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Candidate Biomarkers for the Detection of Serious Infections in Children: A Prospective Clinical Study. CHILDREN 2022; 9:children9050682. [PMID: 35626858 PMCID: PMC9139697 DOI: 10.3390/children9050682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022]
Abstract
Serious bacterial infections (SBI) in children are associated with considerable morbidity and mortality, and their early identification remains challenging. The role of laboratory tests in this setting is still debated, and new biomarkers are needed. This prospective, observational, single-center study aims to evaluate the diagnostic role of blood biomarkers in detecting SBI in children presenting with signs of systemic inflammatory response syndrome (SIRS). A panel of biomarkers was performed, including C-reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBC), absolute neutrophil count (ANC), interleukin (IL)-6, IL-8, IL-10, human terminal complement complex (C5b-9), Plasmalemma-Vesicle-associated protein 1 (PV-1), Intercellular Adhesion Molecule-1 (ICAM-1), and Phospholipase A2 (PLA2). Among 103 patients (median age 2.9 years, 60% males), 39 had a diagnosis of SBI (38%). Significant predictors of SBI were CRP (p = 0.001) and ICAM-1 (p = 0.043). WBC (p = 0.035), ANC (p = 0.012) and ANC/WBC ratio (p = 0.015) were also significantly associated with SBI in children without pre-existing neutropenia. ROC curves, however, revealed suboptimal performance for all variables. Nevertheless, a model that combined CRP and ANC/WBC ratio had more in-depth diagnostic accuracy than either of the two variables. Overall, this study confirms the limited usefulness of blood biomarkers for the early diagnosis of SBI. WBC, ANC, ANC/WBC ratio, CRP, and ICAM-1 showed the best, albeit moderate, diagnostic accuracy.
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Abstract
OBJECTIVE Immune dysregulation is a defining feature of sepsis, but the role for mitochondria in the development of immunoparalysis in pediatric sepsis is not known. We sought to determine if mitochondrial dysfunction measured in peripheral blood mononuclear cells (PBMCs) is associated with immunoparalysis and systemic inflammation in children with sepsis. DESIGN Prospective observational study. SETTING Single-academic pediatric intensive care unit (PICU). PATIENTS One hundred sixty-one children with sepsis/septic shock and 18 noninfected PICU controls. MEASUREMENTS AND MAIN RESULTS Mitochondrial respiration in PBMCs, markers of immune function, and plasma cytokines were measured on days 1 to 2 (T1), 3 to 5 (T2), and 8 to 14 (T3) after sepsis recognition, and once for controls. Immunoparalysis was defined as whole-blood ex vivo lipopolysaccharide-induced tumor necrosis factor-alpha (TNF-α) ≤200 pg/mL or monocyte human leukocyte antigen-DR ≤30%. Mitochondrial respiration was lower in children with versus without immunoparalysis measured at the same timepoint. Mitochondrial respiration measured early (at T1 and T2) was also lower in those with immunoparalysis at T2 and T3, respectively. Although most patients with immunoparalysis exhibited low mitochondrial respiration, this metabolic finding was not specific to the immunoparalysis phenotype. Plasma cytokines, including IL-8, IL-10, TNF-α, and MCP-1, were highest in the subset of sepsis patients with immune paralysis or low mitochondrial respiration at T1. CONCLUSIONS Children with sepsis had lower PBMC mitochondrial respiration when immunoparalysis was present compared with those without immunoparalysis. The subsets with immune paralysis and low mitochondrial respiration exhibited the highest levels of systemic inflammation.
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Bline KE, Moore-Clingenpeel M, Hensley J, Steele L, Greathouse K, Anglim L, Hanson-Huber L, Nateri J, Muszynski JA, Ramilo O, Hall MW. Hydrocortisone treatment is associated with a longer duration of MODS in pediatric patients with severe sepsis and immunoparalysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:545. [PMID: 32887651 PMCID: PMC7650515 DOI: 10.1186/s13054-020-03266-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022]
Abstract
Background Severe critical illness-induced immune suppression, termed immunoparalysis, is associated with longer duration of organ dysfunction in septic children. mRNA studies have suggested differential benefit of hydrocortisone in septic children based on their immune phenotype, but this has not been shown using a functional readout of the immune response. This study represents a secondary analysis of a prospectively conducted immunophenotyping study of pediatric severe sepsis to test the hypothesis that hydrocortisone will be differentially associated with clinical outcomes in children with or without immunoparalysis. Methods Children with severe sepsis/septic shock underwent blood sampling within 48 h of sepsis onset. Immune function was measured by quantifying whole blood ex vivo LPS-induced TNFα production capacity, with a TNFα response < 200 pg/ml being diagnostic of immunoparalysis. The primary outcome measure was number of days in 14 with MODS. Univariate and multivariable negative binomial regression models were used to examine associations between hydrocortisone use, immune function, and duration of MODS. Results One hundred two children were enrolled (age 75 [6–160] months, 60% male). Thirty-one subjects received hydrocortisone and were more likely to be older (106 [52–184] vs 38 [3–153] months, p = 0.04), to have baseline immunocompromise (32 vs 8%, p = 0.006), to have higher PRISM III (13 [8–18] vs 7 [5–13], p = 0.0003) and vasoactive inotrope scores (20 [10–35] vs 10 [3–15], p = 0.0002) scores, and to have more MODS days (3 [1–9] vs 1 [0–3], p = 0.002). Thirty-three subjects had immunoparalysis (TNFα response 78 [52–141] vs 641 [418–1047] pg/ml, p < 0.0001). Hydrocortisone use was associated with longer duration of MODS in children with immunoparalysis after adjusting for covariables (aRR 3.7 [1.8–7.9], p = 0.0006) whereas no association with MODS duration was seen in children without immunoparalysis (aRR 1.2 [0.6–2.3], p = 0.67). Conclusion Hydrocortisone use was independently associated with longer duration of MODS in septic children with immunoparalysis but not in those with more robust immune function. Prospective clinical trials using a priori immunophenotyping are needed to understand optimal hydrocortisone strategies in this population.
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Affiliation(s)
- Katherine E Bline
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Melissa Moore-Clingenpeel
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH, USA
| | - Josey Hensley
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Lisa Steele
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kristin Greathouse
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Larissa Anglim
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Lisa Hanson-Huber
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Jyotsna Nateri
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer A Muszynski
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Octavio Ramilo
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mark W Hall
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Critical Care Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
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Cowell TW, Valera E, Jankelow A, Park J, Schrader AW, Ding R, Berger J, Bashir R, Han HS. Rapid, multiplexed detection of biomolecules using electrically distinct hydrogel beads. LAB ON A CHIP 2020; 20:2274-2283. [PMID: 32490455 PMCID: PMC10409638 DOI: 10.1039/d0lc00243g] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Rapid, low-cost, and multiplexed biomolecule detection is an important goal in the development of effective molecular diagnostics. Our recent work has demonstrated a microfluidic biochip device that can electrically quantitate a protein target with high sensitivity. This platform detects and quantifies a target analyte by counting and capturing micron-sized beads in response to an immunoassay on the bead surface. Existing microparticles limit the technique to the detection of a single protein target and lack the magnetic properties required for separation of the microparticles for direct measurements from whole blood. Here, we report new precisely engineered microparticles that achieve electrical multiplexing and adapt this platform for low-cost and label-free multiplexed electrical detection of biomolecules. Droplet microfluidic synthesis yielded highly-monodisperse populations of magnetic hydrogel beads (MHBs) with the necessary properties for multiplexing the electrical Coulter counting on chip. Each bead population was designed to contain a different amount of the hydrogel material, resulting in a unique electrical impedance signature during Coulter counting, thereby enabling unique identification of each bead. These monodisperse bead populations span a narrow range of sizes ensuring that all can be captured sensitively and selectively under simultaneously flow. Incorporating these newly synthesized beads, we demonstrate versatile and multiplexed biomolecule detection of proteins or DNA targets. This development of multiplexed beads for the electrical detection of biomolecules, provides a critical advancement towards multiplexing the Coulter counting approach and the development of a low cost point-of-care diagnostic sensor.
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Affiliation(s)
- Thomas W Cowell
- Department of Chemistry, University of Illinois at Urbana-Champaign, 505 South Mathews Ave., Urbana, Illinois 61801, USA.
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Angurana SK, Bansal A, Muralidharan J, Aggarwal R, Singhi S. Cytokine Levels in Critically Ill Children With Severe Sepsis and Their Relation With the Severity of Illness and Mortality. J Intensive Care Med 2020; 36:576-583. [PMID: 32207354 DOI: 10.1177/0885066620912989] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To study the baseline cytokine levels and their relation with the severity of illness and mortality in critically ill children with severe sepsis. DESIGN Subgroup analysis of a randomized, double-blind, placebo-controlled trial. SETTING Pediatric intensive care unit of a tertiary level teaching hospital in India. PATIENTS Fifty children with severe sepsis aged 3 months to 12 years. MATERIAL AND METHODS Blood was collected at admission for estimation of pro-inflammatory (interleukin 6 [IL-6], IL-12p70, IL-17, and tumor necrotic factor α [TNF-α]) and anti-inflammatory (IL-10 and transforming growth factor β1 [TGF-β1]) cytokines. PRIMARY OUTCOME To find out correlation between cytokine levels and severity of illness scores (Pediatric Risk of Mortality [PRISM] III score, Sequential Organ Failure Assessment [SOFA], and Vasoactive-Inotropic Score [VIS]). SECONDARY OUTCOMES To compare cytokine levels among survivors and nonsurvivors. RESULTS Baseline pro-inflammatory cytokine levels (median [interquartile range]) were IL-6: 189 (35-285) pg/mL, IL-12p: 48 (28-98) pg/mL, IL-17: 240 (133-345) pg/mL, and TNF-α: 296 (198-430) pg/mL; anti-inflammatory cytokine levels were IL-10: 185 (62-395) pg/mL and TGF-β1: 204 (92-290) ng/mL. Pro-inflammatory cytokines showed positive correlation with PRISM III score: IL-6 (Spearman correlation coefficient, ρ = 0.273, P = .06), IL-12 (ρ = 0.367, P = .01), IL-17 (ρ = 0.197, P = .17), and TNF-α (ρ = 0.284, P = .05), and anti-inflammatory cytokines showed negative correlation: IL-10 (ρ = -0.257, P = .09) and TGF-β (ρ = -0.238, P = .11). Both SOFA and VIS also showed weak positive correlation with IL-12 (ρ = 0.32, P = .03 and ρ = 0.31, P = .03, respectively). Among nonsurvivors (n = 5), the levels of all the measured pro-inflammatory cytokines were significantly higher as compared to survivors, IL-6: 359 (251-499) pg/mL versus 157 (97-223) pg/mL, P < .0001, IL-12p70: 167 (133-196) pg/mL versus 66 (30-100) pg/mL, P < .0001, IL-17: 400 (333-563) pg/mL versus 237 (122-318) pg/mL, P = .009, and TNF-α: 409 (355-503) pg/mL versus 330 (198-415) pg/mL, P = .002, respectively. CONCLUSION In critically ill children with severe sepsis, pro-inflammatory cytokines (especially IL-12p70) showed a weak positive correlation with severity of illness and were significantly higher among nonsurvivors.
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Affiliation(s)
- Suresh Kumar Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritu Aggarwal
- Department of Immunopathology, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sunit Singhi
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.,Department of Pediatrics, Medanta, The Medicity, Gurugram, India
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Carlton EF, McHugh WM, McDonough K, Sturza J, Desch K, Cornell TT. Markers of Endothelial Dysfunction and Cytokines in High-Risk Pediatric Patients with Severe Sepsis. Am J Respir Crit Care Med 2020; 201:380-384. [PMID: 31597044 PMCID: PMC6999097 DOI: 10.1164/rccm.201904-0910le] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Erin F. Carlton
- University of Michigan School of MedicineAnn Arbor, Michiganand
| | - Walker M. McHugh
- University of Michigan School of MedicineAnn Arbor, Michiganand
- PreDxion Bio, Inc.South San Francisco, California
| | - Kelli McDonough
- University of Michigan School of MedicineAnn Arbor, Michiganand
| | - Julie Sturza
- University of Michigan School of MedicineAnn Arbor, Michiganand
| | - Karl Desch
- University of Michigan School of MedicineAnn Arbor, Michiganand
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Carlton EF, Flori HR. Biomarkers in pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:505. [PMID: 31728358 DOI: 10.21037/atm.2019.09.29] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Pediatric acute respiratory distress syndrome (PARDS) is a heterogenous process resulting in a severe acute lung injury. A single indicator does not exist for PARDS diagnosis. Rather, current diagnosis requires a combination of clinical and physiologic variables. Similarly, there is little ability to predict the path of disease, identify those at high risk of poor outcomes or target therapies specific to the underlying pathophysiology. Biomarkers, a measured indicator of a pathologic state or response to intervention, have been studied in PARDS due to their potential in diagnosis, prognostication and measurement of therapeutic response. Additionally, PARDS biomarkers show great promise in furthering our understanding of specific subgroups or endotypes in this highly variable disease, and thereby predict which patients may benefit and which may be harmed by PARDS specific therapies. In this chapter, we review the what, when, why and how of biomarkers in PARDS and discuss future directions in this quickly changing landscape.
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Affiliation(s)
- Erin F Carlton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
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Tan B, Wong JJM, Sultana R, Koh JCJW, Jit M, Mok YH, Lee JH. Global Case-Fatality Rates in Pediatric Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis. JAMA Pediatr 2019; 173:352-362. [PMID: 30742207 PMCID: PMC6450287 DOI: 10.1001/jamapediatrics.2018.4839] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The global patterns and distribution of case-fatality rates (CFRs) in pediatric severe sepsis and septic shock remain poorly described. OBJECTIVE We performed a systematic review and meta-analysis of studies of children with severe sepsis and septic shock to elucidate the patterns of CFRs in developing and developed countries over time. We also described factors associated with CFRs. DATA SOURCES We searched PubMed, Web of Science, Excerpta Medica database, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central systematically for randomized clinical trials and prospective observational studies from earliest publication until January 2017, using the keywords "pediatric," "sepsis," "septic shock," and "mortality." STUDY SELECTION Studies involving children with severe sepsis and septic shock that reported CFRs were included. Retrospective studies and studies including only neonates were excluded. DATA EXTRACTION AND SYNTHESIS We conducted our systematic review and meta-analysis in close accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled case-fatality estimates were obtained using random-effects meta-analysis. The associations of study period, study design, sepsis severity, age, and continents in which studies occurred were assessed with meta-regression. MAIN OUTCOMES AND MEASURES Meta-analyses to provide pooled estimates of CFR of pediatric severe sepsis and septic shock over time. RESULTS Ninety-four studies that included 7561 patients were included. Pooled CFRs were higher in developing countries (31.7% [95% CI, 27.3%-36.4%]) than in developed countries (19.3% [95% CI, 16.4%-22.7%]; P < .001). Meta-analysis of CFRs also showed significant heterogeneity across studies. Continents that include mainly developing countries reported higher CFRs (adjusted odds ratios: Africa, 7.89 [95% CI, 6.02-10.32]; P < .001; Asia, 3.81 [95% CI, 3.60-4.03]; P < .001; South America, 2.91 [95% CI, 2.71-3.12]; P < .001) than North America. Septic shock was associated with higher CFRs than severe sepsis (adjusted odds ratios, 1.47 [95% CI, 1.41-1.54]). Younger age was also a risk factor (adjusted odds ratio, 0.95 [95% CI, 0.94-0.96] per year of increase in age). Earlier study eras were associated with higher CFRs (adjusted odds ratios for 1991-2000, 1.24 [95% CI, 1.13-1.37]; P < .001) compared with 2011 to 2016. Time-trend analysis showed higher CFRs over time in developing countries than developed countries. CONCLUSIONS AND RELEVANCE Despite the declining trend of pediatric severe sepsis and septic shock CFRs, the disparity between developing and developed countries persists. Further characterizations of vulnerable populations and collaborations between developed and developing countries are warranted to reduce the burden of pediatric sepsis globally.
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Affiliation(s)
| | - Judith Ju-Ming Wong
- Children’s Intensive Care Unit, KK Women’s
and Children’s Hospital, Singapore
| | | | | | - Mark Jit
- London School of Hygiene and Tropical Medicine,
London, United Kingdom
| | - Yee Hui Mok
- Children’s Intensive Care Unit, KK Women’s
and Children’s Hospital, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore,Children’s Intensive Care Unit, KK Women’s
and Children’s Hospital, Singapore
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Abstract
OBJECTIVES Subclassification based on clinical or biologic commonalities (endotypes) is one approach to reduce heterogeneity in acute hypoxemic respiratory failure. In adults, biomarker-defined endotypes of respiratory failure have been described, with differential outcome profiles and response to therapy. To date, no studies have tested whether endotypes exist in pediatric acute hypoxemic respiratory failure, although messenger RNA expression-based endotypes have been described in pediatric sepsis. The aim of the present study was to test whether endotypes identified in pediatric sepsis are applicable to pediatric acute hypoxemic respiratory failure. DESIGN Secondary analysis of a previously reported microarray-based study of pediatric sepsis. SETTING Multiple PICUs in the United States. PATIENTS Sixty-seven children with acute hypoxemic respiratory failure caused by sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the larger septic shock cohort, 67 met eligibility for acute hypoxemic respiratory failure. Twenty-three subjects were assigned to endotype A, and 44 to endotype B. Subjects assigned to endotype A had over four-fold greater unadjusted 28-day mortality, and nearly three-fold greater rates of complicated course. The association with mortality (odds ratio, 8.0; 95% CI, 1.6-41.0) and complicated course (odds ratio, 4.2; 95% CI, 1.2-14.9) persisted after adjustment for age, severity of illness, and PaO2/FIO2. CONCLUSIONS Applying a previously reported endotyping strategy in children with septic shock identified endotypes of pediatric acute hypoxemic respiratory failure secondary to sepsis, with differential risk for poor outcomes. To our knowledge, this is the first demonstration of endotypes in pediatric respiratory failure. Our results support an investigation into using transcriptomics to identify messenger RNA-based endotypes in a dedicated, well-defined acute hypoxemic respiratory failure cohort.
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10
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The Pediatric Sepsis Biomarker Risk Model (PERSEVERE) Biomarkers Predict Clinical Deterioration and Mortality in Immunocompromised Children Evaluated for Infection. Sci Rep 2019; 9:424. [PMID: 30675002 PMCID: PMC6344559 DOI: 10.1038/s41598-018-36743-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/13/2018] [Indexed: 01/08/2023] Open
Abstract
Pediatric sepsis and bacterial infection cause significant morbidity and mortality worldwide, with immunocompromised patients being at particularly high risk of rapid deterioration and death. This study evaluated if PERSEVERE, PERSEVERE-II, or the PERSEVERE biomarkers, can reliably estimate the risk of clinical deterioration and 28-day mortality among immunocompromised pediatric patients. This is a single-center prospective cohort study conducted from July 2016 through September 2017 incorporating 400 episodes of suspected bacterial infection from the inpatient units at Cincinnati Children’s Hospital Medical Center, a large, tertiary care children’s hospital. The primary analysis assessed clinical deterioration within 72 hours of evaluation for infection. Secondarily, we assessed 28-day mortality. Clinical deterioration was seen in 15% of subjects. Twenty-eight day mortality was 5%, but significantly higher among critically ill patients. Neither PERSEVERE nor PERSEVERE-II performed well to predict clinical deterioration or 28-day mortality, thus we derived new stratification models using the PERSEVERE biomarkers with both high sensitivity and negative predictive value. In conclusion, we evaluated previously validated biomarker risk models in a novel population of largely non-critically ill immunocompromised pediatric patients, and attempted to stratify patients based on a new outcome metric, clinical deterioration. The new highly predictive models indicate common physiologic pathways to clinical deterioration or death from bacterial infection.
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11
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Abstract
Sepsis-related biomarkers have a variety of potential applications. The most well-known application is to differentiate patients with signs of systemic inflammation caused by infection, from those with systemic inflammation due to a non-infectious cause. This application is important for timely and judicious prescription of antibiotics. Apart from diagnostic applications, biomarkers can also be used to identify patients with sepsis who are at risk for poor outcome and to subgroup patients with sepsis based on biological commonalities. The latter two applications embody the concepts of prognostic and predictive enrichment, which are fundamental to precision medicine. This review will elaborate on these concepts, provide relevant examples, and discuss important considerations in the process of biomarkers discovery and development.
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Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States
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12
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Hypofibrinogenemia Is Associated With Poor Outcome and Secondary Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome in Pediatric Severe Sepsis. Pediatr Crit Care Med 2018; 19:397-405. [PMID: 29470247 PMCID: PMC9630256 DOI: 10.1097/pcc.0000000000001507] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Some children with sepsis exhibit a sustained hyperinflammatory response that can trigger secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. Although hypofibrinogenemia is a shared feature of sepsis and hemophagocytic lymphohistiocytosis, there are no data about fibrinogen as a biomarker to identify children with sepsis/secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome overlap. We hypothesized that hypofibrinogenemia is associated with poor outcomes and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome and has utility as a screening biomarker for this sepsis phenotype. DESIGN A retrospective cohort study of patients less than or equal to 21 years treated for severe sepsis from January 2012 to December 2014. SETTING Emergency department and PICU at a single academic children's hospital. PATIENTS Consecutive patients with greater than or equal to one episode of hypofibrinogenemia (serum fibrinogen < 150 mg/dL) within 7 days of sepsis were compared with a random sample of patients without hypofibrinogenemia using an a priori sample size target of 190. Thirty-eight patients with hypofibrinogenemia were compared with 154 without hypofibrinogenemia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was "complicated course" (composite of 28-d mortality or ≥ two organ failures at 7 d). Secondary outcomes were 28-day mortality and fulfillment of diagnostic criteria for secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. We used Wilcoxon rank-sum, Fisher exact test, and multivariable logistic regression to compare patients with versus without hypofibrinogenemia. Patients with hypofibrinogenemia were more likely to have a complicated course (73.7% vs 29.2%; p < 0.001), 28-day mortality (26.3% vs 7.1%, p = 0.002), and meet diagnostic criteria for secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome (21.1% vs 1.3%; p < 0.001). After controlling for confounders, hypofibrinogenemia remained associated with complicated course (adjusted odds ratio, 8.8; 95% CI, 3.5-22.4), mortality (adjusted odds ratio, 6.0; 95% CI, 2.0-18.1), and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome (adjusted odds ratio, 27.6; 95% CI, 4.4-173). CONCLUSIONS Hypofibrinogenemia was independently associated with poor outcome and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome in pediatric sepsis. Measurement of fibrinogen may provide a pragmatic biomarker to identify children with possible sepsis/secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome overlap for whom further diagnostic testing and consideration of adjunctive immunomodulatory therapies should be considered.
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13
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Sinha M, Jupe J, Mack H, Coleman TP, Lawrence SM, Fraley SI. Emerging Technologies for Molecular Diagnosis of Sepsis. Clin Microbiol Rev 2018; 31:e00089-17. [PMID: 29490932 PMCID: PMC5967692 DOI: 10.1128/cmr.00089-17] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Rapid and accurate profiling of infection-causing pathogens remains a significant challenge in modern health care. Despite advances in molecular diagnostic techniques, blood culture analysis remains the gold standard for diagnosing sepsis. However, this method is too slow and cumbersome to significantly influence the initial management of patients. The swift initiation of precise and targeted antibiotic therapies depends on the ability of a sepsis diagnostic test to capture clinically relevant organisms along with antimicrobial resistance within 1 to 3 h. The administration of appropriate, narrow-spectrum antibiotics demands that such a test be extremely sensitive with a high negative predictive value. In addition, it should utilize small sample volumes and detect polymicrobial infections and contaminants. All of this must be accomplished with a platform that is easily integrated into the clinical workflow. In this review, we outline the limitations of routine blood culture testing and discuss how emerging sepsis technologies are converging on the characteristics of the ideal sepsis diagnostic test. We include seven molecular technologies that have been validated on clinical blood specimens or mock samples using human blood. In addition, we discuss advances in machine learning technologies that use electronic medical record data to provide contextual evaluation support for clinical decision-making.
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Affiliation(s)
- Mridu Sinha
- Bioengineering Department, University of California, San Diego, San Diego, California, USA
| | - Julietta Jupe
- Donald Danforth Plant Science Center, Saint Louis, Missouri, USA
| | - Hannah Mack
- Bioengineering Department, University of California, San Diego, San Diego, California, USA
| | - Todd P Coleman
- Bioengineering Department, University of California, San Diego, San Diego, California, USA
- Center for Microbiome Innovation, University of California, San Diego, San Diego, California, USA
| | - Shelley M Lawrence
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of California, San Diego, San Diego, California, USA
- Rady Children's Hospital of San Diego, San Diego, California, USA
- Clinical Translational Research Institute, University of California, San Diego, San Diego, California, USA
- Center for Microbiome Innovation, University of California, San Diego, San Diego, California, USA
| | - Stephanie I Fraley
- Bioengineering Department, University of California, San Diego, San Diego, California, USA
- Clinical Translational Research Institute, University of California, San Diego, San Diego, California, USA
- Center for Microbiome Innovation, University of California, San Diego, San Diego, California, USA
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14
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Lebet RM, Asaro LA, Zuppa AF, Curley MAQ. Face and content validity of variables associated with the difficult-to-sedate child in the paediatric intensive care unit: A survey of paediatric critical care clinicians. Aust Crit Care 2018; 31:167-173. [PMID: 29567042 DOI: 10.1016/j.aucc.2017.12.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 12/12/2017] [Accepted: 12/28/2017] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Clinicians recognise that some critically ill children are difficult-to-sedate. It may be possible to identify this clinical phenotype for sedation response using statistical modelling techniques adopted from machine learning. This requires identification of a finite number of variables to include in the statistical model. OBJECTIVE To establish face and content validity for 17 candidate variables identified in the international literature as characteristic of the difficult-to-sedate child phenotype. METHODS Paediatric critical care clinicians rated the relevance of 17 variables characterising the difficult-to-sedate child using a four-point scale ranging from not (1) to highly relevant (4). Face and content validity of these variables were assessed by calculating a mean score for each item and computing an item-level content validity index. Items with a mean score >1 were rated as having adequate face validity. An item-level content validity index ≥0.70 indicated good to excellent content validity. SETTING AND PARTICIPANTS Web-based survey emailed to members of the Pediatric Acute Lung Injury and Sepsis Investigators Network or the Society of Critical Care Medicine Pediatric Sedation Study Group. RESULTS Of 411 possible respondents, 121 useable surveys were returned for a response rate of 29%. All items had a mean score >1, indicating adequate face validity. Ten of 17 items scored an item-level content validity index ≥0.70. The highest scoring items were requiring three or more sedation classes simultaneously, daily modal sedation score indicating agitation, sedation score indicating agitation for 2 consecutive hours, receiving sedatives at a dose >90th percentile of the usual starting dose, and receiving intermittent paralytic doses for sedation. CONCLUSIONS Computation of an item-level content validity index validated variables to include in statistical modelling of the difficult-to-sedate phenotype. The results indicate consensus among paediatric critical care clinicians that the majority of candidate variables identified through literature review are characteristic of the difficult-to-sedate child.
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Affiliation(s)
- Ruth M Lebet
- University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, USA; Department of Nursing Research and Evidence-based Practice, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Athena F Zuppa
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; The Children's Hospital of Philadelphia, Anesthesiology and Critical Care, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Martha A Q Curley
- University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, USA; Children's Hospital of Philadelphia Research Institute, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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15
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Shores DR, Everett AD. Children as Biomarker Orphans: Progress in the Field of Pediatric Biomarkers. J Pediatr 2018; 193:14-20.e31. [PMID: 29031860 PMCID: PMC5794519 DOI: 10.1016/j.jpeds.2017.08.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Darla R Shores
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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16
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Abstract
INTRODUCTION Selecting participants for research based on their risk is an enrichment strategy with potential for enhancing clinical trials in sepsis. Adult Septic Shock Information and Stratification (ASSIST) is a tool for estimating mortality risk that incorporates a panel of biomarkers, age, lactate, and chronic health status. We assessed the utility of ASSIST as an enrichment strategy in a clinical trial testing the efficacy of a polyclonal antitumor necrosis factor-α fragment antibody (AZD9773) in adults with severe sepsis or septic shock. We hypothesized that the effects of AZD9773 are dependent on baseline mortality risk, as estimated by ASSIST. METHODS This was a post hoc analysis of a recently completed trial of 300 subjects, randomized to placebo, low-dose AZD9773, or high-dose AZD9773. The study's primary endpoint was number of ventilator-free days. There were 286 subjects with available plasma samples from study entry. We measured the ASSIST biomarkers and assigned each subject to low, intermediate, and high-risk strata based on their ASSIST mortality probability. To mirror the study's original statistical plan, we estimated the least squares mean ventilator-free days for each study arm within risk strata. RESULTS The effect of study arm within ASSIST-based risk strata was significant (P = 0.017). Within the low-risk group, there was an increase in ventilator-free days for both drug arms. Within the intermediate-risk group, there was an increase in ventilator-free days among those in the low-dose arm, but a decrease in the high-dose arm. Among high-risk patients, there was a decrease of ventilator-free days in both drug arms. Analogous associations were observed when modeling 28-day mortality. CONCLUSIONS In this study, a beneficial effect of AZD9773 might have been observed if the trial selected low to intermediate-risk patients. ASSIST has the potential to serve as an enrichment tool for sepsis clinical trials.
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Affiliation(s)
- Hector R Wong
- *Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio †Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio ‡Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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17
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Combining Biomarkers with EMR Data to Identify Patients in Different Phases of Sepsis. Sci Rep 2017; 7:10800. [PMID: 28883645 PMCID: PMC5589821 DOI: 10.1038/s41598-017-09766-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023] Open
Abstract
Sepsis is a leading cause of death and is the most expensive condition to treat in U.S. hospitals. Despite targeted efforts to automate earlier detection of sepsis, current techniques rely exclusively on using either standard clinical data or novel biomarker measurements. In this study, we apply machine learning techniques to assess the predictive power of combining multiple biomarker measurements from a single blood sample with electronic medical record data (EMR) for the identification of patients in the early to peak phase of sepsis in a large community hospital setting. Combining biomarkers and EMR data achieved an area under the receiver operating characteristic (ROC) curve (AUC) of 0.81, while EMR data alone achieved an AUC of 0.75. Furthermore, a single measurement of six biomarkers (IL-6, nCD64, IL-1ra, PCT, MCP1, and G-CSF) yielded the same predictive power as collecting an additional 16 hours of EMR data(AUC of 0.80), suggesting that the biomarkers may be useful for identifying these patients earlier. Ultimately, supervised learning using a subset of biomarker and EMR data as features may be capable of identifying patients in the early to peak phase of sepsis in a diverse population and may provide a tool for more timely identification and intervention.
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18
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Wong HR, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald JC, Checchia PA, Meyer K, Quasney M, Hall M, Gedeit R, Freishtat RJ, Nowak J, Raj SS, Gertz S, Grunwell JR, Lindsell CJ. Improved Risk Stratification in Pediatric Septic Shock Using Both Protein and mRNA Biomarkers. PERSEVERE-XP. Am J Respir Crit Care Med 2017; 196:494-501. [PMID: 28324661 DOI: 10.1164/rccm.201701-0066oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
RATIONALE We previously derived and validated the Pediatric Sepsis Biomarker Risk Model (PERSEVERE) to estimate baseline mortality risk in children with septic shock. The PERSEVERE biomarkers are serum proteins selected from among the proteins directly related to 80 mortality risk assessment genes. The initial approach to selecting the PERSEVERE biomarkers left 68 genes unconsidered. OBJECTIVES To determine if the 68 previously unconsidered genes can improve upon the performance of PERSEVERE and to provide biological information regarding the pathophysiology of septic shock. METHODS We reduced the number of variables by determining the biological linkage of the 68 previously unconsidered genes. The genes identified through variable reduction were combined with the PERSEVERE-based mortality probability to derive a risk stratification model for 28-day mortality using classification and regression tree methodology (n = 307). The derived tree, PERSEVERE-XP, was then tested in a separate cohort (n = 77). MEASUREMENTS AND MAIN RESULTS Variable reduction revealed a network consisting of 18 mortality risk assessment genes related to tumor protein 53 (TP53). In the derivation cohort, PERSEVERE-XP had an area under the receiver operating characteristic curve (AUC) of 0.90 (95% confidence interval, 0.85-0.95) for differentiating between survivors and nonsurvivors. In the test cohort, the AUC was 0.96 (95% confidence interval, 0.91-1.0). The AUC of PERSEVERE-XP was superior to that of PERSEVERE. CONCLUSIONS PERSEVERE-XP combines protein and mRNA biomarkers to provide mortality risk stratification with possible clinical utility. PERSEVERE-XP significantly improves on PERSEVERE and suggests a role for TP53-related cellular division, repair, and metabolism in the pathophysiology of septic shock.
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Affiliation(s)
- Hector R Wong
- 1 Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio.,2 Department of Pediatrics and
| | | | - Nick Anas
- 4 Children's Hospital of Orange County, Orange, California
| | | | - Neal J Thomas
- 6 Penn State Children's Hospital, Hershey, Pennsylvania
| | | | - Scott L Weiss
- 8 The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Paul A Checchia
- 9 Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Keith Meyer
- 10 Miami Children's Hospital, Miami, Florida
| | - Michael Quasney
- 11 C. S. Mott Children's Hospital at the University of Michigan, Ann Arbor, Michigan
| | - Mark Hall
- 12 Nationwide Children's Hospital, Columbus, Ohio
| | - Rainer Gedeit
- 13 Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | - Jeffrey Nowak
- 15 Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Shekhar S Raj
- 16 Riley Hospital for Children, Indianapolis, Indiana
| | - Shira Gertz
- 17 Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey; and
| | | | - Christopher J Lindsell
- 19 Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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19
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Randolph AG. A Biosignature Predicting Complicated Course in Children Presenting with Septic Shock. Why PERSEVERE? Am J Respir Crit Care Med 2017; 196:411-413. [PMID: 28809515 DOI: 10.1164/rccm.201704-0759ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Adrienne G Randolph
- 1 Department of Anesthesiology, Perioperative and Pain Medicine Boston Children's Hospital Boston, Massachusetts.,2 Department of Anaesthesia and.,3 Department of Pediatrics Harvard Medical School Boston, Massachusetts
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20
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Abstract
Bacteremia and sepsis are conditions associated with high mortality and are of great impact to health care operations. Among the top causes of mortality in the United States, these conditions cause over 600 fatalities each day. Empiric, broad-spectrum treatment is a common but often a costly approach that may fail to effectively target the correct microbe, may inadvertently harm patients via antimicrobial toxicity or downstream antimicrobial resistance. To meet the diagnostic challenges of bacteremia and sepsis, laboratories must understand the complexity of diagnosing and treating septic patients, in order to focus on creating algorithms that can help direct a more targeted approach to antimicrobial therapy and synergize with existing clinical practices defined in new Surviving Sepsis Guidelines. Significant advances have been made in improving blood culture media; as yet no molecular or antigen-based method has proven superior for the detection of bacteremia in terms of limit of detection. Several methods for rapid molecular identification of pathogens from blood cultures bottles are available and many more are on the diagnostic horizon. Ultimately, early intervention by molecular detection of bacteria and fungi directly from whole blood could provide the most patient benefit and contribute to tailored antibiotic coverage of the patient early on in the course of the disease. Although blood cultures remain as the best means of diagnosing bacteremia and candidemia, complementary testing with antigen tests, microbiologic investigations from other body sites, and histopathology can often aid in the diagnosis of disseminated disease, and application of emerging nucleic acid test methods and other new technology may greatly impact our ability to bacteremic and septic patients, particularly those who are immunocompromised.
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21
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Pierce RW, Giuliano JS, Pober JS. Endothelial Cell Function and Dysfunction in Critically Ill Children. Pediatrics 2017; 140:peds.2017-0355. [PMID: 28759412 PMCID: PMC9923607 DOI: 10.1542/peds.2017-0355] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 11/24/2022] Open
Abstract
Endothelial cells (ECs) line the lumen of the entire vascular system and actively regulate blood flow; maintain blood fluidity; control water, solute, and macromolecular transfer between blood and tissue; and modulate circulating immune cell recruitment and activation. These vital functions, combined with the broad anatomic distribution of ECs, implicate them in all forms of critical illness. The present article discusses how ECs adapt and break down during the course of critical illness. We first review the biology of ECs, highlighting the vascular segmental differences and their specific roles in the maintenance of homeostasis. We then discuss how ECs acquire new functions to restore local and systemic homeostasis (activation) as well as how breakdowns in EC functions (dysfunction) contribute to local and systemic pathologic responses, with clinical correlations. Lastly, how these processes have been studied in critically ill children is discussed.
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Affiliation(s)
- Richard W. Pierce
- Departments of Pediatrics and,Address correspondence to Richard W. Pierce, MD, MS, Department of Pediatrics, Section of Critical Care Medicine, Yale University, 333 Cedar St, PO Box 208064, New Haven, CT 06520. E-mail:
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22
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Jacobs L, Wong HR. Emerging infection and sepsis biomarkers: will they change current therapies? Expert Rev Anti Infect Ther 2016; 14:929-41. [PMID: 27533847 PMCID: PMC5087989 DOI: 10.1080/14787210.2016.1222272] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/05/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sepsis is a heterogeneous syndrome characterized by both immune hyperactivity and relative immune suppression. Biomarkers have the potential to improve recognition and management of sepsis through three main applications: diagnosis, monitoring response to treatment, and stratifying patients based on prognosis or underlying biological response. AREAS COVERED This review focuses on specific examples of well-studied, evidence-supported biomarkers, and discusses their role in clinical practice with special attention to antibiotic stewardship and cost-effectiveness. Biomarkers were selected based on availability of robust prospective trials and meta-analyses which supported their role as emerging tools to improve the clinical management of sepsis. Expert commentary: Great strides have been made in candidate sepsis biomarker discovery and testing, with the biomarkers in this review showing promise. Yet sepsis remains a dynamic illness with a great degree of biological heterogeneity - heterogeneity which may be further resolved by recently discovered gene expression-based endotypes in septic shock.
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Affiliation(s)
- Lauren Jacobs
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati OH, 45229, , Tel: 513-636-4529, Fax: 513-636-4267
| | - Hector R Wong
- Professor of Pediatrics, Director, Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, (corresponding author), Tel: 513-636-4529, Fax: 513-636-4267
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23
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Abstract
OBJECTIVES In this review, we will discuss risk factors for developing sepsis; the role of biomarkers in establishing an early diagnosis, in monitoring therapeutic efficacy, in stratification, and for the identification of sepsis endotypes; and the pathophysiology and management of severe sepsis and septic shock, with an emphasis on the impact of sepsis on cardiovascular function. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS There is a lot of excitement in the field of sepsis research today. Scientific advances in the diagnosis and clinical staging of sepsis, as well as a personalized approach to the treatment of sepsis, offer tremendous promise for the future. However, at the same time, it is also evident that sepsis mortality has not improved enough, even with progress in our understanding of the molecular pathophysiology of sepsis.
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24
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HU L, ZHU Y, CHEN M, LI X, LU X, LIANG Y, TAN H. Development and Validation of a Disease Severity Scoring Model for Pediatric Sepsis. IRANIAN JOURNAL OF PUBLIC HEALTH 2016; 45:875-84. [PMID: 27516993 PMCID: PMC4980341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multiple severity scoring systems have been devised and evaluated in adult sepsis, but a simplified scoring model for pediatric sepsis has not yet been developed. This study aimed to develop and validate a new scoring model to stratify the severity of pediatric sepsis, thus assisting the treatment of sepsis in children. METHODS Data from 634 consecutive patients who presented with sepsis at Children's hospital of Hunan province in China in 2011-2013 were analyzed, with 476 patients placed in training group and 158 patients in validation group. Stepwise discriminant analysis was used to develop the accurate discriminate model. A simplified scoring model was generated using weightings defined by the discriminate coefficients. The discriminant ability of the model was tested by receiver operating characteristic curves (ROC). RESULTS The discriminant analysis showed that prothrombin time, D-dimer, total bilirubin, serum total protein, uric acid, PaO2/FiO2 ratio, myoglobin were associated with severity of sepsis. These seven variables were assigned with values of 4, 3, 3, 4, 3, 3, 3 respectively based on the standardized discriminant coefficients. Patients with higher scores had higher risk of severe sepsis. The areas under ROC (AROC) were 0.836 for accurate discriminate model, and 0.825 for simplified scoring model in validation group. CONCLUSIONS The proposed disease severity scoring model for pediatric sepsis showed adequate discriminatory capacity and sufficient accuracy, which has important clinical significance in evaluating the severity of pediatric sepsis and predicting its progress.
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Affiliation(s)
- Li HU
- School of Public Health, Central South University, Changsha, P. R. China
| | - Yimin ZHU
- Institute of Emergency Medicine, People’s Hospital of Hunan Province, Changsha, P. R. China,Corresponding Author:
| | - Mengshi CHEN
- Pediatric Intensive Critical Unit, Children’s Hospital of Hunan Province, Changsha, P. R. China
| | - Xun LI
- School of Public Health, Central South University, Changsha, P. R. China
| | - Xiulan LU
- Pediatric Intensive Critical Unit, Children’s Hospital of Hunan Province, Changsha, P. R. China
| | - Ying LIANG
- School of Public Health, Central South University, Changsha, P. R. China
| | - Hongzhuan TAN
- School of Public Health, Central South University, Changsha, P. R. China,Corresponding Author:
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25
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Maher KO, Chang AC, Shin A, Hunt J, Wong HR. Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care. World J Pediatr Congenit Heart Surg 2016; 6:588-96. [PMID: 26467873 DOI: 10.1177/2150135115606087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care.
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Affiliation(s)
- Kevin O Maher
- Children's Hospital of Atlanta, Cardiac Intensive Care Unit, Sibley Heart Center Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anthony C Chang
- Sharon Disney Lund Medical Intelligence and Innovation Institute (MI3), Children's Hospital of Orange County, Orange, CA, USA Honors Cooperative Program in Biomedical Informatics and Artificial Intelligence, Stanford School of Medicine, Stanford, CA, USA
| | - Andrew Shin
- Cardiac Intensive Care Unit, Lucille Packard Children's Hospital, Palo Alto, CA, USA Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliette Hunt
- Cardiac Intensive Care Unit, Children's Hospital of Orange County, Orange, CA, USA Department of Pediatrics, University of California at Irvine School of Medicine, Irvine, CA, USA
| | - Hector R Wong
- Pediatric Intensive Care Unit, Cincinnati Children's Hospital, Cincinnati, OH, USA Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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26
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Abstract
Sepsis mortality rates have decreased in recent years but remain unacceptably high. Risk stratification and prognostication is of particular importance because high-risk patients may benefit from earlier clinical interventions, whereas low-risk patients may benefit from not undergoing unnecessary procedures. Prognostication is currently done mostly via clinical criteria and blood lactate levels. This article summarizes the literature on the complexity of changes at the molecular level for the casual reader.
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Affiliation(s)
- Timothy E Sweeney
- Department of Surgery, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC2005, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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27
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Wong HR, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald J, Checchia PA, Meyer K, Quasney M, Hall M, Gedeit R, Freishtat RJ, Nowak J, Raj SS, Gertz S, Howard K, Harmon K, Lahni P, Frank E, Hart KW, Lindsell CJ. Prospective Testing and Redesign of a Temporal Biomarker Based Risk Model for Patients With Septic Shock: Implications for Septic Shock Biology. EBioMedicine 2015; 2:2087-93. [PMID: 26844289 PMCID: PMC4703723 DOI: 10.1016/j.ebiom.2015.11.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/07/2015] [Accepted: 11/19/2015] [Indexed: 01/01/2023] Open
Abstract
The temporal version of the pediatric sepsis biomarker risk model (tPERSEVERE) estimates the risk of a complicated course in children with septic shock based on biomarker changes from days 1 to 3 of septic shock. We validated tPERSEVERE performance in a prospective cohort, with an a priori plan to redesign tPERSEVERE if it did not perform well. Biomarkers were measured in the validation cohort (n = 168) and study subjects were classified according to tPERSEVERE. To redesign tPERSEVERE, the validation cohort and the original derivation cohort (n = 299) were combined and randomly allocated to training (n = 374) and test (n = 93) sets. tPERSEVERE was redesigned using the training set and CART methodology. tPERSEVERE performed poorly in the validation cohort, with an area under the curve (AUC) of 0.67 (95% CI: 0.58–0.75). Failure analysis revealed potential confounders related to clinical characteristics. The redesigned tPERSEVERE model had an AUC of 0.83 (0.79–0.87) and a sensitivity of 93% (68–97) for estimating the risk of a complicated course. Similar performance was seen in the test set. The classification tree segregated patients into two broad endotypes of septic shock characterized by either excessive inflammation or immune suppression. We prospectively tested the performance of the temporal version of the pediatric sepsis biomarker risk model (tPERSEVERE). tPERSEVERE performed poorly in the test cohort, prompting a redesign. The redesigned tPERSEVERE model performed well upon testing. The redesigned tPERSEVERE provides information regarding septic shock endotypes.
Septic shock is characterized by individual heterogeneity and it is not known who is at greatest risk of poor outcome and would thus benefit from more aggressive treatment. We designed a biomarker-based model to estimate the risk of poor outcome in children with septic shock. The model measures biomarker concentrations over the early period of disease evolution, and estimates how the biomarker changes reflect changing risk for poor outcome. The model has potential to serve as a monitor to evaluate the effectiveness of therapy in children with septic shock and may provide information regarding the biological mechanisms of septic shock.
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Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | | | - Nick Anas
- Children's Hospital of Orange County, Orange, CA, United States
| | | | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA, United States
| | | | - Scott L Weiss
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Julie Fitzgerald
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Paul A Checchia
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX, United States
| | - Keith Meyer
- Miami Children's Hospital, Miami, FL, United States
| | - Michael Quasney
- CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI, United States
| | - Mark Hall
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Rainer Gedeit
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | | | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN, United States
| | - Shekhar S Raj
- Riley Hospital for Children, Indianapolis, IN, United States
| | - Shira Gertz
- Hackensack University Medical Center, Joseph M. Sanzari Children's Hospital, Hackensack, NJ, United States
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, United States
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, United States
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, United States
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, United States
| | - Kimberly W Hart
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Christopher J Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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28
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Wong HR, Walley KR, Pettilä V, Meyer NJ, Russell JA, Karlsson S, Shashaty MGS, Lindsell CJ. Comparing the prognostic performance of ASSIST to interleukin-6 and procalcitonin in patients with severe sepsis or septic shock. Biomarkers 2015; 20:132-5. [PMID: 25578228 DOI: 10.3109/1354750x.2014.1000971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT We recently derived and validated a multi-biomarker-based model (ASSIST) to stratify patients with sepsis based on initial mortality risk. OBJECTIVE The objective of this study was to compare the performance of ASSIST to interleukin-6 (IL6) and procalcitonin (PCT). METHODS The area-under-the-receiver operating characteristic curve for predicting 28-d mortality using ASSIST was compared with that of IL6 (n = 452) and PCT (n = 235). RESULTS The area under the curve for ASSIST was greater than that of IL6 and PCT. CONCLUSIONS ASSIST estimated the probability of mortality more reliably than IL6 and PCT in this cohort of patients with sepsis.
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Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Hospital Research Foundation , Cincinnati, OH , USA
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Weiss SL, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Shanley TP, Bigham MT, Fitzgerald J, Banschbach S, Beckman E, Howard K, Frank E, Harmon K, Wong HR. Differential expression of the nuclear-encoded mitochondrial transcriptome in pediatric septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:623. [PMID: 25410281 PMCID: PMC4247726 DOI: 10.1186/s13054-014-0623-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 10/28/2014] [Indexed: 01/09/2023]
Abstract
Introduction Increasing evidence supports a role for mitochondrial dysfunction in organ injury and immune dysregulation in sepsis. Although differential expression of mitochondrial genes in blood cells has been reported for several diseases in which bioenergetic failure is a postulated mechanism, there are no data about the blood cell mitochondrial transcriptome in pediatric sepsis. Methods We conducted a focused analysis using a multicenter genome-wide expression database of 180 children ≤10 years of age with septic shock and 53 healthy controls. Using total RNA isolated from whole blood within 24 hours of PICU admission for septic shock, we evaluated 296 nuclear-encoded mitochondrial genes using a false discovery rate of 1%. A series of bioinformatic approaches were applied to compare differentially expressed genes across previously validated gene expression-based subclasses (groups A, B, and C) of pediatric septic shock. Results In total, 118 genes were differentially regulated in subjects with septic shock compared to healthy controls, including 48 genes that were upregulated and 70 that were downregulated. The top scoring canonical pathway was oxidative phosphorylation, with general downregulation of the 51 genes corresponding to the electron transport system (ETS). The top two gene networks were composed primarily of mitochondrial ribosomal proteins highly connected to ETS complex I, and genes encoding for ETS complexes I, II, and IV that were highly connected to the peroxisome proliferator activated receptor (PPAR) family. There were 162 mitochondrial genes differentially regulated between groups A, B, and C. Group A, which had the highest maximum number of organ failures and mortality, exhibited a greater downregulation of mitochondrial genes compared to groups B and C. Conclusions Based on a focused analysis of a pediatric septic shock transcriptomic database, nuclear-encoded mitochondrial genes were differentially regulated early in pediatric septic shock compared to healthy controls, as well as across genotypic and phenotypic distinct pediatric septic shock subclasses. The nuclear genome may be an important mechanism contributing to alterations in mitochondrial bioenergetic function and outcomes in pediatric sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0623-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Scott L Weiss
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA. .,Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.
| | - Natalie Z Cvijanovich
- UCSF Benioff Children's Hospital Oakland, 1411 East 31st Street, Oakland, CA, 94602, USA.
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Neal J Thomas
- Penn State Children's Hospital, 500 University Drive, Hershey, PA, 17033, USA.
| | - Robert J Freishtat
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
| | - Nick Anas
- Children's Hospital of Orange County, 1201 W La Veta Avenue, Orange, CA, 92868, USA.
| | - Keith Meyer
- Miami Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
| | - Paul A Checchia
- Texas Children's Hospital, 6621 Fannin Street, Houston, TX, 77030, USA.
| | - Thomas P Shanley
- CS Mott Children's Hospital at the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109, USA.
| | - Michael T Bigham
- Akron Children's Hospital, 1 Perkins Square, Akron, OH, 44302, USA.
| | - Julie Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA.
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA.
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Atkinson SJ, Cvijanovich NZ, Thomas NJ, Allen GL, Anas N, Bigham MT, Hall M, Freishtat RJ, Sen A, Meyer K, Checchia PA, Shanley TP, Nowak J, Quasney M, Weiss SL, Banschbach S, Beckman E, Howard K, Frank E, Harmon K, Lahni P, Lindsell CJ, Wong HR. Corticosteroids and pediatric septic shock outcomes: a risk stratified analysis. PLoS One 2014; 9:e112702. [PMID: 25386653 PMCID: PMC4227847 DOI: 10.1371/journal.pone.0112702] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/09/2014] [Indexed: 12/17/2022] Open
Abstract
Background The potential benefits of corticosteroids for septic shock may depend on initial mortality risk. Objective We determined associations between corticosteroids and outcomes in children with septic shock who were stratified by initial mortality risk. Methods We conducted a retrospective analysis of an ongoing, multi-center pediatric septic shock clinical and biological database. Using a validated biomarker-based stratification tool (PERSEVERE), 496 subjects were stratified into three initial mortality risk strata (low, intermediate, and high). Subjects receiving corticosteroids during the initial 7 days of admission (n = 252) were compared to subjects who did not receive corticosteroids (n = 244). Logistic regression was used to model the effects of corticosteroids on 28-day mortality and complicated course, defined as death within 28 days or persistence of two or more organ failures at 7 days. Results Subjects who received corticosteroids had greater organ failure burden, higher illness severity, higher mortality, and a greater requirement for vasoactive medications, compared to subjects who did not receive corticosteroids. PERSEVERE-based mortality risk did not differ between the two groups. For the entire cohort, corticosteroids were associated with increased risk of mortality (OR 2.3, 95% CI 1.3–4.0, p = 0.004) and a complicated course (OR 1.7, 95% CI 1.1–2.5, p = 0.012). Within each PERSEVERE-based stratum, corticosteroid administration was not associated with improved outcomes. Similarly, corticosteroid administration was not associated with improved outcomes among patients with no comorbidities, nor in groups of patients stratified by PRISM. Conclusions Risk stratified analysis failed to demonstrate any benefit from corticosteroids in this pediatric septic shock cohort.
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Affiliation(s)
- Sarah J. Atkinson
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Department of Surgery, University of Cincinnati, Cincinnati, OH, United States of America
| | | | - Neal J. Thomas
- Penn State Hershey Children’s Hospital, Hershey, PA, United States of America
| | - Geoffrey L. Allen
- Children’s Mercy Hospital, Kansas City, MO, United States of America
| | - Nick Anas
- Children’s Hospital of Orange County, Orange, CA, United States of America
| | | | - Mark Hall
- Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Robert J. Freishtat
- Children’s National Medical Center, Washington, DC, United States of America
| | - Anita Sen
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY, United States of America
| | - Keith Meyer
- Miami Children’s Hospital, Miami, FL, United States of America
| | - Paul A. Checchia
- Texas Children’s Hospital, Houston, TX, United States of America
| | - Thomas P. Shanley
- C. S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI, United States of America
| | - Jeffrey Nowak
- Children’s Hospital and Clinics of Minnesota, Minneapolis, MN, United States of America
| | - Michael Quasney
- C. S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI, United States of America
| | - Scott L. Weiss
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Christopher J. Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- * E-mail:
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Wang K, Bhandari V, Giuliano JS, O′Hern CS, Shattuck MD, Kirby M. Angiopoietin-1, angiopoietin-2 and bicarbonate as diagnostic biomarkers in children with severe sepsis. PLoS One 2014; 9:e108461. [PMID: 25255212 PMCID: PMC4178003 DOI: 10.1371/journal.pone.0108461] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/26/2014] [Indexed: 12/16/2022] Open
Abstract
Severe pediatric sepsis continues to be associated with high mortality rates in children. Thus, an important area of biomedical research is to identify biomarkers that can classify sepsis severity and outcomes. The complex and heterogeneous nature of sepsis makes the prospect of the classification of sepsis severity using a single biomarker less likely. Instead, we employ machine learning techniques to validate the use of a multiple biomarkers scoring system to determine the severity of sepsis in critically ill children. The study was based on clinical data and plasma samples provided by a tertiary care center's Pediatric Intensive Care Unit (PICU) from a group of 45 patients with varying sepsis severity at the time of admission. Canonical Correlation Analysis with the Forward Selection and Random Forests methods identified a particular set of biomarkers that included Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), and Bicarbonate (HCO) as having the strongest correlations with sepsis severity. The robustness and effectiveness of these biomarkers for classifying sepsis severity were validated by constructing a linear Support Vector Machine diagnostic classifier. We also show that the concentrations of Ang-1, Ang-2, and HCO enable predictions of the time dependence of sepsis severity in children.
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Affiliation(s)
- Kun Wang
- Department of Mathematics, Colorado State University, Fort Collins, Colorado, United States of America
- Department of Mechanical Engineering & Materials Science, Yale University, New Haven, Connecticut, United States of America
| | - Vineet Bhandari
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - John S. Giuliano
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Corey S. O′Hern
- Department of Mechanical Engineering & Materials Science, Yale University, New Haven, Connecticut, United States of America
- Department of Applied Physics, Department of Physics, and Graduate Program in Computational Biology & Bioinformatics, Yale University, New Haven, Connecticut, United States of America
| | - Mark D. Shattuck
- Benjamin Levich Institute and Physics Department, The City College of New York, New York, New York, United States of America
| | - Michael Kirby
- Department of Mathematics, Colorado State University, Fort Collins, Colorado, United States of America
- * E-mail:
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Sandquist M, Wong HR. Biomarkers of sepsis and their potential value in diagnosis, prognosis and treatment. Expert Rev Clin Immunol 2014; 10:1349-56. [PMID: 25142036 DOI: 10.1586/1744666x.2014.949675] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Biomarkers have great potential to improve the diagnosis and treatment of sepsis. The available literature supports the potential utility of sTREM-1, IL-27, suPAR, neutrophil CD64, presepsin, cfDNA and miRNAs as novel diagnostic, prognostic and treatment response biomarkers. The future of sepsis biomarkers lies in extensive validation studies of such novel biomarkers across heterogeneous populations and exploration of their power in combination. Furthermore, the use of a companion diagnostics model may augment the ability of investigators to identify novel sepsis biomarkers and develop specific therapeutic strategies based on biomarker information.
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Affiliation(s)
- Mary Sandquist
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA and Cincinnati Children's Hospital Research Foundation, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH 45229-3039, USA
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Briassoulis G, Galani A. Prognostic markers of pediatric meningococcal sepsis. Expert Rev Anti Infect Ther 2014; 12:1017-20. [DOI: 10.1586/14787210.2014.945431] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- George Briassoulis
- Pediatric Intensive Care Unit, University Hospital, University of Crete,
71110 Heraklion, Crete, Greece
| | - Angeliki Galani
- Pediatric Intensive Care Unit, University Hospital, University of Crete,
71110 Heraklion, Crete, Greece
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Wong HR, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Weiss SL, Shanley TP, Bigham MT, Banschbach S, Beckman E, Harmon K, Zimmerman JJ. Corticosteroids are associated with repression of adaptive immunity gene programs in pediatric septic shock. Am J Respir Crit Care Med 2014; 189:940-6. [PMID: 24650276 DOI: 10.1164/rccm.201401-0171oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Corticosteroids are prescribed commonly for patients with septic shock, but their use remains controversial and concerns remain regarding side effects. OBJECTIVES To determine the effect of adjunctive corticosteroids on the genomic response of pediatric septic shock. METHODS We retrospectively analyzed an existing transcriptomic database of pediatric septic shock. Subjects receiving any formulation of systemic corticosteroids at the time of blood draw for microarray analysis were classified in the septic shock corticosteroid group. We compared normal control subjects (n = 52), a septic shock no corticosteroid group (n = 110), and a septic shock corticosteroid group (n = 70) using analysis of variance. Genes differentially regulated between the no corticosteroid group and the corticosteroid group were analyzed using Ingenuity Pathway Analysis. MEASUREMENTS AND MAIN RESULTS The two study groups did not differ with respect to illness severity, organ failure burden, mortality, or mortality risk. There were 319 gene probes differentially regulated between the no corticosteroid group and the corticosteroid group. These genes corresponded predominately to adaptive immunity-related signaling pathways, and were down-regulated relative to control subjects. Notably, the degree of down-regulation was significantly greater in the corticosteroid group, compared with the no corticosteroid group. A similar pattern was observed for genes corresponding to the glucocorticoid receptor signaling pathway. CONCLUSIONS Administration of corticosteroids in pediatric septic shock is associated with additional repression of genes corresponding to adaptive immunity. These data should be taken into account when considering the benefit to risk ratio of adjunctive corticosteroids for septic shock.
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Affiliation(s)
- Hector R Wong
- 1 Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Alder MN, Lindsell CJ, Wong HR. The pediatric sepsis biomarker risk model: potential implications for sepsis therapy and biology. Expert Rev Anti Infect Ther 2014; 12:809-16. [PMID: 24754535 DOI: 10.1586/14787210.2014.912131] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Sepsis remains a major cause of morbidity and mortality in adult and pediatric intensive care units. Heterogeneity of demographics, comorbidities, biological mechanisms, and severity of illness leads to difficulty in determining which patients are at highest risk of mortality. Determining mortality risk is important for weighing the potential benefits of more aggressive interventions and for deciding whom to enroll in clinical trials. Biomarkers can be used to parse patients into different risk categories and can outperform current methods of patient risk stratification based on physiologic parameters. Here we review the Pediatric Sepsis Biomarker Risk Model that has also been modified and applied to estimate mortality risk in adult patients. We compare the two models and speculate on the biological implications of the biomarkers in patients with sepsis.
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Affiliation(s)
- Matthew N Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH, USA
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