- Joint Laboratory of Artificial Intelligence for Critical Care Medicine, Department of Critical Care Medicine and Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, 610212, PR China.
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4
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Laferrière-Langlois P, Imrie F, Geraldo MA, Wingert T, Lahrichi N, van der Schaar M, Cannesson M. Novel Preoperative Risk Stratification Using Digital Phenotyping Applying a Scalable Machine-Learning Approach. Anesth Analg 2024; 139:174-185. [PMID: 38051671 PMCID: PMC11150330 DOI: 10.1213/ane.0000000000006753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Classification of perioperative risk is important for patient care, resource allocation, and guiding shared decision-making. Using discriminative features from the electronic health record (EHR), machine-learning algorithms can create digital phenotypes among heterogenous populations, representing distinct patient subpopulations grouped by shared characteristics, from which we can personalize care, anticipate clinical care trajectories, and explore therapies. We hypothesized that digital phenotypes in preoperative settings are associated with postoperative adverse events including in-hospital and 30-day mortality, 30-day surgical redo, intensive care unit (ICU) admission, and hospital length of stay (LOS). METHODS We identified all laminectomies, colectomies, and thoracic surgeries performed over a 9-year period from a large hospital system. Seventy-seven readily extractable preoperative features were first selected from clinical consensus, including demographics, medical history, and lab results. Three surgery-specific datasets were built and split into derivation and validation cohorts using chronological occurrence. Consensus k -means clustering was performed independently on each derivation cohort, from which phenotypes' characteristics were explored. Cluster assignments were used to train a random forest model to assign patient phenotypes in validation cohorts. We reconducted descriptive analyses on validation cohorts to confirm the similarity of patient characteristics with derivation cohorts, and quantified the association of each phenotype with postoperative adverse events by using the area under receiver operating characteristic curve (AUROC). We compared our approach to American Society of Anesthesiologists (ASA) alone and investigated a combination of our phenotypes with the ASA score. RESULTS A total of 7251 patients met inclusion criteria, of which 2770 were held out in a validation dataset based on chronological occurrence. Using segmentation metrics and clinical consensus, 3 distinct phenotypes were created for each surgery. The main features used for segmentation included urgency of the procedure, preoperative LOS, age, and comorbidities. The most relevant characteristics varied for each of the 3 surgeries. Low-risk phenotype alpha was the most common (2039 of 2770, 74%), while high-risk phenotype gamma was the rarest (302 of 2770, 11%). Adverse outcomes progressively increased from phenotypes alpha to gamma, including 30-day mortality (0.3%, 2.1%, and 6.0%, respectively), in-hospital mortality (0.2%, 2.3%, and 7.3%), and prolonged hospital LOS (3.4%, 22.1%, and 25.8%). When combined with the ASA score, digital phenotypes achieved higher AUROC than the ASA score alone (hospital mortality: 0.91 vs 0.84; prolonged hospitalization: 0.80 vs 0.71). CONCLUSIONS For 3 frequently performed surgeries, we identified 3 digital phenotypes. The typical profiles of each phenotype were described and could be used to anticipate adverse postoperative events.
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Affiliation(s)
- Pascal Laferrière-Langlois
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, USA
- Department of Mathematics and Industrial Engineering, Polytechnique Montreal, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital Research Center, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l’Est de L’Ile de Montréal, Montréal, Québec, Canada
| | - Fergus Imrie
- Department of Electrical and Computer Engineering, UCLA, Los Angeles, USA
| | - Marc-Andre Geraldo
- Department of Mathematics and Industrial Engineering, Polytechnique Montreal, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital Research Center, Montréal, Québec, Canada
| | - Theodora Wingert
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Nadia Lahrichi
- Department of Mathematics and Industrial Engineering, Polytechnique Montreal, Montreal, Quebec, Canada
| | - Mihaela van der Schaar
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, UK
- The Alan Turing Institute, London, UK
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, Los Angeles, USA
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5
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Ding S, Zhang S, Hu X, Zou N. Identify and mitigate bias in electronic phenotyping: A comprehensive study from computational perspective. J Biomed Inform 2024:104671. [PMID: 38876452 DOI: 10.1016/j.jbi.2024.104671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 05/26/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
Electronic phenotyping is a fundamental task that identifies the special group of patients, which plays an important role in precision medicine in the era of digital health. Phenotyping provides real-world evidence for other related biomedical research and clinical tasks, e.g., disease diagnosis, drug development, and clinical trials, etc. With the development of electronic health records, the performance of electronic phenotyping has been significantly boosted by advanced machine learning techniques. In the healthcare domain, precision and fairness are both essential aspects that should be taken into consideration. However, most related efforts are put into designing phenotyping models with higher accuracy. Few attention is put on the fairness perspective of phenotyping. The neglection of bias in phenotyping leads to subgroups of patients being underrepresented which will further affect the following healthcare activities such as patient recruitment in clinical trials. In this work, we are motivated to bridge this gap through a comprehensive experimental study to identify the bias existing in electronic phenotyping models and evaluate the widely-used debiasing methods' performance on these models. We choose pneumonia and sepsis as our phenotyping target diseases. We benchmark 9 kinds of electronic phenotyping methods spanning from rule-based to data-driven methods. Meanwhile, we evaluate the performance of the 5 bias mitigation strategies covering pre-processing, in-processing, and post-processing. Through the extensive experiments, we summarize several insightful findings from the bias identified in the phenotyping and key points of the bias mitigation strategies in phenotyping.
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Affiliation(s)
- Sirui Ding
- Department of Computer Science & Engineering, Texas A&M University, College Station, TX, United States
| | - Shenghan Zhang
- Department of Biomedical Informatics, Harvard University, Boston, MA, United States
| | - Xia Hu
- Department of Computer Science, Rice University, Houston, TX, United States
| | - Na Zou
- Department of Industrial Engineering, University of Houston, Houston, TX, United States.
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6
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Mi Y, Burnham KL, Charles PD, Heilig R, Vendrell I, Whalley J, Torrance HD, Antcliffe DB, May SM, Neville MJ, Berridge G, Hutton P, Geoghegan CG, Radhakrishnan J, Nesvizhskii AI, Yu F, Davenport EE, McKechnie S, Davies R, O'Callaghan DJP, Patel P, Del Arroyo AG, Karpe F, Gordon AC, Ackland GL, Hinds CJ, Fischer R, Knight JC. High-throughput mass spectrometry maps the sepsis plasma proteome and differences in patient response. Sci Transl Med 2024; 16:eadh0185. [PMID: 38838133 DOI: 10.1126/scitranslmed.adh0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
Sepsis, the dysregulated host response to infection causing life-threatening organ dysfunction, is a global health challenge requiring better understanding of pathophysiology and new therapeutic approaches. Here, we applied high-throughput tandem mass spectrometry to delineate the plasma proteome for sepsis and comparator groups (noninfected critical illness, postoperative inflammation, and healthy volunteers) involving 2612 samples (from 1611 patients) and 4553 liquid chromatography-mass spectrometry analyses acquired through a single batch of continuous measurements, with a throughput of 100 samples per day. We show how this scale of data can delineate proteins, pathways, and coexpression modules in sepsis and be integrated with paired leukocyte transcriptomic data (837 samples from n = 649 patients). We mapped the plasma proteomic landscape of the host response in sepsis, including changes over time, and identified features relating to etiology, clinical phenotypes (including organ failures), and severity. This work reveals subphenotypes informative for sepsis response state, disease processes, and outcome; identifies potential biomarkers; and advances opportunities for a precision medicine approach to sepsis.
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Affiliation(s)
- Yuxin Mi
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Katie L Burnham
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Wellcome Sanger Institute, Wellcome Genome Campus, Cambridge CB10 1SA, UK
| | - Philip D Charles
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
| | - Raphael Heilig
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
| | - Iolanda Vendrell
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
- Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford OX3 7BN, UK
| | - Justin Whalley
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Hew D Torrance
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College, London SW7 2AZ, UK
| | - David B Antcliffe
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College, London SW7 2AZ, UK
- Department of Critical Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Shaun M May
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Matt J Neville
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Georgina Berridge
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
| | - Paula Hutton
- Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7JX, UK
| | - Cyndi G Geoghegan
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | - Jayachandran Radhakrishnan
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| | | | - Fengchao Yu
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Emma E Davenport
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Wellcome Sanger Institute, Wellcome Genome Campus, Cambridge CB10 1SA, UK
| | - Stuart McKechnie
- Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7JX, UK
| | - Roger Davies
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College, London SW7 2AZ, UK
| | - David J P O'Callaghan
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College, London SW7 2AZ, UK
- Department of Critical Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Parind Patel
- Department of Critical Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Ana G Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Fredrik Karpe
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College, London SW7 2AZ, UK
- Department of Critical Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Charles J Hinds
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Roman Fischer
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
- Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford OX3 7BN, UK
| | - Julian C Knight
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford OX3 7BN, UK
- NIHR Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
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Ginestra JC, Coz Yataco AO, Dugar SP, Dettmer MR. Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity. Chest 2024; 165:1421-1430. [PMID: 38246522 PMCID: PMC11177099 DOI: 10.1016/j.chest.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Sepsis causes more than a quarter million deaths among hospitalized adults in the United States each year. Although most cases of sepsis are present on admission, up to one-quarter of patients with sepsis develop this highly morbid and mortal condition while hospitalized. Compared with patients with community-onset sepsis (COS), patients with hospital-onset sepsis (HOS) are twice as likely to require mechanical ventilation and ICU admission, have more than two times longer ICU and hospital length of stay, accrue five times higher hospital costs, and are twice as likely to die. Patients with HOS differ from those with COS with respect to underlying comorbidities, admitting diagnosis, clinical manifestations of infection, and severity of illness. Despite the differences between these patient populations, patients with HOS sepsis are understudied and warrant expanded investigation. Here, we outline important knowledge gaps in the recognition and management of HOS in adults and propose associated research priorities for investigators. Of particular importance are questions regarding standardization of research and clinical case identification, understanding of clinical heterogeneity among patients with HOS, development of tailored management recommendations, identification of impactful prevention strategies, optimization of care delivery and quality metrics, identification and correction of disparities in care and outcomes, and how to ensure goal-concordant care for patients with HOS.
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Affiliation(s)
- Jennifer C Ginestra
- Palliative and Advanced Illness Research (PAIR) Center, Division of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA
| | - Angel O Coz Yataco
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Siddharth P Dugar
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew R Dettmer
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Center for Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH.
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Barbash IJ, Davis BS, Saul M, Hwa R, Brant EB, Seymour CW, Kahn JM. Association Between Medicare's Sepsis Reporting Policy (SEP-1) and the Documentation of a Sepsis Diagnosis in the Clinical Record. Med Care 2024; 62:388-395. [PMID: 38620117 DOI: 10.1097/mlr.0000000000001997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
STUDY DESIGN Interrupted time series analysis of a retrospective, electronic health record cohort. OBJECTIVE To determine the association between the implementation of Medicare's sepsis reporting measure (SEP-1) and sepsis diagnosis rates as assessed in clinical documentation. BACKGROUND The role of health policy in the effort to improve sepsis diagnosis remains unclear. PATIENTS AND METHODS Adult patients hospitalized with suspected infection and organ dysfunction within 6 hours of presentation to the emergency department, admitted to one of 11 hospitals in a multi-hospital health system from January 2013 to December 2017. Clinician-diagnosed sepsis, as reflected by the inclusion of the terms "sepsis" or "septic" in the text of clinical notes in the first two calendar days following presentation. RESULTS Among 44,074 adult patients with sepsis admitted to 11 hospitals over 5 years, the proportion with sepsis documentation was 32.2% just before the implementation of SEP-1 in the third quarter of 2015 and increased to 37.3% by the fourth quarter of 2017. Of the 9 post-SEP-1 quarters, 8 had odds ratios for a sepsis diagnosis >1 (overall range: 0.98-1.26; P value for a joint test of statistical significance = 0.005). The effects were clinically modest, with a maximum effect of an absolute increase of 4.2% (95% CI: 0.9-7.8) at the end of the study period. The effect was greater in patients who did not require vasopressors compared with patients who required vasopressors ( P value for test of interaction = 0.02). CONCLUSIONS SEP-1 implementation was associated with modest increases in sepsis diagnosis rates, primarily among patients who did not require vasoactive medications.
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Affiliation(s)
- Ian J Barbash
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Billie S Davis
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Melissa Saul
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca Hwa
- Department of Computer Science, School of Computing and Information, University of Pittsburgh, Pittsburgh, PA
| | - Emily B Brant
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher W Seymour
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jeremy M Kahn
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Zimmermann CJ, Kuchta K, Amundson JR, VanDruff VN, Joseph S, Che S, Hedberg HM, Ujiki M. Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes. Surg Endosc 2024; 38:3273-3278. [PMID: 38658390 DOI: 10.1007/s00464-024-10756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/16/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Anti-reflux operations are effective treatments for GERD. Despite standardized surgical techniques, variability in post-operative outcomes persists. Most patients with GERD possess one or more characteristics that augment their disease and may affect post-operative outcomes-a GERD "phenotype". We sought to define these phenotypes and to compare their post-operative outcomes. METHODS We performed a retrospective review of a prospective gastroesophageal database at our institution, selecting all patients who underwent an anti-reflux procedure for GERD. Patients were grouped into different phenotypes based on the presence of four characteristics known to play a role in GERD: hiatal or paraesophageal hernia (PEH), hypotensive LES, esophageal dysmotility, delayed gastric emptying (DGE), and obesity. Patient-reported outcomes (GERD-HRQL, dysphagia, and reflux symptom index (RSI) scores) were compared across phenotypes using the Wilcoxon rank-sum test. RESULTS 690 patients underwent an anti-reflux procedure between 2008 and 2022. Most patients underwent a Nissen fundoplication (302, 54%), followed by a Toupet or Dor fundoplication (205, 37%). Twelve distinct phenotypes emerged. Non-obese patients with normal esophageal motility, normotensive LES, no DGE, with a PEH represented the most common phenotype (134, 24%). The phenotype with the best post-operative GERD-HRQL scores at one year was defined by obesity, hypotensive LES, and PEH, while the phenotype with the worst scores was defined by obesity, ineffective motility, and PEH (1.5 ± 2.4 vs 9.8 ± 11.4, p = 0.010). There was no statistically significant difference in GERD-HRQL, dysphagia, or RSI scores between phenotypes after five years. CONCLUSIONS We have identified distinct phenotypes based on common GERD-associated patient characteristics. With further study these phenotypes may aid surgeons in prognosticating outcomes to individual patients considering an anti-reflux procedure.
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Affiliation(s)
- Christopher J Zimmermann
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
- Surgery, UCHealth Northern Colorado, Fort Collins, USA.
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | | | | | - Stephanie Joseph
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Simon Che
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
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10
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Rodríguez A, Gómez J, Franquet Á, Trefler S, Díaz E, Sole-Violán J, Zaragoza R, Papiol E, Suberviola B, Vallverdú M, Jimenez-Herrera M, Albaya-Moreno A, Canabal Berlanga A, Del Valle Ortíz M, Carlos Ballesteros J, López Amor L, Sancho Chinesta S, de Alba-Aparicio M, Estella A, Martín-Loeches I, Bodi M. Applicability of an unsupervised cluster model developed on first wave COVID-19 patients in second/third wave critically ill patients. Med Intensiva 2024; 48:326-340. [PMID: 38462398 DOI: 10.1016/j.medine.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/04/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To validate the unsupervised cluster model (USCM) developed during the first pandemic wave in a cohort of critically ill patients from the second and third pandemic waves. DESIGN Observational, retrospective, multicentre study. SETTING Intensive Care Unit (ICU). PATIENTS Adult patients admitted with COVID-19 and respiratory failure during the second and third pandemic waves. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Collected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. To validate our original USCM, we assigned a phenotype to each patient of the validation cohort. The performance of the classification was determined by Silhouette coefficient (SC) and general linear modelling. In a post-hoc analysis we developed and validated a USCM specific to the validation set. The model's performance was measured using accuracy test and area under curve (AUC) ROC. RESULTS A total of 2330 patients (mean age 63 [53-82] years, 1643 (70.5%) male, median APACHE II score (12 [9-16]) and SOFA score (4 [3-6]) were included. The ICU mortality was 27.2%. The USCM classified patients into 3 clinical phenotypes: A (n = 1206 patients, 51.8%); B (n = 618 patients, 26.5%), and C (n = 506 patients, 21.7%). The characteristics of patients within each phenotype were significantly different from the original population. The SC was -0.007 and the inclusion of phenotype classification in a regression model did not improve the model performance (0.79 and 0.78 ROC for original and validation model). The post-hoc model performed better than the validation model (SC -0.08). CONCLUSION Models developed using machine learning techniques during the first pandemic wave cannot be applied with adequate performance to patients admitted in subsequent waves without prior validation.
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Affiliation(s)
- Alejandro Rodríguez
- Critical Care Department - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Universidad Rovira & Virgili/Institut d'Investigació Sanitaria Pere Virigili/CIBERES, Tarragona, Spain.
| | - Josep Gómez
- Technical Secretary - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Álvaro Franquet
- Technical Secretary - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Sandra Trefler
- Critical Care Department - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Emili Díaz
- Critical Care Department - Hospital Parc Tauli, Sabadell, Spain
| | - Jordi Sole-Violán
- Critical Care Department - Hospital Universitario Dr. Negrin/Universidad Fernando Pessoa, Las Palmas de Gran Canaria, Spain
| | - Rafael Zaragoza
- Critical Care Department - Hospital Dr. Peset, Valencia, Spain
| | - Elisabeth Papiol
- Critical Care Department - Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Borja Suberviola
- Critical Care Department - Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Montserrat Vallverdú
- Critical Care Department - Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | - Antonio Albaya-Moreno
- Critical Care Department - Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | | | | | - Lucía López Amor
- Critical Care Department - Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Angel Estella
- Critical Care Department - Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - María Bodi
- Critical Care Department - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Universidad Rovira & Virgili/Institut d'Investigació Sanitaria Pere Virigili/CIBERES, Tarragona, Spain
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11
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Iba T, Helms J, Maier CL, Levi M, Scarlatescu E, Levy JH. The role of thromboinflammation in acute kidney injury among patients with septic coagulopathy. J Thromb Haemost 2024; 22:1530-1540. [PMID: 38382739 DOI: 10.1016/j.jtha.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Inflammation and coagulation are critical self-defense mechanisms for mitigating infection that can nonetheless induce tissue injury and organ dysfunction. In severe cases, like sepsis, a dysregulated thromboinflammatory response may result in multiorgan dysfunction. Sepsis-associated acute kidney injury (AKI) is a significant contributor to patient morbidity and mortality. The connection between AKI and thromboinflammation is largely due to unique aspects of the renal vasculature. Specifically, the interaction between blood cells with the endothelial, glomerular, and peritubular capillary systems during thromboinflammation reduces oxygen supply to tubular epithelial cells. Previous studies have focused on tubular epithelial cell damage due to hypoxia, oxidative stress, and nephrotoxins. Although these factors are pivotal in acute tubular injury or necrosis, recent studies have demonstrated that AKI in sepsis encompasses a mixture of tubular and glomerular damage subtypes. In cases of sepsis-induced coagulopathy, thromboinflammation within the glomerulus and peritubular capillaries is an important pathogenic mechanism for AKI. Unfortunately, and despite the use of renal replacement therapy, the development of AKI in sepsis continues to be associated with high morbidity, mortality, and clinical challenges requiring alternative approaches. This review introduces the important role of thromboinflammation in AKI pathogenesis and details innovative vascular-targeting therapeutic strategies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- French National Institute of Health and Medical Research, United Medical Resources 1260, Regenerative Nanomedicine, Federation de Medicine Translationnelle de Strasbourg, Strasbourg University Hospital, Medical Intensive Care Unit - NHC, Strasbourg University, Strasbourg, France
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals National Health Service Foundation Trust, Cardio-metabolic Programme-National Institute for Health and Care Research University College London Hospitals/University College London Biomedical Research Centre, London, United Kingdom
| | - Ecaterina Scarlatescu
- University of Medicine and Pharmacy "Carol Davila," Bucharest, Romania; Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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12
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Nguyen PH, Fay KA, English JM, Gill HS. Serial measurements of SIRS and SEP scores to identify unique phenotypes of sepsis. Intern Emerg Med 2024; 19:1099-1107. [PMID: 38372887 DOI: 10.1007/s11739-023-03512-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 12/12/2023] [Indexed: 02/20/2024]
Abstract
Using scoring systems in discreet microbiologic cohorts in a serial fashion to identify unique phenotypes of sepsis remains unknown. Single-center, retrospective study that screened adults who triggered the hospital's SIRS (systemic inflammatory response syndrome) based sepsis alert into culture positive (Cx +) and culture negative (Cx-) groups. Subgroups were based on the location where the SIRS alert fired. SIRS scores and a novel score called SEP were calculated at t = 0 and at 3, 6, 12, and 24 h before and after t = 0. Primary outcome was a difference in SIRS/SEP scores in Cx + or Cx- groups over time. Secondary outcomes were differences in total SIRS/SEP scores and the components constituting SIRS/SEP scores at various locations over time. The study contained 7955 patients who met inclusion criteria. Cx + and Cx- groups had increases in SIRS/SEP scores and at similar rates starting 6 hours before t = 0. Both culture groups had decreasing SIRS/SEP scores, at varying gradients compared to the change in SIRS/SEP scores seen prior to t = 0. This pattern in SIRS/SEP scores before and after t = 0 was consistent in all location subgroups. Statistically significant differences were seen in the overall SIRS/SEP scores for Cx + and Cx- groups at hours 6, 12, and 24 after t = 0, in the ED group at t = 24 h after t = 0, the floor group at t = 0 h, and in the step-down group at t = 3 h after t = 0 h. Microbiological cohorting and serial assessments may be an effective tool to identify homogenous phenotypes of sepsis.
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Affiliation(s)
- Phuong Hoang Nguyen
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA
| | - Kayla Ashley Fay
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jada Mae English
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA
| | - Harman Singh Gill
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
- Department of Medicine, Section of Pulmonary & Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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13
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Vitt JR, Mainali S. Artificial Intelligence and Machine Learning Applications in Critically Ill Brain Injured Patients. Semin Neurol 2024; 44:342-356. [PMID: 38569520 DOI: 10.1055/s-0044-1785504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
The utilization of Artificial Intelligence (AI) and Machine Learning (ML) is paving the way for significant strides in patient diagnosis, treatment, and prognostication in neurocritical care. These technologies offer the potential to unravel complex patterns within vast datasets ranging from vast clinical data and EEG (electroencephalogram) readings to advanced cerebral imaging facilitating a more nuanced understanding of patient conditions. Despite their promise, the implementation of AI and ML faces substantial hurdles. Historical biases within training data, the challenge of interpreting multifaceted data streams, and the "black box" nature of ML algorithms present barriers to widespread clinical adoption. Moreover, ethical considerations around data privacy and the need for transparent, explainable models remain paramount to ensure trust and efficacy in clinical decision-making.This article reflects on the emergence of AI and ML as integral tools in neurocritical care, discussing their roles from the perspective of both their scientific promise and the associated challenges. We underscore the importance of extensive validation in diverse clinical settings to ensure the generalizability of ML models, particularly considering their potential to inform critical medical decisions such as withdrawal of life-sustaining therapies. Advancement in computational capabilities is essential for implementing ML in clinical settings, allowing for real-time analysis and decision support at the point of care. As AI and ML are poised to become commonplace in clinical practice, it is incumbent upon health care professionals to understand and oversee these technologies, ensuring they adhere to the highest safety standards and contribute to the realization of personalized medicine. This engagement will be pivotal in integrating AI and ML into patient care, optimizing outcomes in neurocritical care through informed and data-driven decision-making.
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Affiliation(s)
- Jeffrey R Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, California
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
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14
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Dobson GP, Letson HL, Morris JL. Revolution in sepsis: a symptoms-based to a systems-based approach? J Biomed Sci 2024; 31:57. [PMID: 38811967 PMCID: PMC11138085 DOI: 10.1186/s12929-024-01043-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
Severe infection and sepsis are medical emergencies. High morbidity and mortality are linked to CNS dysfunction, excessive inflammation, immune compromise, coagulopathy and multiple organ dysfunction. Males appear to have a higher risk of mortality than females. Currently, there are few or no effective drug therapies to protect the brain, maintain the blood brain barrier, resolve excessive inflammation and reduce secondary injury in other vital organs. We propose a major reason for lack of progress is a consequence of the treat-as-you-go, single-nodal target approach, rather than a more integrated, systems-based approach. A new revolution is required to better understand how the body responds to an infection, identify new markers to detect its progression and discover new system-acting drugs to treat it. In this review, we present a brief history of sepsis followed by its pathophysiology from a systems' perspective and future opportunities. We argue that targeting the body's early immune-driven CNS-response may improve patient outcomes. If the barrage of PAMPs and DAMPs can be reduced early, we propose the multiple CNS-organ circuits (or axes) will be preserved and secondary injury will be reduced. We have been developing a systems-based, small-volume, fluid therapy comprising adenosine, lidocaine and magnesium (ALM) to treat sepsis and endotoxemia. Our early studies indicate that ALM therapy shifts the CNS from sympathetic to parasympathetic dominance, maintains cardiovascular-endothelial glycocalyx coupling, reduces inflammation, corrects coagulopathy, and maintains tissue O2 supply. Future research will investigate the potential translation to humans.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
| | - Jodie L Morris
- Heart, Sepsis and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, QLD, 4811, Australia
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15
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Wu F, Shi S, Wang Z, Wang Y, Xia L, Feng Q, Hang X, Zhu M, Zhuang J. Identifying novel clinical phenotypes of acute respiratory distress syndrome using trajectories of daily fluid balance: a secondary analysis of randomized controlled trials. Eur J Med Res 2024; 29:299. [PMID: 38807163 PMCID: PMC11134929 DOI: 10.1186/s40001-024-01866-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Previously identified phenotypes of acute respiratory distress syndrome (ARDS) could not reveal the dynamic change of phenotypes over time. We aimed to identify novel clinical phenotypes in ARDS using trajectories of fluid balance, to test whether phenotypes respond differently to different treatment, and to develop a simplified model for phenotype identification. METHODS FACTT (conservative vs liberal fluid management) trial was classified as a development cohort, joint latent class mixed models (JLCMMs) were employed to identify trajectories of fluid balance. Heterogeneity of treatment effect (HTE) for fluid management strategy across phenotypes was investigated. We also constructed a parsimonious probabilistic model using baseline data to predict the fluid trajectories in the development cohort. The trajectory groups and the probabilistic model were externally validated in EDEN (initial trophic vs full enteral feeding) trial. RESULTS Using JLCMM, we identified two trajectory groups in the development cohort: Class 1 (n = 758, 76.4% of the cohort) had an early positive fluid balance, but achieved negative fluid balance rapidly, and Class 2 (n = 234, 24.6% of the cohort) was characterized by persistent positive fluid balance. Compared to Class 1 patients, patients in Class 2 had significantly higher 60-day mortality (53.5% vs. 17.8%, p < 0.001), and fewer ventilator-free days (0 vs. 20, p < 0.001). A significant HTE between phenotypes and fluid management strategies was observed in the FACTT. An 8-variables model was derived for phenotype assignment. CONCLUSIONS We identified and validated two novel clinical trajectories for ARDS patients, with both prognostic and predictive enrichment. The trajectories of ARDS can be identified with simple classifier models.
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Affiliation(s)
- Fei Wu
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China
| | - Suqin Shi
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China
| | - Zixuan Wang
- School of Nursing, School of Public Health, Yangzhou University, No. 136 Jiangyang Middle Road, Yangzhou, 225009, Jiangsu, China
| | - Yurong Wang
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China
| | - Le Xia
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China
| | - Qingling Feng
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China
| | - Xin Hang
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China
| | - Min Zhu
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China.
| | - Jinqiang Zhuang
- Department of Emergency Intensive Care Unit (EICU), The Affiliated Hospital of Yangzhou University, Yangzhou University, No. 45 Taizhou Road, Guangling District, Yangzhou City, 225000, Jiangsu Province, China.
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16
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Hsu WWQ, Zhang X, Sing CW, Tan KCB, Wong ICK, Lau WCY, Cheung CL. Unveiling unique clinical phenotypes of hip fracture patients and the temporal association with cardiovascular events. Nat Commun 2024; 15:4353. [PMID: 38777819 PMCID: PMC11111763 DOI: 10.1038/s41467-024-48713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
Cardiovascular events are the leading cause of death among hip fracture patients. This study aims to identify subphenotypes of hip fracture patients and investigate their association with incident cardiovascular events, all-cause mortality, and health service utilisation in Hong Kong and the United Kingdom populations. By the latent class analysis, we show three distinct clusters in the Hong Kong cohort (n = 78,417): Cluster 1 has cerebrovascular and hypertensive diseases, hyperlipidemia, and diabetes; Cluster 2 has congestive heart failure; Cluster 3 consists of relatively healthy patients. Compared to Cluster 3, higher risks of major adverse cardiovascular events are observed in Cluster 1 (hazard ratio 1.97, 95% CI 1.83 to 2.12) and Cluster 2 (hazard ratio 4.06, 95% CI 3.78 to 4.35). Clusters 1 and 2 are also associated with a higher risk of mortality, more unplanned accident and emergency visits and longer hospital stays. Self-controlled case series analysis shows a significantly elevated risk of major adverse cardiovascular events within 60 days post-hip fracture. Similar associations are observed in the United Kingdom cohort (n = 27,948). Pre-existing heart failure is identified as a unique subphenotype associated with poor prognosis after hip fractures.
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Affiliation(s)
- Warrington W Q Hsu
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Xiaowen Zhang
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chor-Wing Sing
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Kathryn C B Tan
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Chi-Kei Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
- Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China.
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17
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Spoto S, Basili S, Cangemi R, Yuste JR, Lucena F, Romiti GF, Raparelli V, Argemi J, D’Avanzo G, Locorriere L, Masini F, Calarco R, Testorio G, Spiezia S, Ciccozzi M, Angeletti S. A Focus on the Pathophysiology of Adrenomedullin Expression: Endothelitis and Organ Damage in Severe Viral and Bacterial Infections. Cells 2024; 13:892. [PMID: 38891025 PMCID: PMC11172186 DOI: 10.3390/cells13110892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/03/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
Adrenomedullin (ADM) is a peptide hormone produced primarily in the adrenal glands, playing a crucial role in various physiological processes. As well as improving vascular integrity and decreasing vascular permeability, ADM acts as a vasodilator, positive inotrope, diuretic, natriuretic and bronchodilator, antagonizing angiotensin II by inhibiting aldosterone secretion. ADM also has antihypertrophic, anti-apoptotic, antifibrotic, antioxidant, angiogenic and immunoregulatory effects and antimicrobial properties. ADM expression is upregulated by hypoxia, inflammation-inducing cytokines, viral or bacterial substances, strength of shear stress, and leakage of blood vessels. These pathological conditions are established during systemic inflammation that can result from infections, surgery, trauma/accidents or burns. The ability to rapidly identify infections and the prognostic, predictive power makes it a valuable tool in severe viral and bacterial infections burdened by high incidence and mortality. This review sheds light on the pathophysiological processes that in severe viral or bacterial infections cause endothelitis up to the development of organ damage, the resulting increase in ADM levels dosed through its more stable peptide mid-regional proadrenomedullin (MR-proADM), the most significant studies that attest to its diagnostic and prognostic accuracy in highlighting the severity of viral or bacterial infections and appropriate therapeutic insights.
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Affiliation(s)
- Silvia Spoto
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza University, Viale dell’Università, 30, 00185 Rome, Italy; (S.B.); (R.C.); (V.R.)
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza University, Viale dell’Università, 30, 00185 Rome, Italy; (S.B.); (R.C.); (V.R.)
| | - José Ramón Yuste
- Division of Infectious Diseases, Faculty of Medicine, Clinica Universidad de Navarra, University of Navarra, Avda. Pío XII, 36, 31008 Pamplona, Spain;
- Department of Internal Medicine, Faculty of Medicine, Clinica Universidad de Navarra, University of Navarra, Avda. Pío XII, 36, 31008 Pamplona, Spain
| | - Felipe Lucena
- Departamento de Medicina Interna, Clinica Universidad de Navarra, Avda. Pío XII, 36, 31008 Pamplona, Spain; (F.L.); (J.A.)
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza University, Viale dell’Università, 30, 00185 Rome, Italy; (S.B.); (R.C.); (V.R.)
| | - Valeria Raparelli
- Department of Translational and Precision Medicine, Sapienza University, Viale dell’Università, 30, 00185 Rome, Italy; (S.B.); (R.C.); (V.R.)
| | - Josepmaria Argemi
- Departamento de Medicina Interna, Clinica Universidad de Navarra, Avda. Pío XII, 36, 31008 Pamplona, Spain; (F.L.); (J.A.)
| | - Giorgio D’Avanzo
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Luciana Locorriere
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Francesco Masini
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Rodolfo Calarco
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Giulia Testorio
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Serenella Spiezia
- Diagnostic and Therapeutic Medicine Department, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (G.D.); (L.L.); (F.M.); (R.C.); (G.T.); (S.S.)
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, Università Campus Bio-Medico di Roma, 00128 Rome, Italy;
| | - Silvia Angeletti
- Unit of Laboratory, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy;
- Research Unit of Clinical Laboratory Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Rome, Italy
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18
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Wu Y, Wang L, Li Y, Cao Y, Wang M, Deng Z, Kang H. Immunotherapy in the context of sepsis-induced immunological dysregulation. Front Immunol 2024; 15:1391395. [PMID: 38835773 PMCID: PMC11148279 DOI: 10.3389/fimmu.2024.1391395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 06/06/2024] Open
Abstract
Sepsis is a clinical syndrome caused by uncontrollable immune dysregulation triggered by pathogen infection, characterized by high incidence, mortality rates, and disease burden. Current treatments primarily focus on symptomatic relief, lacking specific therapeutic interventions. The core mechanism of sepsis is believed to be an imbalance in the host's immune response, characterized by early excessive inflammation followed by late immune suppression, triggered by pathogen invasion. This suggests that we can develop immunotherapeutic treatment strategies by targeting and modulating the components and immunological functions of the host's innate and adaptive immune systems. Therefore, this paper reviews the mechanisms of immune dysregulation in sepsis and, based on this foundation, discusses the current state of immunotherapy applications in sepsis animal models and clinical trials.
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Affiliation(s)
- Yiqi Wu
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Lu Wang
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yun Li
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuan Cao
- Department of Emergency Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Min Wang
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Zihui Deng
- Department of Basic Medicine, Graduate School, Chinese PLA General Hospital, Beijing, China
| | - Hongjun Kang
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
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19
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Antcliffe DB, Mi Y, Santhakumaran S, Burnham KL, Prevost AT, Ward JK, Marshall TJ, Bradley C, Al-Beidh F, Hutton P, McKechnie S, Davenport EE, Hinds CJ, O'Kane CM, McAuley DF, Shankar-Hari M, Gordon AC, Knight JC. Patient stratification using plasma cytokines and their regulators in sepsis: relationship to outcomes, treatment effect and leucocyte transcriptomic subphenotypes. Thorax 2024; 79:515-523. [PMID: 38471792 PMCID: PMC11137467 DOI: 10.1136/thorax-2023-220538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 02/21/2024] [Indexed: 03/14/2024]
Abstract
RATIONALE Heterogeneity of the host response within sepsis, acute respiratory distress syndrome (ARDS) and more widely critical illness, limits discovery and targeting of immunomodulatory therapies. Clustering approaches using clinical and circulating biomarkers have defined hyper-inflammatory and hypo-inflammatory subphenotypes in ARDS associated with differential treatment response. It is unknown if similar subphenotypes exist in sepsis populations where leucocyte transcriptomic-defined subphenotypes have been reported. OBJECTIVES We investigated whether inflammatory clusters based on cytokine protein abundance were seen in sepsis, and the relationships with previously described transcriptomic subphenotypes. METHODS Hierarchical cluster and latent class analysis were applied to an observational study (UK Genomic Advances in Sepsis (GAinS)) (n=124 patients) and two clinical trial datasets (VANISH, n=155 and LeoPARDS, n=484) in which the plasma protein abundance of 65, 21, 11 circulating cytokines, cytokine receptors and regulators were quantified. Clinical features, outcomes, response to trial treatments and assignment to transcriptomic subphenotypes were compared between inflammatory clusters. MEASUREMENTS AND MAIN RESULTS We identified two (UK GAinS, VANISH) or three (LeoPARDS) inflammatory clusters. A group with high levels of pro-inflammatory and anti-inflammatory cytokines was seen that was associated with worse organ dysfunction and survival. No interaction between inflammatory clusters and trial treatment response was found. We found variable overlap of inflammatory clusters and leucocyte transcriptomic subphenotypes. CONCLUSIONS These findings demonstrate that differences in response at the level of cytokine biology show clustering related to severity, but not treatment response, and may provide complementary information to transcriptomic sepsis subphenotypes. TRIAL REGISTRATION NUMBER ISRCTN20769191, ISRCTN12776039.
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Affiliation(s)
- David Benjamin Antcliffe
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Centre for Perioperative and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - Yuxin Mi
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Shalini Santhakumaran
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Katie L Burnham
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - Josie K Ward
- Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland
| | - Timothy J Marshall
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Central Clinical School Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Bradley
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Paula Hutton
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | | | | | - Charles J Hinds
- William Harvey Research Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, UK
| | - Manu Shankar-Hari
- The Queen's Medical Research Institute, The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Centre for Perioperative and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - Julian C Knight
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, UK
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20
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Viktorsson SA, Turnbull IR. Sepsis in surgical patients: Personalized medicine in the future treatment of sepsis. Surgery 2024:S0039-6060(24)00205-8. [PMID: 38760228 DOI: 10.1016/j.surg.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 05/19/2024]
Abstract
Sepsis results when a severe infection overwhelms the normal regulatory mechanisms of the immune system, resulting in a dysregulated host response characterized by new-onset organ failure. A wide range of infectious challenges can induce sepsis, resulting in an even wider range of maladaptive immune responses. This makes sepsis a syndromic diagnosis without a unifying, underlying molecular mechanism. The next step toward personalized medicine for sepsis is to resolve the heterogeneity across the universe of septic patients in order to establish pathobiologically homogenous sepsis "endotypes" that have uniformly defined changes in physiology and immunology. Defining the mechanisms of immune dysfunction within these endotypes will provide a roadmap for the application of immunomodulatory therapies for sepsis. This approach can drive in a paradigm shift in sepsis treatment, moving beyond supportive care and toward active efforts to restore normal immune function.
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Affiliation(s)
- Sindri A Viktorsson
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Isaiah R Turnbull
- Department of Surgery, Washington University School of Medicine, St. Louis, MO.
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21
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Burton RJ, Raffray L, Moet LM, Cuff SM, White DA, Baker SE, Moser B, O’Donnell VB, Ghazal P, Morgan MP, Artemiou A, Eberl M. Conventional and unconventional T-cell responses contribute to the prediction of clinical outcome and causative bacterial pathogen in sepsis patients. Clin Exp Immunol 2024; 216:293-306. [PMID: 38430552 PMCID: PMC11097916 DOI: 10.1093/cei/uxae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/12/2024] [Accepted: 02/28/2024] [Indexed: 03/04/2024] Open
Abstract
Sepsis is characterized by a dysfunctional host response to infection culminating in life-threatening organ failure that requires complex patient management and rapid intervention. Timely diagnosis of the underlying cause of sepsis is crucial, and identifying those at risk of complications and death is imperative for triaging treatment and resource allocation. Here, we explored the potential of explainable machine learning models to predict mortality and causative pathogen in sepsis patients. By using a modelling pipeline employing multiple feature selection algorithms, we demonstrate the feasibility of identifying integrative patterns from clinical parameters, plasma biomarkers, and extensive phenotyping of blood immune cells. While no single variable had sufficient predictive power, models that combined five and more features showed a macro area under the curve (AUC) of 0.85 to predict 90-day mortality after sepsis diagnosis, and a macro AUC of 0.86 to discriminate between Gram-positive and Gram-negative bacterial infections. Parameters associated with the cellular immune response contributed the most to models predictive of 90-day mortality, most notably, the proportion of T cells among PBMCs, together with expression of CXCR3 by CD4+ T cells and CD25 by mucosal-associated invariant T (MAIT) cells. Frequencies of Vδ2+ γδ T cells had the most profound impact on the prediction of Gram-negative infections, alongside other T-cell-related variables and total neutrophil count. Overall, our findings highlight the added value of measuring the proportion and activation patterns of conventional and unconventional T cells in the blood of sepsis patients in combination with other immunological, biochemical, and clinical parameters.
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Affiliation(s)
- Ross J Burton
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Adult Critical Care, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Loïc Raffray
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Department of Internal Medicine, Félix Guyon University Hospital of La Réunion, Saint Denis, Réunion Island, France
| | - Linda M Moet
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Simone M Cuff
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Daniel A White
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Sarah E Baker
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Bernhard Moser
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Systems Immunity Research Institute, Cardiff University, Cardiff, UK
| | - Valerie B O’Donnell
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Systems Immunity Research Institute, Cardiff University, Cardiff, UK
| | - Peter Ghazal
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Systems Immunity Research Institute, Cardiff University, Cardiff, UK
| | - Matt P Morgan
- Adult Critical Care, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Andreas Artemiou
- School of Mathematics, Cardiff University, Cardiff, UK
- Department of Information Technologies, University of Limassol, 3025 Limassol, Cyprus
| | - Matthias Eberl
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
- Systems Immunity Research Institute, Cardiff University, Cardiff, UK
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22
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Zhang P, Yang Q, Yin C, Cai Z, Lu H, Li H, Li L, Tian Y, Bai L, Huang L. Association between septic shock and tracheal injury score in intensive care unit patients with invasive ventilation: a prospective single-centre cohort study in China. BMJ Open 2024; 14:e078763. [PMID: 38740497 PMCID: PMC11097891 DOI: 10.1136/bmjopen-2023-078763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 04/08/2024] [Indexed: 05/16/2024] Open
Abstract
OBJECTIVES There was no evidence regarding the relationship between septic shock and tracheal injury scores. Investigate whether septic shock was independently associated with tracheal injury scores in intensive care unit (ICU) patients with invasive ventilation. DESIGN Prospective observational cohort study. SETTING Our study was conducted in a Class III hospital in Hebei province, China. PARTICIPANTS Patients over 18 years of age admitted to the ICU between 31 May 2020 and 3 May 2022 with a tracheal tube and expected to be on the tube for more than 24 hours. PRIMARY AND SECONDARY OUTCOME MEASURES Tracheal injuries were evaluated by examining hyperaemia, ischaemia, ulcers and tracheal perforation by fiberoptic bronchoscope. Depending on the number of lesions, the lesions were further classified as moderate, severe or confluent. RESULTS Among the 97 selected participants, the average age was 56.6±16.5 years, with approximately 64.9% being men. The results of adjusted linear regression showed that septic shock was associated with tracheal injury scores (β: 2.99; 95% CI 0.70 to 5.29). Subgroup analysis revealed a stronger association with a duration of intubation ≥8 days (p=0.013). CONCLUSION Patients with septic shock exhibit significantly higher tracheal injury scores compared with those without septic shock, suggesting that septic shock may serve as an independent risk factor for tracheal injury. TRIAL REGISTRATION NUMBER ChiCTR2000037842, registered 03 September 2020. Retrospectively registered, https://www.chictr.org.cn/edit.aspx?pid=57011&htm=4.
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Affiliation(s)
- Pei Zhang
- Department of Anesthesiology and Intensive Care, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qilin Yang
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chunhua Yin
- Department of Anesthesiology and Intensive Care, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhigang Cai
- Department of Respiratory Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huaihai Lu
- Department of Anesthesiology and Intensive Care, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haitao Li
- Department of Respiratory Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Liwen Li
- Department of Anesthesiology and Intensive Care, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ye Tian
- Department of Anesthesiology and Intensive Care, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Long Bai
- Department of Anesthesiology and Intensive Care, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lining Huang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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23
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Slim MA, van Amstel RBE, Bos LDJ, Cremer OL, Wiersinga WJ, van der Poll T, van Vught LA. Inflammatory subphenotypes previously identified in ARDS are associated with mortality at intensive care unit discharge: a secondary analysis of a prospective observational study. Crit Care 2024; 28:151. [PMID: 38715131 PMCID: PMC11077885 DOI: 10.1186/s13054-024-04929-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8, protein C and bicarbonate have been identified in patients admitted with acute respiratory distress syndrome (ARDS) that are prognostic of outcome and predictive of treatment response. We hypothesized that if these inflammatory subphenotypes previously identified among ARDS patients are assigned at ICU discharge in a more general critically ill population, they are associated with short- and long-term outcome. METHODS A secondary analysis of a prospective observational cohort study conducted in two Dutch ICUs between 2011 and 2014 was performed. All patients discharged alive from the ICU were at ICU discharge adjudicated to the previously identified inflammatory subphenotypes applying a validated parsimonious model using variables measured median 10.6 h [IQR, 8.0-31.4] prior to ICU discharge. Subphenotype distribution at ICU discharge, clinical characteristics and outcomes were analyzed. As a sensitivity analysis, a latent class analysis (LCA) was executed for subphenotype identification based on plasma protein biomarkers at ICU discharge reflective of coagulation activation, endothelial cell activation and inflammation. Concordance between the subphenotyping strategies was studied. RESULTS Of the 8332 patients included in the original cohort, 1483 ICU-survivors had plasma biomarkers available and could be assigned to the inflammatory subphenotypes. At ICU discharge 6% (n = 86) was assigned to the hyperinflammatory and 94% (n = 1397) to the hypoinflammatory subphenotype. Patients assigned to the hyperinflammatory subphenotype were discharged with signs of more severe organ dysfunction (SOFA scores 7 [IQR 5-9] vs. 4 [IQR 2-6], p < 0.001). Mortality was higher in patients assigned to the hyperinflammatory subphenotype (30-day mortality 21% vs. 11%, p = 0.005; one-year mortality 48% vs. 28%, p < 0.001). LCA deemed 2 subphenotypes most suitable. ICU-survivors from class 1 had significantly higher mortality compared to class 2. Patients belonging to the hyperinflammatory subphenotype were mainly in class 1. CONCLUSIONS Patients assigned to the hyperinflammatory subphenotype at ICU discharge showed significantly stronger anomalies in coagulation activation, endothelial cell activation and inflammation pathways implicated in the pathogenesis of critical disease and increased mortality until one-year follow up.
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Affiliation(s)
- Marleen A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands.
| | - Rombout B E van Amstel
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam Institute for Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
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24
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Schlapbach LJ, Ganesamoorthy D, Wilson C, Raman S, George S, Snelling PJ, Phillips N, Irwin A, Sharp N, Le Marsney R, Chavan A, Hempenstall A, Bialasiewicz S, MacDonald AD, Grimwood K, Kling JC, McPherson SJ, Blumenthal A, Kaforou M, Levin M, Herberg JA, Gibbons KS, Coin LJM. Host gene expression signatures to identify infection type and organ dysfunction in children evaluated for sepsis: a multicentre cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:325-338. [PMID: 38513681 DOI: 10.1016/s2352-4642(24)00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Sepsis is defined as dysregulated host response to infection that leads to life-threatening organ dysfunction. Biomarkers characterising the dysregulated host response in sepsis are lacking. We aimed to develop host gene expression signatures to predict organ dysfunction in children with bacterial or viral infection. METHODS This cohort study was done in emergency departments and intensive care units of four hospitals in Queensland, Australia, and recruited children aged 1 month to 17 years who, upon admission, underwent a diagnostic test, including blood cultures, for suspected sepsis. Whole-blood RNA sequencing of blood was performed with Illumina NovaSeq (San Diego, CA, USA). Samples with completed phenotyping, monitoring, and RNA extraction by March 31, 2020, were included in the discovery cohort; samples collected or completed thereafter and by Oct 27, 2021, constituted the Rapid Paediatric Infection Diagnosis in Sepsis (RAPIDS) internal validation cohort. An external validation cohort was assembled from RNA sequencing gene expression count data from the observational European Childhood Life-threatening Infectious Disease Study (EUCLIDS), which recruited children with severe infection in nine European countries between 2012 and 2016. Feature selection approaches were applied to derive novel gene signatures for disease class (bacterial vs viral infection) and disease severity (presence vs absence of organ dysfunction 24 h post-sampling). The primary endpoint was the presence of organ dysfunction 24 h after blood sampling in the presence of confirmed bacterial versus viral infection. Gene signature performance is reported as area under the receiver operating characteristic curves (AUCs) and 95% CI. FINDINGS Between Sept 25, 2017, and Oct 27, 2021, 907 patients were enrolled. Blood samples from 595 patients were included in the discovery cohort, and samples from 312 children were included in the RAPIDS validation cohort. We derived a ten-gene disease class signature that achieved an AUC of 94·1% (95% CI 90·6-97·7) in distinguishing bacterial from viral infections in the RAPIDS validation cohort. A ten-gene disease severity signature achieved an AUC of 82·2% (95% CI 76·3-88·1) in predicting organ dysfunction within 24 h of sampling in the RAPIDS validation cohort. Used in tandem, the disease class and disease severity signatures predicted organ dysfunction within 24 h of sampling with an AUC of 90·5% (95% CI 83·3-97·6) for patients with predicted bacterial infection and 94·7% (87·8-100·0) for patients with predicted viral infection. In the external EUCLIDS validation dataset (n=362), the disease class and disease severity predicted organ dysfunction at time of sampling with an AUC of 70·1% (95% CI 44·1-96·2) for patients with predicted bacterial infection and 69·6% (53·1-86·0) for patients with predicted viral infection. INTERPRETATION In children evaluated for sepsis, novel host transcriptomic signatures specific for bacterial and viral infection can identify dysregulated host response leading to organ dysfunction. FUNDING Australian Government Medical Research Future Fund Genomic Health Futures Mission, Children's Hospital Foundation Queensland, Brisbane Diamantina Health Partners, Emergency Medicine Foundation, Gold Coast Hospital Foundation, Far North Queensland Foundation, Townsville Hospital and Health Services SERTA Grant, and Australian Infectious Diseases Research Centre.
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Affiliation(s)
- Luregn J Schlapbach
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia.
| | - Devika Ganesamoorthy
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Clare Wilson
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Sainath Raman
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Shane George
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia; School of Medicine and Dentistry and the Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Peter J Snelling
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia; School of Medicine and Dentistry and the Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Natalie Phillips
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Adam Irwin
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia; Infection Management and Prevention Services, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Natalie Sharp
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Renate Le Marsney
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, Townsville University Hospital, Townsville, QLD, Australia
| | | | - Seweryn Bialasiewicz
- School of Chemistry and Molecular Biosciences, The Australian Centre for Ecogenomics, and Queensland Paediatric Infectious Diseases Laboratory, The University of Queensland, Brisbane, QLD, Australia
| | - Anna D MacDonald
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Keith Grimwood
- School of Medicine and Dentistry and the Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia; Department of Infectious Disease and Paediatrics, Gold Coast Health, Southport, QLD, Australia
| | - Jessica C Kling
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
| | | | - Antje Blumenthal
- Frazer Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Myrsini Kaforou
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Michael Levin
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Jethro A Herberg
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Lachlan J M Coin
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia; Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
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Angriman F, Saoraya J, Lawler PR, Shah BR, Martin CM, Scales DC. Preexisting Diabetes Mellitus and All-Cause Mortality in Adult Patients With Sepsis: A Population-Based Cohort Study. Crit Care Explor 2024; 6:e1085. [PMID: 38709081 DOI: 10.1097/cce.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVES We assessed the association of preexisting diabetes mellitus with all-cause mortality and organ support receipt in adult patients with sepsis. DESIGN Population-based cohort study. SETTING Ontario, Canada (2008-2019). POPULATION Adult patients (18 yr old or older) with a first sepsis-related hospitalization episode. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main exposure of interest was preexisting diabetes (either type 1 or 2). The primary outcome was all-cause mortality by 90 days; secondary outcomes included receipt of invasive mechanical ventilation and new renal replacement therapy. We report adjusted (for baseline characteristics using standardization) risk ratios (RRs) alongside 95% CIs. A main secondary analysis evaluated the potential mediation by prior metformin use of the association between preexisting diabetes and all-cause mortality following sepsis. Overall, 503,455 adults with a first sepsis-related hospitalization episode were included; 36% had preexisting diabetes. Mean age was 73 years, and 54% of the cohort were females. Preexisting diabetes was associated with a lower adjusted risk of all-cause mortality at 90 days (RR, 0.81; 95% CI, 0.80-0.82). Preexisting diabetes was associated with an increased risk of new renal replacement therapy (RR, 1.53; 95% CI, 1.46-1.60) but not invasive mechanical ventilation (RR, 1.03; 95% CI, 1.00-1.05). Overall, 21% (95% CI, 19-28) of the association between preexisting diabetes and reduced risk of all-cause mortality was mediated by prior metformin use. CONCLUSIONS Preexisting diabetes is associated with a lower risk of all-cause mortality and higher risk of new renal replacement therapy among adult patients with sepsis. Future studies should evaluate the underlying mechanisms of these associations.
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jutamas Saoraya
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, Chulalongkorn University, Pathum Wan, Bangkok, Thailand
- McGill University Health Centre, Montreal, QC, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | - Baiju R Shah
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, Chulalongkorn University, Pathum Wan, Bangkok, Thailand
- McGill University Health Centre, Montreal, QC, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Gu Q, Wei J, Yoon CH, Yuan K, Jones N, Brent A, Llewelyn M, Peto TEA, Pouwels KB, Eyre DW, Walker AS. Distinct patterns of vital sign and inflammatory marker responses in adults with suspected bloodstream infection. J Infect 2024; 88:106156. [PMID: 38599549 DOI: 10.1016/j.jinf.2024.106156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES To identify patterns in inflammatory marker and vital sign responses in adult with suspected bloodstream infection (BSI) and define expected trends in normal recovery. METHODS We included patients ≥16 y from Oxford University Hospitals with a blood culture taken between 1-January-2016 and 28-June-2021. We used linear and latent class mixed models to estimate trajectories in C-reactive protein (CRP), white blood count, heart rate, respiratory rate and temperature and identify CRP response subgroups. Centile charts for expected CRP responses were constructed via the lambda-mu-sigma method. RESULTS In 88,348 suspected BSI episodes; 6908 (7.8%) were culture-positive with a probable pathogen, 4309 (4.9%) contained potential contaminants, and 77,131(87.3%) were culture-negative. CRP levels generally peaked 1-2 days after blood culture collection, with varying responses for different pathogens and infection sources (p < 0.0001). We identified five CRP trajectory subgroups: peak on day 1 (36,091; 46.3%) or 2 (4529; 5.8%), slow recovery (10,666; 13.7%), peak on day 6 (743; 1.0%), and low response (25,928; 33.3%). Centile reference charts tracking normal responses were constructed from those peaking on day 1/2. CONCLUSIONS CRP and other infection response markers rise and recover differently depending on clinical syndrome and pathogen involved. However, centile reference charts, that account for these differences, can be used to track if patients are recovering line as expected and to help personalise infection.
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Affiliation(s)
- Qingze Gu
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jia Wei
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chang Ho Yoon
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kevin Yuan
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Brent
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - David W Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.
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Zhang YF, Yi ZJ, Zhang WF, Yang L, Qi F, Yu T, Zhu Z, Li MJ, Cheng Y, Zhao L, Gong JP, Li PZ. Single-Cell Sequencing Reveals MYOF-Enriched Monocyte/Macrophage Subcluster as a Favorable Prognostic Factor in Sepsis. Adv Biol (Weinh) 2024; 8:e2300673. [PMID: 38456367 DOI: 10.1002/adbi.202300673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/13/2024] [Indexed: 03/09/2024]
Abstract
This research utilized single-cell RNA sequencing to map the immune cell landscape in sepsis, revealing 28 distinct cell clusters and categorizing them into nine major types. Delving into the monocyte/macrophage subclusters, 12 unique subclusters are identified and pathway enrichment analyses are conducted using KEGG and GO, discovering enriched pathways such as oxidative phosphorylation and antigen processing. Further GSVA and AUCell assessments show varied activation of interferon pathways, especially in subclusters 4 and 11. The clinical correlation analysis reveals genes significantly linked to survival outcomes. Additionally, cellular differentiation in these subclusters is explored. Building on these insights, the differential gene expression within these subclusters is specifically scrutinized, which reveal MYOF as a key gene with elevated expression levels in the survivor group. This finding is further supported by in-depth pathway enrichment analysis and the examination of cellular differentiation trajectories, where MYOF's role became evident in the context of immune response regulation and sepsis progression. Validating the role of the MYOF gene in sepsis, a dose-dependent response to LPS in THP-1 cells and C57 mice is observed. Finally, inter-cellular communications are analyzed, particularly focusing on the MYOF+Mono/Macro subcluster, which indicates a pivotal role in immune regulation and potential therapeutic targeting.
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Affiliation(s)
- Yi-Fan Zhang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zhu-Jun Yi
- Department of Hepatobiliary Surgery, Chongqing University Three Gorges Hospital, Chongqing, 404100, China
| | - Wen-Feng Zhang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lian Yang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Feng Qi
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ting Yu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zhu Zhu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ming-Jie Li
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lei Zhao
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jian-Ping Gong
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Pei-Zhi Li
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
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28
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Catling FJR, Nagendran M, Festor P, Bien Z, Harris S, Faisal AA, Gordon AC, Komorowski M. Can Machine Learning Personalize Cardiovascular Therapy in Sepsis? Crit Care Explor 2024; 6:e1087. [PMID: 38709088 DOI: 10.1097/cce.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Large randomized trials in sepsis have generally failed to find effective novel treatments. This is increasingly attributed to patient heterogeneity, including heterogeneous cardiovascular changes in septic shock. We discuss the potential for machine learning systems to personalize cardiovascular resuscitation in sepsis. While the literature is replete with proofs of concept, the technological readiness of current systems is low, with a paucity of clinical trials and proven patient benefit. Systems may be vulnerable to confounding and poor generalization to new patient populations or contemporary patterns of care. Typical electronic health records do not capture rich enough data, at sufficient temporal resolution, to produce systems that make actionable treatment suggestions. To resolve these issues, we recommend a simultaneous focus on technical challenges and removing barriers to translation. This will involve improving data quality, adopting causally grounded models, prioritizing safety assessment and integration into healthcare workflows, conducting randomized clinical trials and aligning with regulatory requirements.
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Affiliation(s)
- Finneas J R Catling
- Institute of Healthcare Engineering, University College London, London, United Kingdom
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, United Kingdom
| | - Myura Nagendran
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, United Kingdom
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, United Kingdom
| | - Paul Festor
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, United Kingdom
- Department of Computing, Imperial College London, London, United Kingdom
| | - Zuzanna Bien
- School of Life Course & Population Sciences, King's College London, United Kingdom
| | - Steve Harris
- Department of Critical Care, University College London Hospital, London, United Kingdom
- Institute of Health Informatics, University College London, London, United Kingdom
| | - A Aldo Faisal
- UKRI Centre for Doctoral Training in AI for Healthcare, Imperial College London, London, United Kingdom
- Department of Computing, Imperial College London, London, United Kingdom
- Institute of Artificial and Human Intelligence, Universität Bayreuth, Bayreuth, Germany
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, United Kingdom
| | - Matthieu Komorowski
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, United Kingdom
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Choudhary T, Upadhyaya P, Davis CM, Yang P, Tallowin S, Lisboa FA, Schobel SA, Coopersmith CM, Elster EA, Buchman TG, Dente CJ, Kamaleswaran R. Derivation and Validation of Generalized Sepsis-induced Acute Respiratory Failure Phenotypes Among Critically Ill Patients: A Retrospective Study. RESEARCH SQUARE 2024:rs.3.rs-4307475. [PMID: 38746442 PMCID: PMC11092838 DOI: 10.21203/rs.3.rs-4307475/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate their generalizability across multi-ICU specialties, considering multi-organ dynamics. Methods We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥24 hours. Data from two different high-volume academic hospital systems were used as a derivation set with N=3,225 medical ICU (MICU) patients and a validation set with N=848 MICU patients. For the multi-ICU validation, we utilized retrospective data from two surgical ICUs at the same hospitals (N=1,577). Clinical data from 24 hours preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts. Results Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F=123]), C (mild hypoxia [median P/F=240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing an external MICU from second hospital and SICUs from both centers. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes (p<0.01) and consistent across both centers. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy. Conclusion The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eric A Elster
- Uniformed Services University of the Health Sciences
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30
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Sim PJW, Li Z, Aung AH, Coia JE, Chen M, Nielsen SL, Jensen TG, Møller JK, Dessau RB, Póvoa P, Gradel KO, Chow A. Comparative epidemiology of bacteraemia in two ageing populations: Singapore and Denmark. Epidemiol Infect 2024; 152:e74. [PMID: 38682588 PMCID: PMC11094380 DOI: 10.1017/s0950268824000645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 02/21/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
Burden of bacteraemia is rising due to increased average life expectancy in developed countries. This study aimed to compare the epidemiology and outcomes of bacteraemia in two similarly ageing populations with different ethnicities in Singapore and Denmark. Historical cohorts from the second largest acute-care hospital in Singapore and in the hospitals of two Danish regions included patients aged 15 and above who were admitted from 1 January 2006 to 31 December 2016 with at least 1 day of hospital stay and a pathogenic organism identified. Among 13 144 and 39 073 bacteraemia patients from Singapore and Denmark, similar 30-day mortality rates (16.5%; 20.3%), length of hospital stay (median 14 (IQR: 9-28) days; 11 (6-21)), and admission rate to ICU (15.5%; 15.6%) were observed, respectively. Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus ranked among the top four in both countries. However, Singaporeans had a higher proportion of patients with diabetes (46.8%) and renal disease (29.5%) than the Danes (28.0% and 13.7%, respectively), whilst the Danes had a higher proportion of patients with chronic pulmonary disease (18.0%) and malignancy (35.3%) than Singaporeans (9.7% and 16.2%, respectively). Our study showed that top four causative organisms and clinical outcomes were similar between the two cohorts despite pre-existing comorbidities differed.
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Affiliation(s)
- Patrick Jian Wei Sim
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Zongbin Li
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Aung Hein Aung
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - John Eugenio Coia
- Department of Clinical Microbiology, Esbjerg Hospital, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ming Chen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Microbiology, Hospital of Southern Jutland, Sønderborg, Denmark
| | - Stig Lønberg Nielsen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Thøger Gorm Jensen
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
- Department of Clinical Microbiology, Odense University Hospital, Odense C, Denmark
| | - Jens Kjølseth Møller
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Microbiology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ram Benny Dessau
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Microbiology, Zealand University Hospital, Slagelse, Denmark
| | - Pedro Póvoa
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
- The Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Estrada do Forte do Alto do Duque, Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Kim Oren Gradel
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Angela Chow
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
- Infectious Diseases Research and Training Office, National Centre for Infectious Diseases, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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31
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Tang G, Luo Y, Song H, Liu W, Huang Y, Wang X, Zou S, Sun Z, Hou H, Wang F. The immune landscape of sepsis and using immune clusters for identifying sepsis endotypes. Front Immunol 2024; 15:1287415. [PMID: 38707899 PMCID: PMC11066285 DOI: 10.3389/fimmu.2024.1287415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/01/2024] [Indexed: 05/07/2024] Open
Abstract
Background The dysregulated immune response to sepsis still remains unclear. Stratification of sepsis patients into endotypes based on immune indicators is important for the future development of personalized therapies. We aimed to evaluate the immune landscape of sepsis and the use of immune clusters for identifying sepsis endotypes. Methods The indicators involved in innate, cellular, and humoral immune cells, inhibitory immune cells, and cytokines were simultaneously assessed in 90 sepsis patients and 40 healthy controls. Unsupervised k-means cluster analysis of immune indicator data were used to identify patient clusters, and a random forest approach was used to build a prediction model for classifying sepsis endotypes. Results We depicted that the impairment of innate and adaptive immunity accompanying increased inflammation was the most prominent feature in patients with sepsis. However, using immune indicators for distinguishing sepsis from bacteremia was difficult, most likely due to the considerable heterogeneity in sepsis patients. Cluster analysis of sepsis patients identified three immune clusters with different survival rates. Cluster 1 (36.7%) could be distinguished from the other clusters as being an "effector-type" cluster, whereas cluster 2 (34.4%) was a "potential-type" cluster, and cluster 3 (28.9%) was a "dysregulation-type" cluster, which showed the lowest survival rate. In addition, we established a prediction model based on immune indicator data, which accurately classified sepsis patients into three immune endotypes. Conclusion We depicted the immune landscape of patients with sepsis and identified three distinct immune endotypes with different survival rates. Cluster membership could be predicted with a model based on immune data.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Hongyan Hou
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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32
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Hao C, Hao R, Zhao H, Zhang Y, Sheng M, An Y. Identification and validation of sepsis subphenotypes using time-series data. Heliyon 2024; 10:e28520. [PMID: 38689952 PMCID: PMC11059505 DOI: 10.1016/j.heliyon.2024.e28520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose The recognition of sepsis as a heterogeneous syndrome necessitates identifying distinct subphenotypes to select targeted treatment. Methods Patients with sepsis from the MIMIC-IV database (2008-2019) were randomly divided into a development cohort (80%) and an internal validation cohort (20%). Patients with sepsis from the ICU database of Peking University People's Hospital (2008-2022) were included in the external validation cohort. Time-series k-means clustering analysis and dynamic time warping was performed to develop and validate sepsis subphenotypes by analyzing the trends of 21 vital signs and laboratory indicators within 24 h after sepsis onset. Inflammatory biomarkers were compared in the ICU database of Peking University People's Hospital, whereas treatment heterogeneity was compared in the MIMIC-IV database. Findings Three sub-phenotypes were identified in the development cohort. Type A patients (N = 2525, 47%) exhibited stable vital signs and fair organ function, type B (N = 1552, 29%) was exhibited an obvious inflammatory response and stable organ function, and type C (N = 1251, 24%) exhibited severely impaired organ function with a deteriorating tendency. Type C demonstrated the highest mortality rate (33%) and levels of inflammatory biomarkers, followed by type B (24%), whereas type A exhibited the lowest mortality rate (11%) and levels of inflammatory biomarkers. These subphenotypes were confirmed in both the internal and external cohorts, demonstrating similar features and comparable mortality rates. In type C patients, survivors had significantly lower fluid intake within 24 h after sepsis onset (median 2891 mL, interquartile range (IQR) 1530-5470 mL) than that in non-survivors (median 4342 mL, IQR 2189-7305 mL). For types B and C, survivors showed a higher proportion of indwelling central venous catheters (p < 0.05). Conclusion Three novel phenotypes of patients with sepsis were identified and validated using time-series data, revealing significant heterogeneity in inflammatory biomarkers, treatments, and consistency across cohorts.
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Affiliation(s)
- Chenxiao Hao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Rui Hao
- School of Computer Science, Beijing University of Posts and Telecommunications, Haidian District, Beijing, 100876, China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Yong Zhang
- BNRist, DCST, RIIT, Tsinghua University, Beijing, 100084, China
| | - Ming Sheng
- BNRist, DCST, RIIT, Tsinghua University, Beijing, 100084, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, 100044, China
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Ren Y, Li Y, Loftus TJ, Balch J, Abbott KL, Ruppert MM, Guan Z, Shickel B, Rashidi P, Ozrazgat-Baslanti T, Bihorac A. Identifying acute illness phenotypes via deep temporal interpolation and clustering network on physiologic signatures. Sci Rep 2024; 14:8442. [PMID: 38600110 PMCID: PMC11006654 DOI: 10.1038/s41598-024-59047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 04/05/2024] [Indexed: 04/12/2024] Open
Abstract
Using clustering analysis for early vital signs, unique patient phenotypes with distinct pathophysiological signatures and clinical outcomes may be revealed and support early clinical decision-making. Phenotyping using early vital signs has proven challenging, as vital signs are typically sampled sporadically. We proposed a novel, deep temporal interpolation and clustering network to simultaneously extract latent representations from irregularly sampled vital signs and derive phenotypes. Four distinct clusters were identified. Phenotype A (18%) had the greatest prevalence of comorbid disease with increased prevalence of prolonged respiratory insufficiency, acute kidney injury, sepsis, and long-term (3-year) mortality. Phenotypes B (33%) and C (31%) had a diffuse pattern of mild organ dysfunction. Phenotype B's favorable short-term clinical outcomes were tempered by the second highest rate of long-term mortality. Phenotype C had favorable clinical outcomes. Phenotype D (17%) exhibited early and persistent hypotension, high incidence of early surgery, and substantial biomarker incidence of inflammation. Despite early and severe illness, phenotype D had the second lowest long-term mortality. After comparing the sequential organ failure assessment scores, the clustering results did not simply provide a recapitulation of previous acuity assessments. This tool may impact triage decisions and have significant implications for clinical decision-support under time constraints and uncertainty.
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Affiliation(s)
- Yuanfang Ren
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Yanjun Li
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Natural Products, Drug Discovery and Development, University of Florida, Gainesville, FL, USA
| | - Tyler J Loftus
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Jeremy Balch
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Kenneth L Abbott
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Matthew M Ruppert
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Ziyuan Guan
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Benjamin Shickel
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Parisa Rashidi
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Tezcan Ozrazgat-Baslanti
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA
| | - Azra Bihorac
- Intelligent Clinical Care Center, University of Florida, Gainesville, FL, USA.
- Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, PO Box 100224, Gainesville, FL, 32610-0254, USA.
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Kumar NR, Balraj TA, Shivashankar KK, Jayaram TC, Prashant A. Inflammaging in Multidrug-Resistant Sepsis of Geriatric ICU Patients and Healthcare Challenges. Geriatrics (Basel) 2024; 9:45. [PMID: 38667512 PMCID: PMC11049875 DOI: 10.3390/geriatrics9020045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
Multidrug-resistant sepsis (MDR) is a pressing concern in intensive care unit (ICU) settings, specifically among geriatric patients who experience age-related immune system changes and comorbidities. The aim of this review is to explore the clinical impact of MDR sepsis in geriatric ICU patients and shed light on healthcare challenges associated with its management. We conducted a comprehensive literature search using the National Center for Biotechnology Information (NCBI) and Google Scholar search engines. Our search incorporated keywords such as "multidrug-resistant sepsis" OR "MDR sepsis", "geriatric ICU patients" OR "elderly ICU patients", and "complications", "healthcare burdens", "diagnostic challenges", and "healthcare challenges" associated with MDR sepsis in "ICU patients" and "geriatric/elderly ICU patients". This review explores the specific risk factors contributing to MDR sepsis, the complexities of diagnostic challenges, and the healthcare burden faced by elderly ICU patients. Notably, the elderly population bears a higher burden of MDR sepsis (57.5%), influenced by various factors, including comorbidities, immunosuppression, age-related immune changes, and resource-limited ICU settings. Furthermore, sepsis imposes a significant economic burden on healthcare systems, with annual costs exceeding $27 billion in the USA. These findings underscore the urgency of addressing MDR sepsis in geriatric ICU patients and the need for tailored interventions to improve outcomes and reduce healthcare costs.
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Affiliation(s)
- Nishitha R. Kumar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India; (N.R.K.); (K.K.S.)
| | - Tejashree A. Balraj
- Department of Microbiology, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India;
| | - Kusuma K. Shivashankar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India; (N.R.K.); (K.K.S.)
| | - Tejaswini C. Jayaram
- Department of Geriatrics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India;
| | - Akila Prashant
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India; (N.R.K.); (K.K.S.)
- Department of Medical Genetics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570015, India
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Cajander S, Kox M, Scicluna BP, Weigand MA, Mora RA, Flohé SB, Martin-Loeches I, Lachmann G, Girardis M, Garcia-Salido A, Brunkhorst FM, Bauer M, Torres A, Cossarizza A, Monneret G, Cavaillon JM, Shankar-Hari M, Giamarellos-Bourboulis EJ, Winkler MS, Skirecki T, Osuchowski M, Rubio I, Bermejo-Martin JF, Schefold JC, Venet F. Profiling the dysregulated immune response in sepsis: overcoming challenges to achieve the goal of precision medicine. THE LANCET. RESPIRATORY MEDICINE 2024; 12:305-322. [PMID: 38142698 DOI: 10.1016/s2213-2600(23)00330-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 12/26/2023]
Abstract
Sepsis is characterised by a dysregulated host immune response to infection. Despite recognition of its significance, immune status monitoring is not implemented in clinical practice due in part to the current absence of direct therapeutic implications. Technological advances in immunological profiling could enhance our understanding of immune dysregulation and facilitate integration into clinical practice. In this Review, we provide an overview of the current state of immune profiling in sepsis, including its use, current challenges, and opportunities for progress. We highlight the important role of immunological biomarkers in facilitating predictive enrichment in current and future treatment scenarios. We propose that multiple immune and non-immune-related parameters, including clinical and microbiological data, be integrated into diagnostic and predictive combitypes, with the aid of machine learning and artificial intelligence techniques. These combitypes could form the basis of workable algorithms to guide clinical decisions that make precision medicine in sepsis a reality and improve patient outcomes.
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Affiliation(s)
- Sara Cajander
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Matthijs Kox
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Brendon P Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, Mater Dei hospital, University of Malta, Msida, Malta; Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raquel Almansa Mora
- Department of Cell Biology, Genetics, Histology and Pharmacology, University of Valladolid, Valladolid, Spain
| | - Stefanie B Flohé
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ignacio Martin-Loeches
- St James's Hospital, Dublin, Ireland; Hospital Clinic, Institut D'Investigacions Biomediques August Pi i Sunyer, Universidad de Barcelona, Barcelona, Spain
| | - Gunnar Lachmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany
| | - Massimo Girardis
- Department of Intensive Care and Anesthesiology, University Hospital of Modena, Modena, Italy
| | - Alberto Garcia-Salido
- Hospital Infantil Universitario Niño Jesús, Pediatric Critical Care Unit, Madrid, Spain
| | - Frank M Brunkhorst
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Antoni Torres
- Pulmonology Department. Hospital Clinic of Barcelona, University of Barcelona, Ciberes, IDIBAPS, ICREA, Barcelona, Spain
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Guillaume Monneret
- Immunology Laboratory, Hôpital E Herriot - Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon-1, Hôpital E Herriot, Lyon, France
| | | | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, The University of Edinburgh, Edinburgh, UK
| | | | - Martin Sebastian Winkler
- Department of Anesthesiology and Intensive Care, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Tomasz Skirecki
- Department of Translational Immunology and Experimental Intensive Care, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marcin Osuchowski
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Ignacio Rubio
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany; Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Jesus F Bermejo-Martin
- Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain; School of Medicine, Universidad de Salamanca, Salamanca, Spain; Centro de Investigación Biomédica en Red en Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabienne Venet
- Immunology Laboratory, Hôpital E Herriot - Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Inserm U1111, CNRS, UMR5308, Ecole Normale Supeérieure de Lyon, Universiteé Claude Bernard-Lyon 1, Lyon, France.
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Liu S, Zhuge C, Zhang J, Cui N, Long Y. SIMPLIFIED IMMUNE-DYSREGULATION INDEX: A NOVEL MARKER PREDICTS 28-DAY MORTALITY OF INTENSIVE CARE PATIENTS WITH SEPSIS. Shock 2024; 61:570-576. [PMID: 38411593 DOI: 10.1097/shk.0000000000002316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
ABSTRACT Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. There is currently no simple immune-imbalance-driven indicator for patients with sepsis. Methods: This study was conducted in Peking Union Medical College Hospital. Patients with sepsis were identified according to Sepsis 3.0 after reviewing patient data from May 2018 through October 2022. Least absolute shrinkage and selection operator logistic regression was used for features selection. Receiver operating characteristic curves for 28-day mortality were used to compare the predictive performance of level of interleukin 6 (IL-6) and lymphocyte count (LY#) with that of the combined ratio, namely, the IL-6/LY# ratio. A Cox hazard model was also used to test the predictive performance of IL-6/LY# versus several other measurements. The dynamic trend of IL-6/LY# based on day 1 IL-6/LY# level was analyzed. Results: The mortality rate was 24.5% (220/898) in the study cohort. The LY#, IL-6 level, blood platelet count, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation II score, heart rate, age and Fi o2 level were identified as key factors for predicting 28-day mortality. IL-6/LY# was identified as a core indicator according to Least absolute shrinkage and selection operator logistic regression analysis. IL-6/LY# was significantly higher in nonsurvivors than in survivors (348 [154.6-1371.7] vs. 42.3 [15.4-117.1]). IL-6/LY# yielded a higher area under the curve (0.852 [95% CI = 0.820-0.879]) than the level of IL-6 (0.776 [95% CI = 0.738-0.809]) and LY# (0.719 [95% CI = 0.677-0.755]) separately. Survival analysis of mortality risk versus the IL-6/LY# ratio suggested that IL-6/LY# was significantly more predictive of patient risk than the Sequential Organ Failure Assessment score or the other factors ( P = 1.5 × 10 -33 ). In trend analysis, as the trend of D1-D3-D7 IL-6/LY# decreases, the morality rate is lower than increase or fluctuate group (42.1% vs. 58.3%, 37.9% vs. 43.8%, 37.5% vs. 38.5% in high, moderate, and low D1 IL-6/LY# group separately). Conclusion: IL-6/LY# examined on first day in intensive care unit can be used as an immune-imbalance alert to identify sepsis patients with higher risk of 28-day mortality. Decreasing trend of IL-6/LY# suggests a lower 28-day mortality rate of sepsis patients.
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Affiliation(s)
- Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Changjing Zhuge
- Beijing Institute for Scientific and Engineering Computing, Department of Mathematics, School of Mathematics, Statistics and Mechanics, Beijing University of Technology, Beijing, China
| | - Jiahui Zhang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Prasad PA, Esmaili AM, Oreper S, Beagle AJ, Hubbard C, Raffel KE, Abe‐Jones Y, Fang MC, Liu KD, Matthay MA, Kangelaris KN. Timing of antibiotic treatment identifies distinct clinical presentations among patients presenting with suspected septic shock. J Am Coll Emerg Physicians Open 2024; 5:e13149. [PMID: 38596320 PMCID: PMC11002635 DOI: 10.1002/emp2.13149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/23/2024] [Accepted: 03/04/2024] [Indexed: 04/11/2024] Open
Abstract
Objective Recent clinical guidelines for sepsis management emphasize immediate antibiotic initiation for suspected septic shock. Though hypotension is a high-risk marker of sepsis severity, prior studies have not considered the precise timing of hypotension in relation to antibiotic initiation and how clinical characteristics and outcomes may differ. Our objective was to evaluate antibiotic initiation in relation to hypotension to characterize differences in sepsis presentation and outcomes in patients with suspected septic shock. Methods Adults presenting to the emergency department (ED) June 2012-December 2018 diagnosed with sepsis (Sepsis-III electronic health record [EHR] criteria) and hypotension (non-resolving for ≥30 min, systolic blood pressure <90 mmHg) within 24 h. We categorized patients who received antibiotics before hypotension ("early"), 0-60 min after ("immediate"), and >60 min after ("late") treatment. Results Among 2219 patients, 55% received early treatment, 13% immediate, and 32% late. The late subgroup often presented to the ED with hypotension (median 0 min) but received antibiotics a median of 191 min post-ED presentation. Clinical characteristics notable for this subgroup included higher prevalence of heart failure and liver disease (p < 0.05) and later onset of systemic inflammatory response syndrome (SIRS) criteria compared to early/immediate treatment subgroups (median 87 vs. 35 vs. 20 min, p < 0.0001). After adjustment, there was no difference in clinical outcomes among treatment subgroups. Conclusions There was significant heterogeneity in presentation and timing of antibiotic initiation for suspected septic shock. Patients with later treatment commonly had hypotension on presentation, had more hypotension-associated comorbidities, and developed overt markers of infection (eg, SIRS) later. While these factors likely contribute to delays in clinician recognition of suspected septic shock, it may not impact sepsis outcomes.
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Affiliation(s)
- Priya A. Prasad
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Armond M. Esmaili
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Sandra Oreper
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | | | - Colin Hubbard
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Katie E. Raffel
- Division of Hospital MedicineSchool of MedicineUniversity of ColoradoDenverColoradoUSA
| | - Yumiko Abe‐Jones
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Margaret C. Fang
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Kathleen D. Liu
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Division of NephrologyDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Michael A. Matthay
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Cardiovascular Research InstituteUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Kirsten N. Kangelaris
- Division of Hospital MedicineDepartment of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Jain S, Krumholz HM. Patient Privacy and Data Provenance in Pulmonary and Critical Care Research Using Big Data. Ann Am Thorac Soc 2024; 21:538-540. [PMID: 38259228 PMCID: PMC10995548 DOI: 10.1513/annalsats.202305-497ip] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 01/22/2024] [Indexed: 01/24/2024] Open
Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut; and
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
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Bertolotto M, Verzola D, Contini P, de Totero D, Tirandi A, Ramoni D, Ministrini S, Giacobbe DR, Bonaventura A, Vecchié A, Castellani L, Mirabella M, Arboscello E, Liberale L, Viazzi F, Bassetti M, Montecucco F, Carbone F. Osteopontin is associated with neutrophil extracellular trap formation in elderly patients with severe sepsis. Eur J Clin Invest 2024; 54:e14159. [PMID: 38264915 DOI: 10.1111/eci.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Maria Bertolotto
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Daniela Verzola
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paola Contini
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Daniela de Totero
- Molecular Pathology Unit IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Amedeo Tirandi
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Davide Ramoni
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Stefano Ministrini
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Daniele Roberto Giacobbe
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Aldo Bonaventura
- Medicina Generale 1, Medical Center, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - Alessandra Vecchié
- Medicina Generale 1, Medical Center, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | | | | | | | - Luca Liberale
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa, Italian Cardiovascular Network, Genoa, Italy
| | - Francesca Viazzi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Clinic of Nephrology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Fabrizio Montecucco
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa, Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa, Italian Cardiovascular Network, Genoa, Italy
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Jiang S, Gai X, Treggiari MM, Stead WW, Zhao Y, Page CD, Zhang AR. Soft phenotyping for sepsis via EHR time-aware soft clustering. J Biomed Inform 2024; 152:104615. [PMID: 38423266 PMCID: PMC11073833 DOI: 10.1016/j.jbi.2024.104615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Sepsis is one of the most serious hospital conditions associated with high mortality. Sepsis is the result of a dysregulated immune response to infection that can lead to multiple organ dysfunction and death. Due to the wide variability in the causes of sepsis, clinical presentation, and the recovery trajectories, identifying sepsis sub-phenotypes is crucial to advance our understanding of sepsis characterization, to choose targeted treatments and optimal timing of interventions, and to improve prognostication. Prior studies have described different sub-phenotypes of sepsis using organ-specific characteristics. These studies applied clustering algorithms to electronic health records (EHRs) to identify disease sub-phenotypes. However, prior approaches did not capture temporal information and made uncertain assumptions about the relationships among the sub-phenotypes for clustering procedures. METHODS We developed a time-aware soft clustering algorithm guided by clinical variables to identify sepsis sub-phenotypes using data available in the EHR. RESULTS We identified six novel sepsis hybrid sub-phenotypes and evaluated them for medical plausibility. In addition, we built an early-warning sepsis prediction model using logistic regression. CONCLUSION Our results suggest that these novel sepsis hybrid sub-phenotypes are promising to provide more accurate information on sepsis-related organ dysfunction and sepsis recovery trajectories which can be important to inform management decisions and sepsis prognosis.
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Affiliation(s)
- Shiyi Jiang
- Department of Electrical & Computer Engineering, Duke University, Durham, 27708, NC, USA
| | - Xin Gai
- Department of Statistical Science, Duke University, Durham, 27708, NC, USA
| | | | - William W Stead
- Department of Biomedical Informatics, Vanderbilt University, Nashville, 37235, TN, USA
| | - Yuankang Zhao
- Department of Biostatistics & Bioinformatics, Duke University, Durham, 27708, NC, USA
| | - C David Page
- Department of Biostatistics & Bioinformatics, Duke University, Durham, 27708, NC, USA
| | - Anru R Zhang
- Department of Biostatistics & Bioinformatics, Duke University, Durham, 27708, NC, USA; Department of Computer Science, Duke University, Durham, 27708, NC, USA.
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Fu Y, Xiang Y, Wei Q, Ilatovskaya D, Dong Z. Rodent models of AKI and AKI-CKD transition: an update in 2024. Am J Physiol Renal Physiol 2024; 326:F563-F583. [PMID: 38299215 DOI: 10.1152/ajprenal.00402.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/02/2024] Open
Abstract
Despite known drawbacks, rodent models are essential tools in the research of renal development, physiology, and pathogenesis. In the past decade, rodent models have been developed and used to mimic different etiologies of acute kidney injury (AKI), AKI to chronic kidney disease (CKD) transition or progression, and AKI with comorbidities. These models have been applied for both mechanistic research and preclinical drug development. However, current rodent models have their limitations, especially since they often do not fully recapitulate the pathophysiology of AKI in human patients, and thus need further refinement. Here, we discuss the present status of these rodent models, including the pathophysiologic compatibility, clinical translational significance, key factors affecting model consistency, and their main limitations. Future efforts should focus on establishing robust models that simulate the major clinical and molecular phenotypes of human AKI and its progression.
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Affiliation(s)
- Ying Fu
- Department of Nephrology, Institute of Nephrology, The Second Xiangya Hospital at Central South University, Changsha, People's Republic of China
| | - Yu Xiang
- Department of Nephrology, Institute of Nephrology, The Second Xiangya Hospital at Central South University, Changsha, People's Republic of China
| | - Qingqing Wei
- Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia, United States
| | - Daria Ilatovskaya
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, United States
| | - Zheng Dong
- Department of Nephrology, Institute of Nephrology, The Second Xiangya Hospital at Central South University, Changsha, People's Republic of China
- Department of Cellular Biology and Anatomy, Medical College of Georgia at Augusta University and Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia, United States
- Research Department, Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia, United States
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Shankar-Hari M, Calandra T, Soares MP, Bauer M, Wiersinga WJ, Prescott HC, Knight JC, Baillie KJ, Bos LDJ, Derde LPG, Finfer S, Hotchkiss RS, Marshall J, Openshaw PJM, Seymour CW, Venet F, Vincent JL, Le Tourneau C, Maitland-van der Zee AH, McInnes IB, van der Poll T. Reframing sepsis immunobiology for translation: towards informative subtyping and targeted immunomodulatory therapies. THE LANCET. RESPIRATORY MEDICINE 2024; 12:323-336. [PMID: 38408467 PMCID: PMC11025021 DOI: 10.1016/s2213-2600(23)00468-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 02/28/2024]
Abstract
Sepsis is a common and deadly condition. Within the current model of sepsis immunobiology, the framing of dysregulated host immune responses into proinflammatory and immunosuppressive responses for the testing of novel treatments has not resulted in successful immunomodulatory therapies. Thus, the recent focus has been to parse observable heterogeneity into subtypes of sepsis to enable personalised immunomodulation. In this Personal View, we highlight that many fundamental immunological concepts such as resistance, disease tolerance, resilience, resolution, and repair are not incorporated into the current sepsis immunobiology model. The focus for addressing heterogeneity in sepsis should be broadened beyond subtyping to encompass the identification of deterministic molecular networks or dominant mechanisms. We explicitly reframe the dysregulated host immune responses in sepsis as altered homoeostasis with pathological disruption of immune-driven resistance, disease tolerance, resilience, and resolution mechanisms. Our proposal highlights opportunities to identify novel treatment targets and could enable successful immunomodulation in the future.
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Affiliation(s)
- Manu Shankar-Hari
- Institute for Regeneration and Repair, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK.
| | - Thierry Calandra
- Service of Immunology and Allergy, Center of Human Immunology Lausanne, Department of Medicine and Department of Laboratory Medicine and Pathology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | - Michael Bauer
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine and Division of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Julian C Knight
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kenneth J Baillie
- Institute for Regeneration and Repair, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Lieuwe D J Bos
- Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
| | - Lennie P G Derde
- Intensive Care Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Richard S Hotchkiss
- Department of Anesthesiology and Critical Care Medicine, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - John Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | | | - Christopher W Seymour
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Fabienne Venet
- Immunology Laboratory, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), Institut Curie, Paris-Saclay University, Paris, France
| | - Anke H Maitland-van der Zee
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Iain B McInnes
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine and Division of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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Jukema BN, de Hond TAP, Kroon M, Maranus AE, Koenderman L, Kaasjager KAH. Point-of-care neutrophil and monocyte surface markers differentiate bacterial from viral infections at the emergency department within 30 min. J Leukoc Biol 2024; 115:714-722. [PMID: 38169315 DOI: 10.1093/jleuko/qiad163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/21/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
Rapid discrimination between viral and bacterial infections in a point-of-care setting will improve clinical outcome. Expression of CD64 on neutrophils (neuCD64) increases during bacterial infections, whereas expression of CD169 on classical monocytes (cmCD169) increases during viral infections. The diagnostic value of automated point-of-care neuCD64 and cmCD169 analysis was assessed for detecting bacterial and viral infections at the emergency department. Additionally, their value as input for machine learning models was studied. A prospective observational cohort study in patients suspected of infection was performed at an emergency department. A fully automated point-of-care flow cytometer measured neuCD64, cmCD169, and additional leukocyte surface markers. Flow cytometry data were gated using the FlowSOM algorithm. Bacterial and viral infections were assessed in standardized clinical care. The sole and combined diagnostic value of the markers was investigated. Clustering based on unsupervised machine learning identified unique patient clusters. Eighty-six patients were included. Thirty-five had a bacterial infection, 30 had a viral infection, and 21 had no infection. neuCD64 was increased in bacterial infections (P < 0.001), with an area under the receiver operating characteristic curve (AUROC) of 0.73. cmCD169 was higher in virally infected patients (P < 0.001; AUROC 0.79). Multivariate analyses incorporating additional markers increased the AUROC for bacterial and viral infections to 0.86 and 0.93, respectively. The additional clustering identified 4 distinctive patient clusters based on infection type and outcome. Automated neuCD64 and cmCD169 determination can discriminate between bacterial and viral infections. These markers can be determined within 30 min, allowing fast infection diagnostics in the acute clinical setting.
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Affiliation(s)
- Bernard N Jukema
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Centre for Translational Immunology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Titus A P de Hond
- Department of Internal Medicine and Acute Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Martijn Kroon
- Centre for Translational Immunology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Anna E Maranus
- Centre for Translational Immunology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Centre for Translational Immunology, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine and Acute Medicine, University Medical Centre Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
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Jiang Y, Dang Y, Wu Q, Yuan B, Gao L, You C. Using a k-means clustering to identify novel phenotypes of acute ischemic stroke and development of its Clinlabomics models. Front Neurol 2024; 15:1366307. [PMID: 38601342 PMCID: PMC11004235 DOI: 10.3389/fneur.2024.1366307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Objective Acute ischemic stroke (AIS) is a heterogeneous condition. To stratify the heterogeneity, identify novel phenotypes, and develop Clinlabomics models of phenotypes that can conduct more personalized treatments for AIS. Methods In a retrospective analysis, consecutive AIS and non-AIS inpatients were enrolled. An unsupervised k-means clustering algorithm was used to classify AIS patients into distinct novel phenotypes. Besides, the intergroup comparisons across the phenotypes were performed in clinical and laboratory data. Next, the least absolute shrinkage and selection operator (LASSO) algorithm was used to select essential variables. In addition, Clinlabomics predictive models of phenotypes were established by a support vector machines (SVM) classifier. We used the area under curve (AUC), accuracy, sensitivity, and specificity to evaluate the performance of the models. Results Of the three derived phenotypes in 909 AIS patients [median age 64 (IQR: 17) years, 69% male], in phenotype 1 (N = 401), patients were relatively young and obese and had significantly elevated levels of lipids. Phenotype 2 (N = 463) was associated with abnormal ion levels. Phenotype 3 (N = 45) was characterized by the highest level of inflammation, accompanied by mild multiple-organ dysfunction. The external validation cohort prospectively collected 507 AIS patients [median age 60 (IQR: 18) years, 70% male]. Phenotype characteristics were similar in the validation cohort. After LASSO analysis, Clinlabomics models of phenotype 1 and 2 were constructed by the SVM algorithm, yielding high AUC (0.977, 95% CI: 0.961-0.993 and 0.984, 95% CI: 0.971-0.997), accuracy (0.936, 95% CI: 0.922-0.956 and 0.952, 95% CI: 0.938-0.972), sensitivity (0.984, 95% CI: 0.968-0.998 and 0.958, 95% CI: 0.939-0.984), and specificity (0.892, 95% CI: 0.874-0.926 and 0.945, 95% CI: 0.923-0.969). Conclusion In this study, three novel phenotypes that reflected the abnormal variables of AIS patients were identified, and the Clinlabomics models of phenotypes were established, which are conducive to individualized treatments.
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Affiliation(s)
- Yao Jiang
- Laboratory Medicine Center, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, China
| | - Yingqiang Dang
- Laboratory Medicine Center, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, China
| | - Qian Wu
- Laboratory Medicine Center, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, China
| | - Boyao Yuan
- Department of Neurology, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, China
| | - Lina Gao
- Laboratory Medicine Center, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, China
| | - Chongge You
- Laboratory Medicine Center, The Second Hospital and Clinical Medical School, Lanzhou University, Lanzhou, China
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Ceccato A, Forne C, Bos LD, Camprubí-Rimblas M, Areny-Balagueró A, Campaña-Duel E, Quero S, Diaz E, Roca O, De Gonzalo-Calvo D, Fernández-Barat L, Motos A, Ferrer R, Riera J, Lorente JA, Peñuelas O, Menendez R, Amaya-Villar R, Añón JM, Balan-Mariño A, Barberà C, Barberán J, Blandino-Ortiz A, Boado MV, Bustamante-Munguira E, Caballero J, Carbajales C, Carbonell N, Catalán-González M, Franco N, Galbán C, Gumucio-Sanguino VD, de la Torre MDC, Estella Á, Gallego E, García-Garmendia JL, Garnacho-Montero J, Gómez JM, Huerta A, Jorge-García RN, Loza-Vázquez A, Marin-Corral J, Martínez de la Gándara A, Martin-Delgado MC, Martínez-Varela I, Messa JL, Muñiz-Albaiceta G, Nieto MT, Novo MA, Peñasco Y, Pozo-Laderas JC, Pérez-García F, Ricart P, Roche-Campo F, Rodríguez A, Sagredo V, Sánchez-Miralles A, Sancho-Chinesta S, Socias L, Solé-Violan J, Suarez-Sipmann F, Tamayo-Lomas L, Trenado J, Úbeda A, Valdivia LJ, Vidal P, Bermejo J, Gonzalez J, Barbe F, Calfee CS, Artigas A, Torres A. Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort. Crit Care 2024; 28:91. [PMID: 38515193 PMCID: PMC10958830 DOI: 10.1186/s13054-024-04876-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster. METHODS Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3. RESULTS Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3. CONCLUSIONS During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis.
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Affiliation(s)
- Adrian Ceccato
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain.
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
- Intensive Care Unit, Hospital Universitari Sagrat Cor, Grupo Quironsalud, Barcelona, Spain.
| | - Carles Forne
- Heorfy Consulting, Lleida, Spain
- Department of Basic Medical Sciences, University of Lleida, Lleida, Spain
| | - Lieuwe D Bos
- Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC Location AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marta Camprubí-Rimblas
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Aina Areny-Balagueró
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Campaña-Duel
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Quero
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Emili Diaz
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - David De Gonzalo-Calvo
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Translational Research in Respiratory Medicine, Respiratory Department, Hospital Universitari Aranu de Vilanova and Santa Maria, IRBLleida, Lleida, Spain
| | - Laia Fernández-Barat
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pneumology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Motos
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pneumology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Jose A Lorente
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain
- Department of Bioengineering, Universidad Carlos III, Madrid, Spain
| | - Oscar Peñuelas
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain
| | - Rosario Menendez
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Pulmonary Department, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Rosario Amaya-Villar
- Intensive Care Clinical Unit, Hospital Universitario Virgen de Rocío, Seville, Spain
| | - José M Añón
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Medicina Intensiva, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | | | | | - José Barberán
- Hospital Universitario HM Montepríncipe, Facultad HM Hospitales de Ciencias de La Salud, Universidad Camilo Jose Cela, Madrid, Spain
| | - Aaron Blandino-Ortiz
- Servicio de Medicina Intensiva, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Intensive Care Unit, and Emergency Medicine, Universidad de Alcalá, Madrid, Spain
| | | | - Elena Bustamante-Munguira
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Intensive Care Medicine, Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Jesús Caballero
- Critical Intensive Medicine Department, Hospital Universitari Arnau de Vilanova de Lleida, IRBLleida, Lleida, Spain
| | | | - Nieves Carbonell
- Intensive Care Unit, Hospital Clínico Universitario, Valencia, Spain
| | | | | | - Cristóbal Galbán
- Department of Critical Care Medicine, CHUS, Complejo Hospitalario Universitario de Santiago, Santiago, Spain
| | - Víctor D Gumucio-Sanguino
- Department of Intensive Care, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Maria Del Carmen de la Torre
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Hospital de Mataró de Barcelona, Barcelona, Spain
| | - Ángel Estella
- Department of Medicine, Intensive Care Unit University Hospital of Jerez, University of Cádiz, INIBiCA, Cádiz, Spain
| | - Elena Gallego
- Unidad de Cuidados Intensivos, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain
| | | | - José Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - José M Gómez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Arturo Huerta
- Pulmonary and Critical Care Division, Emergency Department, Clínica Sagrada Família, Barcelona, Spain
| | | | - Ana Loza-Vázquez
- Unidad de Medicina Intensiva, Hospital Universitario Virgen de Valme, Seville, Spain
| | | | | | | | | | | | - Guillermo Muñiz-Albaiceta
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Hospital Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | | | - Mariana Andrea Novo
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Palma, Illes Balears, Spain
| | - Yhivian Peñasco
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Juan Carlos Pozo-Laderas
- UGC-Medicina Intensiva, Hospital Universitario Reina Sofia, Instituto Maimonides IMIBIC, Córdoba, Spain
| | - Felipe Pérez-García
- Servicio de Microbiología Clínica, Facultad de Medicina, Departamento de Biomedicina y Biotecnología, Hospital Universitario Príncipe de Asturias - Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Pilar Ricart
- Servei de Medicina Intensiva, Hospital Universitari Germans Trias, Badalona, Spain
| | - Ferran Roche-Campo
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
| | - Alejandro Rodríguez
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Hospital Universitario Joan XXIII, CIBERES, Rovira and Virgili University, IISPV, Tarragona, Spain
| | | | - Angel Sánchez-Miralles
- Intensive Care Unit, Hospital Universitario Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, Spain
| | - Susana Sancho-Chinesta
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Lorenzo Socias
- Intensive Care Unit, Hospital Son Llàtzer, Illes Balears, Palma, Spain
| | - Jordi Solé-Violan
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Hospital Universitario de GC Dr. Negrín, Universidad Fernando Pessoa Canarias, Las Palmas, Gran Canaria, Spain
| | - Fernando Suarez-Sipmann
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Intensive Care Unit, Hospital Universitario La Princesa, Madrid, Spain
| | - Luis Tamayo-Lomas
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Hospital Universitario Río Hortega de Valladolid, Valladolid, Spain
| | - José Trenado
- Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Alejandro Úbeda
- Servicio de Medicina Intensiva, Hospital Punta de Europa, Algeciras, Spain
| | | | - Pablo Vidal
- Complexo Hospitalario Universitario de Ourense, Orense, Spain
| | - Jesus Bermejo
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario Río Hortega de Valladolid, Valladolid, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Gerencia Regional de Salud de Castilla y León, Salamanca, Spain
| | - Jesica Gonzalez
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Translational Research in Respiratory Medicine, Respiratory Department, Hospital Universitari Aranu de Vilanova and Santa Maria, IRBLleida, Lleida, Spain
| | - Ferran Barbe
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Translational Research in Respiratory Medicine, Respiratory Department, Hospital Universitari Aranu de Vilanova and Santa Maria, IRBLleida, Lleida, Spain
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Antonio Artigas
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Department of Medicine, Universitat Autonoma de Barcelona, Plaça Torre de L'Aigua, S/N, 08208, Sabadell, Spain.
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Antoni Torres
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pneumology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, Barcelona, Spain
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Legrand M, Bagshaw SM, Bhatraju PK, Bihorac A, Caniglia E, Khanna AK, Kellum JA, Koyner J, Harhay MO, Zampieri FG, Zarbock A, Chung K, Liu K, Mehta R, Pickkers P, Ryan A, Bernholz J, Dember L, Gallagher M, Rossignol P, Ostermann M. Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials. Crit Care 2024; 28:92. [PMID: 38515121 PMCID: PMC10958912 DOI: 10.1186/s13054-024-04877-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/17/2024] [Indexed: 03/23/2024] Open
Abstract
Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.
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Affiliation(s)
- Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, UCSF, 521 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
- Kidney Research Institute, University of Washington, Seattle, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Ellen Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Koyner
- University Section of Nephrology, Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Department of Biostatistics, Epidemiology, and Informatics, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | | | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Ravindra Mehta
- Department of Medicine, University of California, San Diego, USA
| | - Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Abigail Ryan
- Chronic Care Policy Group, Division of Chronic Care Management, Center for Medicare and Medicaid Services, Center for Medicare, Baltimore, MD, USA
| | | | - Laura Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Patrick Rossignol
- FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, Université de Lorraine, Nancy, France
- Medicine and Nephrology-Hemodialysis Departments, Monaco Private Hemodialysis Centre, Princess Grace Hospital, Monaco, Monaco
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
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Tachino J, Seno S, Matsumoto H, Kitamura T, Hirayama A, Nakao S, Katayama Y, Ogura H, Oda J. Association between tranexamic acid administration and mortality based on the trauma phenotype: a retrospective analysis of a nationwide trauma registry in Japan. Crit Care 2024; 28:89. [PMID: 38504320 PMCID: PMC10953216 DOI: 10.1186/s13054-024-04871-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/13/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND In trauma systems, criteria for individualised and optimised administration of tranexamic acid (TXA), an antifibrinolytic, are yet to be established. This study used nationwide cohort data from Japan to evaluate the association between TXA and in-hospital mortality among all patients with blunt trauma based on clinical phenotypes (trauma phenotypes). METHODS A retrospective analysis was conducted using data from the Japan Trauma Data Bank (JTDB) spanning 2019 to 2021. RESULTS Of 80,463 patients with trauma registered in the JTDB, 53,703 met the inclusion criteria, and 8046 (15.0%) received TXA treatment. The patients were categorised into eight trauma phenotypes. After adjusting with inverse probability treatment weighting, in-hospital mortality of the following trauma phenotypes significantly reduced with TXA administration: trauma phenotype 1 (odds ratio [OR] 0.68 [95% confidence interval [CI] 0.57-0.81]), trauma phenotype 2 (OR 0.73 [0.66-0.81]), trauma phenotype 6 (OR 0.52 [0.39-0.70]), and trauma phenotype 8 (OR 0.67 [0.60-0.75]). Conversely, trauma phenotypes 3 (OR 2.62 [1.98-3.47]) and 4 (OR 1.39 [1.11-1.74]) exhibited a significant increase in in-hospital mortality. CONCLUSIONS This is the first study to evaluate the association between TXA administration and survival outcomes based on clinical phenotypes. We found an association between trauma phenotypes and in-hospital mortality, indicating that treatment with TXA could potentially influence this relationship. Further studies are needed to assess the usefulness of these phenotypes.
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Affiliation(s)
- Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan.
| | - Shigeto Seno
- Department of Bioinformatic Engineering, Graduate School of Information Science and Technology, Osaka University, 1-5 Yamada-oka, Suita City, Osaka, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Atsushi Hirayama
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
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Qiao H, Tan J, Yan J, Sun C, Yin X, Li Z, Wu J, Guan H, Wen S, Zhang M, Xu S, Jin L. A comprehensive evaluation of the phenotype-first and data-driven approaches in analyzing facial morphological traits. iScience 2024; 27:109325. [PMID: 38487017 PMCID: PMC10937830 DOI: 10.1016/j.isci.2024.109325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/17/2024] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
The phenotype-first approach (PFA) and data-driven approach (DDA) have both greatly facilitated anthropological studies and the mapping of trait-associated genes. However, the pros and cons of the two approaches are poorly understood. Here, we systematically evaluated the two approaches and analyzed 14,838 facial traits in 2,379 Han Chinese individuals. Interestingly, the PFA explained more facial variation than the DDA in the top 100 and 1,000 except in the top 10 phenotypes. Accordingly, the ratio of heterogeneous traits extracted from the PFA was much greater, while more homogenous traits were found using the DDA for different sex, age, and BMI groups. Notably, our results demonstrated that the sex factor accounted for 30% of phenotypic variation in all traits extracted. Furthermore, we linked DDA phenotypes to PFA phenotypes with explicit biological explanations. These findings provide new insights into the analysis of multidimensional phenotypes and expand the understanding of phenotyping approaches.
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Affiliation(s)
- Hui Qiao
- State Key Laboratory of Genetic Engineering, Center for Evolutionary Biology, Human Phenome Institute, Zhangjiang Fudan International Innovation Center, School of Life Sciences, Fudan University, Shanghai 200438, China
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Jingze Tan
- State Key Laboratory of Genetic Engineering, Center for Evolutionary Biology, Human Phenome Institute, Zhangjiang Fudan International Innovation Center, School of Life Sciences, Fudan University, Shanghai 200438, China
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Jun Yan
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Chang Sun
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Xing Yin
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Zijun Li
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Jiazi Wu
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Haijuan Guan
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
| | - Shaoqing Wen
- Institute of Archaeological Science, Fudan University, Shanghai 200433, China
| | - Menghan Zhang
- Ministry of Education Key Laboratory of Contemporary Anthropology, Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai 201203, China
- Institute of Modern Languages and Linguistics, Fudan University, Shanghai 200433, China
- Research Institute of Intelligent Complex Systems, Fudan University, Shanghai 200433, China
| | - Shuhua Xu
- State Key Laboratory of Genetic Engineering, Center for Evolutionary Biology, Human Phenome Institute, Zhangjiang Fudan International Innovation Center, School of Life Sciences, Fudan University, Shanghai 200438, China
- Department of Liver Surgery and Transplantation Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Li Jin
- State Key Laboratory of Genetic Engineering, Center for Evolutionary Biology, Human Phenome Institute, Zhangjiang Fudan International Innovation Center, School of Life Sciences, Fudan University, Shanghai 200438, China
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DeMerle KM, Kennedy JN, Chang CCH, Delucchi K, Huang DT, Kravitz MS, Shapiro NI, Yealy DM, Angus DC, Calfee CS, Seymour CW. Identification of a hyperinflammatory sepsis phenotype using protein biomarker and clinical data in the ProCESS randomized trial. Sci Rep 2024; 14:6234. [PMID: 38485953 PMCID: PMC10940677 DOI: 10.1038/s41598-024-55667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/26/2024] [Indexed: 03/18/2024] Open
Abstract
Sepsis is a heterogeneous syndrome and phenotypes have been proposed using clinical data. Less is known about the contribution of protein biomarkers to clinical sepsis phenotypes and their importance for treatment effects in randomized trials of resuscitation. The objective is to use both clinical and biomarker data in the Protocol-Based Care for Early Septic Shock (ProCESS) randomized trial to determine sepsis phenotypes and to test for heterogeneity of treatment effect by phenotype comparing usual care to protocolized early, goal-directed therapy(EGDT). In this secondary analysis of a subset of patients with biomarker sampling in the ProCESS trial (n = 543), we identified sepsis phenotypes prior to randomization using latent class analysis of 20 clinical and biomarker variables. Logistic regression was used to test for interaction between phenotype and treatment arm for 60-day inpatient mortality. Among 543 patients with severe sepsis or septic shock in the ProCESS trial, a 2-class model best fit the data (p = 0.01). Phenotype 1 (n = 66, 12%) had increased IL-6, ICAM, and total bilirubin and decreased platelets compared to phenotype 2 (n = 477, 88%, p < 0.01 for all). Phenotype 1 had greater 60-day inpatient mortality compared to Phenotype 2 (41% vs 16%; p < 0.01). Treatment with EGDT was associated with worse 60-day inpatient mortality compared to usual care (58% vs. 23%) in Phenotype 1 only (p-value for interaction = 0.05). The 60-day inpatient mortality was similar comparing EGDT to usual care in Phenotype 2 (16% vs. 17%). We identified 2 sepsis phenotypes using latent class analysis of clinical and protein biomarker data at randomization in the ProCESS trial. Phenotype 1 had increased inflammation, organ dysfunction and worse clinical outcomes compared to phenotype 2. Response to EGDT versus usual care differed by phenotype.
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Affiliation(s)
- Kimberley M DeMerle
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason N Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chung-Chou H Chang
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin Delucchi
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA
| | - David T Huang
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Multidisciplinary Acute Care Research Organization (MACRO), Pittsburgh, PA, USA
| | - Max S Kravitz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Donald M Yealy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, 3459 Fifth Avenue, NW628, Pittsburgh, PA, 15213, USA.
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50
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Wang L, Zhang L, Huang X, Xu H, Huang W. Bloodstream infection clusters for critically ill patients: analysis of two-center retrospective cohorts. BMC Infect Dis 2024; 24:306. [PMID: 38481153 PMCID: PMC10935929 DOI: 10.1186/s12879-024-09203-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/07/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Bloodstream infections (BSI) are highly prevalent in hospitalized patients requiring intensive care. They are among the most serious infections and are highly associated with sepsis or septic shock, which can lead to prolonged hospital stays and high healthcare costs. This study aimed at establishing an easy-to-use nomogram for predicting the prognosis of patients with BSI. METHODS In retrospective study, records of patients with BSI admitted to the intensive care unit (ICU) over the period from Jan 1st 2016 to Dec 31st 2021 were included. We used data from two different China hospitals as development cohort and validation cohort respectively. The demographic and clinical data of patients were collected. Based on all baseline data, k-means algorithm was applied to discover the groups of BSI phenotypes with different prognostic outcomes, which was confirmed by Kaplan-Meier analysis and compared using log-rank tests. Univariate Cox regression analyses were used to estimate the risk of clusters. Random forest was used to identified discriminative predictors in clusters, which were utilized to construct nomogram based on multivariable logistic regression in the discovery cohort. For easy clinical applications, we developed a bloodstream infections clustering (BSIC) score according to the nomogram. The results were validated in the validation cohort over a similar period. RESULTS A total of 360 patients in the discovery cohort and 310 patients in the validation cohort were included in statistical analyses. Based on baseline variables, two distinct clusters with differing prognostic outcomes were identified in the discovery cohort. Population in cluster 1 was 211 with a ICU mortality of 17.1%, while population in cluster 2 was 149 with an ICU mortality of 41.6% (p < 0.001). The survival analysis also revealed a higher risk of death for cluster 2 when compared with cluster 1 (hazard ratio: 2.31 [95% CI, 1.53 to 3.51], p < 0.001), which was confirmed in validation cohort. Four independent predictors (vasoconstrictor use before BSI, mechanical ventilation (MV) before BSI, Deep vein catheterization (DVC) before BSI, and antibiotic use before BSI) were identified and used to develop a nomogram. The nomogram and BSIC score showed good discrimination with AUC of 0.96. CONCLUSION The developed score has potential applications in the identification of high-risk critically ill BSI patients.
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Affiliation(s)
- Lei Wang
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Li Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xiaolong Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Hao Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Wei Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
- The Third Clinical Medical College, Fujian Medical University, Fuzhou, China.
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