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Schertz AR, Eisner AE, Smith SA, Lenoir KM, Thomas KW. Clinical Phenotypes of Sepsis in a Cohort of Hospitalized Patients According to Infection Site. Crit Care Explor 2023; 5:e0955. [PMID: 37614801 PMCID: PMC10443761 DOI: 10.1097/cce.0000000000000955] [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] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES Clinical sepsis phenotypes may be defined by a wide range of characteristics such as site of infection, organ dysfunction patterns, laboratory values, and demographics. There is a paucity of literature regarding the impact of site of infection on the timing and pattern of clinical sepsis markers. This study hypothesizes that important phenotypic variation in clinical markers and outcomes of sepsis exists when stratified by infection site. DESIGN Retrospective cohort study. SETTING Five hospitals within the Wake Forest Health System from June 2019 to December 2019. PATIENTS Six thousand seven hundred fifty-three hospitalized adults with a discharge International Classification of Diseases, 10th Revision code for acute infection who met systemic inflammatory response syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA), or Sequential Organ Failure Assessment (SOFA) criteria during the index hospitalization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome of interest was a composite of 30-day mortality or shock. Infection site was determined by a two-reviewer process. Significant demographic, vital sign, and laboratory result differences were seen across all infection sites. For the composite outcome of shock or 30-day mortality, unknown or unspecified infections had the highest proportion (21.34%) and CNS infections had the lowest proportion (8.11%). Respiratory, vascular, and unknown or unspecified infection sites showed a significantly increased adjusted and unadjusted odds of the composite outcome as compared with the other infection sites except CNS. Hospital time prior to SIRS positivity was shortest in unknown or unspecified infections at a median of 0.88 hours (interquartile range [IQR], 0.22-5.05 hr), and hospital time prior to qSOFA and SOFA positivity was shortest in respiratory infections at a median of 54.83 hours (IQR, 9.55-104.67 hr) and 1.88 hours (IQR, 0.47-17.40 hr), respectively. CONCLUSIONS Phenotypic variation in illness severity and mortality exists when stratified by infection site. There is a significantly higher adjusted and unadjusted odds of the composite outcome of 30-day mortality or shock in respiratory, vascular, and unknown or unspecified infections as compared with other sites.
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Affiliation(s)
- Adam R Schertz
- Department of Internal Medicine, Section of Pulmonology, Critical Care, Allergy & Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Ashley E Eisner
- Department of Internal Medicine, Section of Pulmonology, Critical Care, Allergy & Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sydney A Smith
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Kristin M Lenoir
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Karl W Thomas
- Department of Internal Medicine, Section of Pulmonology, Critical Care, Allergy & Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
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Watkins BA, Newman JW, Kuchel GA, Fiehn O, Kim J. Dietary Docosahexaenoic Acid and Glucose Systemic Metabolic Changes in the Mouse. Nutrients 2023; 15:2679. [PMID: 37375583 DOI: 10.3390/nu15122679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
The endocannabinoid system (ECS) participates in regulating whole body energy balance. Overactivation of the ECS has been associated with the negative consequence of obesity and type 2 diabetes. Since activators of the ECS rely on lipid-derived ligands, an investigation was conducted to determine whether dietary PUFA could influence the ECS to affect glucose clearance by measuring metabolites of macronutrient metabolism. C57/blk6 mice were fed a control or DHA-enriched semi-purified diet for a period of 112 d. Plasma, skeletal muscle, and liver were collected after 56 d and 112 d of feeding the diets for metabolomics analysis. Key findings characterized a shift in glucose metabolism and greater catabolism of fatty acids in mice fed the DHA diet. Glucose use and promotion of fatty acids as substrate were found based on levels of metabolic pathway intermediates and altered metabolic changes related to pathway flux with DHA feeding. Greater levels of DHA-derived glycerol lipids were found subsequently leading to the decrease of arachidonate-derived endocannabinoids (eCB). Levels of 1- and 2-arachidonylglcerol eCB in muscle and liver were lower in the DHA diet group compared to controls. These findings demonstrate that DHA feeding in mice alters macronutrient metabolism and may restore ECS tone by lowering arachidonic acid derived eCB.
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Affiliation(s)
- Bruce A Watkins
- Department of Nutrition, University of California, Davis, Davis, CA 95616, USA
- Center on Aging, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - John W Newman
- United States Department of Agriculture, Agricultural Research Service, Western Human Nutrition Research Center, Davis, CA 95616, USA
| | - George A Kuchel
- Center on Aging, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Oliver Fiehn
- NIH UC Davis West Coast Metabolomics Center, Davis, CA 95616, USA
| | - Jeffrey Kim
- Genome and Biomedical Sciences Facility, University of California, Davis, Davis, CA 95616, USA
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3
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Forceville X, Van Antwerpen P, Annane D, Vincent JL. Selenocompounds and Sepsis-Redox Bypass Hypothesis: Part B-Selenocompounds in the Management of Early Sepsis. Antioxid Redox Signal 2022; 37:998-1029. [PMID: 35287478 DOI: 10.1089/ars.2020.8062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Significance: Endothelial barrier damage, which is in part caused by excess production of reactive oxygen, halogen and nitrogen species (ROHNS), especially peroxynitrite (ONOO-), is a major event in early sepsis and, with leukocyte hyperactivation, part of the generalized dysregulated immune response to infection, which may even become a complex maladaptive state. Selenoenzymes have major antioxidant functions. Their synthesis is related to the need to limit deleterious oxidant redox cycling by small selenocompounds, which may be of therapeutic cytotoxic interest. Plasma selenoprotein-P is crucial for selenium transport from the liver to the tissues and for antioxidant endothelial protection, especially against ONOO-. Above micromolar concentrations, sodium selenite (Na2SeO3) becomes cytotoxic, with a lower cytotoxicity threshold in activated cells, which has led to cancer research. Recent Advances: Plasma selenium (<2% of total body selenium) is mainly contained in selenoprotein-P, and concentrations decrease rapidly in the early phase of sepsis, because of increased selenoprotein-P binding and downregulation of hepatic synthesis and excretion. At low concentrations, Na2SeO3 acts as a selenium donor, favoring selenoprotein-P synthesis in physiology, but probably not in the acute phase of sepsis. Critical Issues: The cytotoxic effects of Na2SeO3 against hyperactivated leukocytes, especially the most immature forms that liberate ROHNS, may be beneficial, but they may also be harmful for activated endothelial cells. Endothelial protection against ROHNS by selenoprotein-P may reduce Na2SeO3 toxicity, which is increased in sepsis. Future Direction: The combination of selenoprotein-P for endothelial protection and the cytotoxic effects of Na2SeO3 against hyperactivated leukocytes may be a promising intervention for early sepsis. Antioxid. Redox Signal. 37, 998-1029.
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Affiliation(s)
- Xavier Forceville
- Medico-surgical Intensive Care Unit, Great Hospital of East Francilien - Meaux site, Meaux, France.,Clinical Investigation Centre (CIC Inserm1414) CHU de Rennes - Université de Rennes 1, Rennes, France
| | - Pierre Van Antwerpen
- Pharmacognosy, Bioanalysis and Drug Discovery and Analytical Platform of the Faculty of Pharmacy, Univesité libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Djillali Annane
- Service de Réanimation Médicale, Hôpital Raymond Poincaré (APHP), Garches, France.,U1173 Lab. of Inflammation & Infection, (Fédération Hospitalo-Universitaire) FHU SEPSIS, Université Paris Saclay-campus (Université de Versailles Saint-Quentin-en-Yvelines) UVSQ, Versailles, France
| | - Jean Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
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4
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Kenzie ES, Parks EL, Carney N, Wakeland W. System dynamics modeling for traumatic brain injury: Mini-review of applications. Front Bioeng Biotechnol 2022; 10:854358. [PMID: 36032727 PMCID: PMC9411712 DOI: 10.3389/fbioe.2022.854358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) is a highly complex phenomenon involving a cascade of disruptions across biomechanical, neurochemical, neurological, cognitive, emotional, and social systems. Researchers and clinicians urgently need a rigorous conceptualization of brain injury that encompasses nonlinear and mutually causal relations among the factors involved, as well as sources of individual variation in recovery trajectories. System dynamics, an approach from systems science, has been used for decades in fields such as management and ecology to model nonlinear feedback dynamics in complex systems. In this mini-review, we summarize some recent uses of this approach to better understand acute injury mechanisms, recovery dynamics, and care delivery for TBI. We conclude that diagram-based approaches like causal-loop diagramming have the potential to support the development of a shared paradigm of TBI that incorporates social support aspects of recovery. When developed using adequate data from large-scale studies, simulation modeling presents opportunities for improving individualized treatment and care delivery.
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Affiliation(s)
- Erin S. Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, OR, United States
- Systems Science Program, Portland State University, Portland, OR, United States
- *Correspondence: Erin S. Kenzie,
| | | | - Nancy Carney
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, United States
| | - Wayne Wakeland
- Systems Science Program, Portland State University, Portland, OR, United States
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5
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Wu TT, Zheng RF, Lin ZZ, Gong HR, Li H. A machine learning model to predict critical care outcomes in patient with chest pain visiting the emergency department. BMC Emerg Med 2021; 21:112. [PMID: 34620086 PMCID: PMC8496015 DOI: 10.1186/s12873-021-00501-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 09/01/2021] [Indexed: 12/23/2022] Open
Abstract
Background Currently, the risk stratification of critically ill patient with chest pain is a challenge. We aimed to use machine learning approach to predict the critical care outcomes in patients with chest pain, and simultaneously compare its performance with HEART, GRACE, and TIMI scores. Methods This was a retrospective, case-control study in patients with acute non-traumatic chest pain who presented to the emergency department (ED) between January 2017 and December 2019. The outcomes included cardiac arrest, transfer to ICU, and death during treatment in ED. In the randomly sampled training set (70%), a LASSO regression model was developed, and presented with nomogram. The performance was measured in both training set (70% participants) and testing set (30% participants), and findings were compared with the three widely used scores. Results We proposed a LASSO regression model incorporating mode of arrival, reperfusion therapy, Killip class, systolic BP, serum creatinine, creatine kinase-MB, and brain natriuretic peptide as independent predictors of critical care outcomes in patients with chest pain. Our model significantly outperformed the HEART, GRACE, TIMI score with AUC of 0.953 (95%CI: 0.922–0.984), 0.754 (95%CI: 0.675–0.832), 0.747 (95%CI: 0.664–0.829), 0.735 (95%CI: 0.655–0.815), respectively. Consistently, our model demonstrated better outcomes regarding the metrics of accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score. Similarly, the decision curve analysis elucidated a greater net benefit of our model over the full ranges of clinical thresholds. Conclusion We present an accurate model for predicting the critical care outcomes in patients with chest pain, and provide substantial support to its application as a decision-making tool in ED.
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Affiliation(s)
- Ting Ting Wu
- The School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Ruo Fei Zheng
- Department of Emergency, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Zhi Zhong Lin
- Department of Radiotherapy, Fujian Provincial Cancer Hospital, Fuzhou, Fujian, China
| | - Hai Rong Gong
- Department of Nursing, Fujian Health College, Fuzhou, Fujian, China
| | - Hong Li
- The School of Nursing, Fujian Medical University, Fuzhou, Fujian, China. .,Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China. .,Department of Nursing, Fujian Provincial Hospital, Fuzhou, Fujian, China.
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6
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Forceville X, Van Antwerpen P, Preiser JC. Selenocompounds and Sepsis: Redox Bypass Hypothesis for Early Diagnosis and Treatment: Part A-Early Acute Phase of Sepsis: An Extraordinary Redox Situation (Leukocyte/Endothelium Interaction Leading to Endothelial Damage). Antioxid Redox Signal 2021; 35:113-138. [PMID: 33567962 DOI: 10.1089/ars.2020.8063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Significance: Sepsis is a health disaster. In sepsis, an initial, beneficial local immune response against infection evolves rapidly into a generalized, dysregulated response or a state of chaos, leading to multiple organ failure. Use of life-sustaining supportive therapies creates an unnatural condition, enabling the complex cascades of the sepsis response to develop in patients who would otherwise die. Multiple attempts to control sepsis at an early stage have been unsuccessful. Recent Advances: Major events in early sepsis include activation and binding of leukocytes and endothelial cells in the microcirculation, damage of the endothelial surface layer (ESL), and a decrease in the plasma concentration of the antioxidant enzyme, selenoprotein-P. These events induce an increase in intracellular redox potential and lymphocyte apoptosis, whereas apoptosis is delayed in monocytes and neutrophils. They also induce endothelial mitochondrial and cell damage. Critical Issues: Neutrophil production increases dramatically, and aggressive immature forms are released. Leukocyte cross talk with other leukocytes and with damaged endothelial cells amplifies the inflammatory response. The release of large quantities of reactive oxygen, halogen, and nitrogen species as a result of the leukocyte respiratory burst, endothelial mitochondrial damage, and ischemia/reperfusion processes, along with the marked decrease in selenoprotein-P concentrations, leads to peroxynitrite damage of the ESL, reducing flow and damaging the endothelial barrier. Future Directions: Endothelial barrier damage by activated leukocytes is a time-sensitive event in sepsis, occurring within hours and representing the first step toward organ failure and death. Reducing or stopping this event is necessary before irreversible damage occurs.
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Affiliation(s)
- Xavier Forceville
- Medico-Surgical Intensive Care Unit, Great Hospital of East Francilien-Meaux Site, Hôpital Saint Faron, Meaux, France.,Clinical Investigation Center (CIC Inserm 1414), CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Pierre Van Antwerpen
- Pharmacognosy, Bioanalysis and Drug Discovery and Analytical Platform of the Faculty of Pharmacy, Université libre de Bruxelles (ULB), Bruxelles, Belgium
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7
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Gholami B, Haddad WM, Bailey JM, Muir WW. Closed-Loop Control for Fluid Resuscitation: Recent Advances and Future Challenges. Front Vet Sci 2021; 8:642440. [PMID: 33708814 PMCID: PMC7940185 DOI: 10.3389/fvets.2021.642440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/02/2021] [Indexed: 11/13/2022] Open
Abstract
Fluid therapy is extensively used to treat traumatized patients as well as patients during surgery. The fluid therapy process is complex due to interpatient variability in response to therapy as well as other complicating factors such as comorbidities and general anesthesia. These complexities can result in under- or over-resuscitation. Given the complexity of the fluid management process as well as the increased capabilities in hemodynamic monitoring, closed-loop fluid management can reduce the workload of the overworked clinician while ensuring specific constraints on hemodynamic endpoints are met with higher accuracy. The goal of this paper is to provide an overview of closed-loop control systems for fluid management and highlight several key steps in transitioning such a technology from bench to the bedside.
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Affiliation(s)
| | - Wassim M Haddad
- School of Aerospace Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - James M Bailey
- Northeast Georgia Medical Center, Gainesville, GA, United States
| | - William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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8
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Abstract
Sepsis is a heterogeneous disease state that is both common and consequential in critically ill patients. Unfortunately, the heterogeneity of sepsis at the individual patient level has hindered advances in the field beyond the current therapeutic standards, which consist of supportive care and antibiotics. This complexity has prompted attempts to develop a precision medicine approach, with research aimed towards stratifying patients into more homogeneous cohorts with shared biological features, potentially facilitating the identification of new therapies. Several investigators have successfully utilized leukocyte-derived mRNA and discovery-based approaches to subgroup patients on the basis of biological similarities defined by transcriptomic signatures. A critical next step is to develop a consensus sepsis subclassification system, which includes transcriptomic signatures as well as other biological and clinical data. This goal will require collaboration among various investigative groups, and validation in both existing data sets and prospective studies. Such studies are required to bring precision medicine to the bedside of critically ill patients with sepsis.
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9
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Feature Engineering for ICU Mortality Prediction Based on Hourly to Bi-Hourly Measurements. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9173525] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mortality prediction for intensive care unit (ICU) patients is a challenging problem that requires extracting discriminative and informative features. This study presents a proof of concept for exploring features that can provide clinical insight. Through a feature engineering approach, it is attempted to improve ICU mortality prediction in field conditions with low frequently measured data (i.e., hourly to bi-hourly). Features are explored by investigating the vital signs measurements of ICU patients, labelled with mortality or survival at discharge. The vital signs of interest in this study are heart and respiration rate, oxygen saturation and blood pressure. The latter comprises systolic, diastolic and mean arterial pressure. In the feature exploration process, it is aimed to extract simple and interpretable features that can provide clinical insight. For this purpose, a classifier is required that maximises the margin between the two classes (i.e., survival and mortality) with minimum tolerance to misclassification errors. Moreover, it preferably has to provide a linear decision surface in the original feature space without mapping to an unlimited dimensionality feature space. Therefore, a linear hard margin support vector machine (SVM) classifier is suggested. The extracted features are grouped in three categories: statistical, dynamic and physiological. Each category plays an important role in enhancing classification error performance. After extracting several features within the three categories, a manual feature fine-tuning is applied to consider only the most efficient features. The final classification, considering mortality as the positive class, resulted in an accuracy of 91.56 % , sensitivity of 90.59 % , precision of 86.52 % and F 1 -score of 88.50 % . The obtained results show that the proposed feature engineering approach and the extracted features are valid to be considered and further enhanced for the mortality prediction purpose. Moreover, the proposed feature engineering approach moved the modelling methodology from black-box modelling to grey-box modelling in combination with the powerful classifier of SVMs.
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10
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A computational analysis of dynamic, multi-organ inflammatory crosstalk induced by endotoxin in mice. PLoS Comput Biol 2018; 14:e1006582. [PMID: 30399158 PMCID: PMC6239343 DOI: 10.1371/journal.pcbi.1006582] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 11/16/2018] [Accepted: 10/15/2018] [Indexed: 12/13/2022] Open
Abstract
Bacterial lipopolysaccharide (LPS) induces an acute inflammatory response across multiple organs, primarily via Toll-like receptor 4 (TLR4). We sought to define novel aspects of the complex spatiotemporal dynamics of LPS-induced inflammation using computational modeling, with a special focus on the timing of pathological systemic spillover. An analysis of principal drivers of LPS-induced inflammation in the heart, gut, lung, liver, spleen, and kidney to assess organ-specific dynamics, as well as in the plasma (as an assessment of systemic spillover), was carried out using data on 20 protein-level inflammatory mediators measured over 0-48h in both C57BL/6 and TLR4-null mice. Using a suite of computational techniques, including a time-interval variant of Principal Component Analysis, we confirm key roles for cytokines such as tumor necrosis factor-α and interleukin-17A, define a temporal hierarchy of organ-localized inflammation, and infer the point at which organ-localized inflammation spills over systemically. Thus, by employing a systems biology approach, we obtain a novel perspective on the time- and organ-specific components in the propagation of acute systemic inflammation. Gram-negative bacterial lipopolysaccharide (LPS) is both a central mediator of sepsis and a canonical inducer of acute inflammation via Toll-like receptor 4 (TLR4). Sepsis involves the systemic spillover of inflammation that normally remains localized in individual organs. The goal of this study was to gain insights into 1) early vs. later drivers of LPS-induced inflammation in various compartments, and 2) the systemic spillover from affected organs vs. local production of inflammatory mediators in the blood. This study involved a large number of data points on the dynamics of inflammatory mediators at the protein level, data-driven computational modeling of principal characteristics and cross-correlations, and validation of key hypotheses. In addition to verifying key mechanisms in LPS/TLR4-driven acute inflammation, this approach yielded key insights into the progression of inflammation across tissues, and also suggested the presence of TLR4-independent pathways (especially in the gut). This is, to our knowledge, the first study examining the dynamic evolution of some key inflammatory mediators and their interactions with each other in both the systemic circulation and within a number of targeted parenchymal organs in mice.
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Lazaridis C, Rusin CG, Robertson CS. Secondary brain injury: Predicting and preventing insults. Neuropharmacology 2018; 145:145-152. [PMID: 29885419 DOI: 10.1016/j.neuropharm.2018.06.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/07/2018] [Accepted: 06/04/2018] [Indexed: 11/17/2022]
Abstract
Mortality or severe disability affects the majority of patients after severe traumatic brain injury (TBI). Adherence to the brain trauma foundation guidelines has overall improved outcomes; however, traditional as well as novel interventions towards intracranial hypertension and secondary brain injury have come under scrutiny after series of negative randomized controlled trials. In fact, it would not be unfair to say there has been no single major breakthrough in the management of severe TBI in the last two decades. One plausible hypothesis for the aforementioned failures is that by the time treatment is initiated for neuroprotection, or physiologic optimization, irreversible brain injury has already set in. We, and others, have recently developed predictive models based on machine learning from continuous time series of intracranial pressure and partial brain tissue oxygenation. These models provide accurate predictions of physiologic crises events in a timely fashion, offering the opportunity for an earlier application of targeted interventions. In this article, we review the rationale for prediction, discuss available predictive models with examples, and offer suggestions for their future prospective testing in conjunction with preventive clinical algorithms. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston, TX, United States; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States.
| | - Craig G Rusin
- Department of Pediatric Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Claudia S Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States.
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12
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Abstract
Multiply injured patients with severe extremity trauma are at risk of acute systemic complications and are at high risk of developing longer term orthopaedic complications including soft-tissue infection, osteomyelitis, posttraumatic osteoarthritis, and nonunion. It is becoming increasingly recognized that injury magnitude and response to injury have major jurisdiction pertaining to patient outcomes and complications. The complexities of injury and injury response that affect outcomes present opportunities to apply precision approaches to understand and quantify injury magnitude and injury response on a patient-specific basis. Here, we present novel approaches to measure injury magnitude by adopting methods that quantify both mechanical and ischemic tissue injury specific to each patient. We also present evolving computational approaches that have provided new insight into the complexities of inflammation and immunologic response to injury specific to each patient. These precision approaches are on the forefront of understanding how to stratify individualized injury and injury response in an effort to optimize titrated orthopaedic surgical interventions, which invariably involve most of the multiply injured patients. Finally, we present novel methods directed at mangled limbs with severe soft-tissue injury that comprise severely injured patients. Specifically, methods being developed to treat mangled limbs with volumetric muscle loss have the potential to improve limb outcomes and also mitigate uncompensated inflammation that occurs in these patients.
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13
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Vincent JL. The coming era of precision medicine for intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:314. [PMID: 29297399 PMCID: PMC5751549 DOI: 10.1186/s13054-017-1910-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Recent advances in technology and better understanding of mechanisms underlying disease are beginning to enable us to better characterize critically ill patients. Instead of using nonspecific syndromic groupings, such as sepsis or acute respiratory distress syndrome, we can now classify individual patients according to various specific characteristics, such as immune status. This "personalized" medicine approach will enable us to distinguish patients who have similar clinical presentations but different cellular and molecular responses that will influence their need for and responses (both negative and positive) to specific treatments. Treatments will be able to be chosen more accurately for each patient, resulting in more rapid institution of appropriate, effective therapy. We will also increasingly be able to conduct trials in groups of patients specifically selected as being most likely to respond to the intervention in question. This has already begun with, for example, some new interventions being tested only in patients with coagulopathy or immunosuppressive patterns. Ultimately, as we embrace this era of precision medicine, we may be able to offer precision therapies specifically designed to target the molecular set-up of an individual patient, as has begun to be done in cancer therapeutics.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, route de Lennik 808, 1070, Bruxelles, Belgium.
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15
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Constantine G, Buliga M, Mi Q, Constantine F, Abboud A, Zamora R, Puccio A, Okonkwo D, Vodovotz Y. Dynamic Profiling: Modeling the Dynamics of Inflammation and Predicting Outcomes in Traumatic Brain Injury Patients. Front Pharmacol 2016; 7:383. [PMID: 27847476 PMCID: PMC5088435 DOI: 10.3389/fphar.2016.00383] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 10/03/2016] [Indexed: 11/13/2022] Open
Abstract
Inflammation induced by traumatic brain injury (TBI) is complex, individual-specific, and associated with morbidity and mortality. We sought to develop dynamic, data-driven, predictive computational models of TBI-induced inflammation based on cerebrospinal fluid (CSF) biomarkers. Thirteen inflammatory mediators were determined in serial CSF samples from 27 severe TBI patients. The Glasgow Coma Scale (GCS) score quantifies the initial severity of the neurological status of the patient on a numerical scale from 3 to 15. The 6-month Glasgow Outcome Scale (GOS) score, the outcome variable, was taken as the variable to express and predict as a function of the other input variables. Data on each subject consisting of ten clinical (one-dimensional) variables, such as age, gender, and presence of infection, along with inflammatory biomarker time series were used to generate both multinomial logistic as well as probit models that predict low (poor outcome) or high (favorable outcome) levels of the GOS score. To determine if CSF inflammation biomarkers could predict TBI outcome, a logistic model for low (≤3; poor neurological outcome) or high levels (≥4; favorable neurological outcome) of the GOS score involving a full effect of the pro-inflammatory cytokine tumor necrosis factor-α and both linear and quadratic effects of the anti-inflammatory cytokine interleukin-10 was obtained. To better stratify patients as their pathology progresses over time, a technique called “Dynamic Profiling” was developed in which patients were clustered, using the spectral Laplacian and Hartigan’s k-means method, into disjoint groups at different stages. Initial clustering was based on GCS score; subsequent clustering was performed based on clinical and demographic information and then further, sequential clustering based on the levels of individual inflammatory mediators over time. These clusters assess the risk of mortality of a new patient after each inflammatory mediator reading, based on the existing information in the previous data in the cluster to which the new patient belongs at the time, in essence acting as a “virtual clinician.” Using the Dynamic Profiling method, we show examples that suggest that severe TBI patient neurological outcomes could be predicted as a function of time post-TBI using CSF inflammatory mediators.
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Affiliation(s)
- Gregory Constantine
- Department of Mathematics and Department of Statistics, University of PittsburghPittsburgh, PA, USA; Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of PittsburghPittsburgh, PA, USA
| | - Marius Buliga
- Department of Mathematics, University of Pittsburgh Bradford, PA, USA
| | - Qi Mi
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of PittsburghPittsburgh, PA, USA; Department of Sports Medicine and Nutrition, University of PittsburghPittsburgh, PA, USA
| | - Florica Constantine
- Department of Applied Mathematics and Statistics, Johns Hopkins University Baltimore, MD, USA
| | - Andrew Abboud
- Department of Surgery, University of Pittsburgh Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh Pittsburgh, PA, USA
| | - Ava Puccio
- Department of Neurological Surgery, University of Pittsburgh Pittsburgh, PA USA
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Pittsburgh, PA USA
| | - Yoram Vodovotz
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of PittsburghPittsburgh, PA, USA; Department of Surgery, University of PittsburghPittsburgh, PA, USA
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Brossier D, Sauthier M, Alacoque X, Masse B, Eltaani R, Guillois B, Jouvet P. Perpetual and Virtual Patients for Cardiorespiratory Physiological Studies. J Pediatr Intensive Care 2016; 5:122-128. [PMID: 31110896 PMCID: PMC6512414 DOI: 10.1055/s-0035-1569998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 10/08/2015] [Indexed: 12/11/2022] Open
Abstract
As a result of innovations in informatics over the last decades, physiologic models elaborated in the second half of the 20th century could be transformed into specific virtual patients called computational models. These models, developed initially for teaching purposes, are of great potential interest in responding to current concerns about improving patient care and safety. However, even if there are obvious advantages to using computational models in cardiorespiratory management, major concerns persist as to their reliability and their ability to recreate real patient physiologic evolution over time. Once developed, these models require complex validation and configuration phases prior to implementation in daily practice. This article focuses on the development of computational models, and reviews the methodologies to clinically validate the models including specific patient databases (perpetual patients) and the use in clinical practice including very high fidelity simulation.
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Affiliation(s)
- David Brossier
- Pediatric Intensive Care Unit, Sainte Justine University Health Centre, Montreal, Quebec, Canada
- Sainte-Justine UHC Research Institute, Sainte Justine University Hospital, Montreal, Canada
| | - Michael Sauthier
- Pediatric Intensive Care Unit, Sainte Justine University Health Centre, Montreal, Quebec, Canada
- Sainte-Justine UHC Research Institute, Sainte Justine University Hospital, Montreal, Canada
| | - Xavier Alacoque
- Department of Anesthesia, Perioperative and Intensive Care, University Hospital of Toulouse, Toulouse, France
- Department of Research, INSERM-Paul Sabattier University, Toulouse, France
| | - Benoit Masse
- Sainte-Justine UHC Research Institute, Sainte Justine University Hospital, Montreal, Canada
| | - Redha Eltaani
- Sainte-Justine UHC Research Institute, Sainte Justine University Hospital, Montreal, Canada
| | - Bernard Guillois
- Department of Neonatology, University Hospital of Caen, Caen, France
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, Sainte Justine University Health Centre, Montreal, Quebec, Canada
- Sainte-Justine UHC Research Institute, Sainte Justine University Hospital, Montreal, Canada
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Almahmoud K, Namas RA, Zaaqoq AM, Abdul-Malak O, Namas R, Zamora R, Sperry J, Billiar TR, Vodovotz Y. Prehospital Hypotension Is Associated With Altered Inflammation Dynamics and Worse Outcomes Following Blunt Trauma in Humans*. Crit Care Med 2015; 43:1395-404. [DOI: 10.1097/ccm.0000000000000964] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Thompson J, Coats T, Sims M. Known knowns, known unknowns, and unknown unknowns: can systems medicine provide a new approach to sepsis? Br J Anaesth 2015; 114:874-7. [DOI: 10.1093/bja/aev097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Network Analysis Identifies Crosstalk Interactions Governing TGF-β Signaling Dynamics during Endoderm Differentiation of Human Embryonic Stem Cells. Processes (Basel) 2015. [DOI: 10.3390/pr3020286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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In vivo and systems biology studies implicate IL-18 as a central mediator in chronic pain. J Neuroimmunol 2015; 283:43-9. [PMID: 26004155 DOI: 10.1016/j.jneuroim.2015.04.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 04/14/2015] [Accepted: 04/23/2015] [Indexed: 12/18/2022]
Abstract
Inflammation is associated with peripheral neuropathy, however the interplay among cytokines, chemokines, and neurons is still unclear. We hypothesized that this neuroinflammatory interaction can be defined by computational modeling based on the dynamics of protein expression in the sciatic nerve of rats subjected to chronic constriction injury. Using Dynamic Bayesian Network inference, we identified interleukin (IL)-18 as a central node associated with neuropathic pain in this animal model. Immunofluorescence supported a role for inflammasome activation and induction of IL-18 at the site of injury. Combined in vivo and in silico approaches may thus highlight novel targets in peripheral neuropathy.
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Human Brain Networks: Spiking Neuron Models, Multistability, Synchronization, Thermodynamics, Maximum Entropy Production, and Anesthetic Cascade Mechanisms. ENTROPY 2014. [DOI: 10.3390/e16073939] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Buchman TG. From data patterns to biological mechanism in critical illness: the role of engineering. J Crit Care 2014; 29:668. [PMID: 24930364 DOI: 10.1016/j.jcrc.2014.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 11/24/2022]
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