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Bhavani SV, Semler M, Qian ET, Verhoef PA, Robichaux C, Churpek MM, Coopersmith CM. Development and validation of novel sepsis subphenotypes using trajectories of vital signs. Intensive Care Med 2022; 48:1582-1592. [PMID: 36152041 PMCID: PMC9510534 DOI: 10.1007/s00134-022-06890-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Sepsis is a heterogeneous syndrome and identification of sub-phenotypes is essential. This study used trajectories of vital signs to develop and validate sub-phenotypes and investigated the interaction of sub-phenotypes with treatment using randomized controlled trial data. METHODS All patients with suspected infection admitted to four academic hospitals in Emory Healthcare between 2014-2017 (training cohort) and 2018-2019 (validation cohort) were included. Group-based trajectory modeling was applied to vital signs from the first 8 h of hospitalization to develop and validate vitals trajectory sub-phenotypes. The associations between sub-phenotypes and outcomes were evaluated in patients with sepsis. The interaction between sub-phenotype and treatment with balanced crystalloids versus saline was tested in a secondary analysis of SMART (Isotonic Solutions and Major Adverse Renal Events Trial). RESULTS There were 12,473 patients with suspected infection in training and 8256 patients in validation cohorts, and 4 vitals trajectory sub-phenotypes were found. Group A (N = 3483, 28%) were hyperthermic, tachycardic, tachypneic, and hypotensive. Group B (N = 1578, 13%) were hyperthermic, tachycardic, tachypneic (not as pronounced as Group A) and hypertensive. Groups C (N = 4044, 32%) and D (N = 3368, 27%) had lower temperatures, heart rates, and respiratory rates, with Group C normotensive and Group D hypotensive. In the 6,919 patients with sepsis, Groups A and B were younger while Groups C and D were older. Group A had the lowest prevalence of congestive heart failure, hypertension, diabetes mellitus, and chronic kidney disease, while Group B had the highest prevalence. Groups A and D had the highest vasopressor use (p < 0.001 for all analyses above). In logistic regression, 30-day mortality was significantly higher in Groups A and D (p < 0.001 and p = 0.03, respectively). In the SMART trial, sub-phenotype significantly modified treatment effect (p = 0.03). Group D had significantly lower odds of mortality with balanced crystalloids compared to saline (odds ratio (OR) 0.39, 95% confidence interval (CI) 0.23-0.67, p < 0.001). CONCLUSION Sepsis sub-phenotypes based on vital sign trajectory were consistent across cohorts, had distinct outcomes, and different responses to treatment with balanced crystalloids versus saline.
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Affiliation(s)
- Sivasubramanium V Bhavani
- Department of Medicine, Emory University, Atlanta, GA, USA.
- Emory Critical Care Center, Atlanta, GA, USA.
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, 615 Michael St., Atlanta, GA, 30322, USA.
| | - Matthew Semler
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Edward T Qian
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Philip A Verhoef
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
- Hawaii Permanente Medical Group, Honolulu, HI, USA
| | - Chad Robichaux
- Department of Biomedical Informatics, Emory University, Atlanta, GA, USA
| | - Matthew M Churpek
- Department of Medicine, University of Wisconsin, Madison, WI, USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Craig M Coopersmith
- Emory Critical Care Center, Atlanta, GA, USA
- Department of Surgery, Emory University, Atlanta, GA, USA
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Bodenes L, N'Guyen QT, Le Mao R, Ferrière N, Pateau V, Lellouche F, L'Her E. Early heart rate variability evaluation enables to predict ICU patients' outcome. Sci Rep 2022; 12:2498. [PMID: 35169170 DOI: 10.1038/s41598-022-06301-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/17/2022] [Indexed: 12/05/2022] Open
Abstract
Heart rate variability (HRV) is a mean to evaluate cardiac effects of autonomic nervous system activity, and a relation between HRV and outcome has been proposed in various types of patients. We attempted to evaluate the best determinants of such variation in survival prediction using a physiological data-warehousing program. Plethysmogram tracings (PPG) were recorded at 75 Hz from the standard monitoring system, for a 2 h period, during the 24 h following ICU admission. Physiological data recording was associated with metadata collection. HRV was derived from PPG in either the temporal and non-linear domains. 540 consecutive patients were recorded. A lower LF/HF, SD2/SD1 ratios and Shannon entropy values on admission were associated with a higher ICU mortality. SpO2/FiO2 ratio and HRV parameters (LF/HF and Shannon entropy) were independent correlated with mortality in the multivariate analysis. Machine-learning using neural network (kNN) enabled to determine a simple decision tree combining the three best determinants (SDNN, Shannon Entropy, SD2/SD1 ratio) of a composite outcome index. HRV measured on admission enables to predict outcome in the ICU or at Day-28, independently of the admission diagnosis, treatment and mechanical ventilation requirement. Trial registration: ClinicalTrials.gov identifier NCT02893462.
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Harris BR, Beesley SJ, Hopkins RO, Hirshberg EL, Wilson E, Butler J, Oniki TA, Kuttler KG, Orme JF, Brown SM. Heart rate variability and subsequent psychological distress among family members of intensive care unit patients. J Int Med Res 2021; 49:3000605211057829. [PMID: 34846178 PMCID: PMC8649465 DOI: 10.1177/03000605211057829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective To determine whether heart rate variability (HRV; a physiological measure of
acute stress) is associated with persistent psychological distress among
family members of adult intensive care unit (ICU) patients. Methods This prospective study investigated family members of patients admitted to a
study ICU. Participants’ variability in heart rate tracings were measured by
low frequency (LF)/high frequency (HF) ratio and detrended fluctuation
analysis (DFA). Questionnaires were completed 3 months after enrollment to
ascertain outcome rates of anxiety, depression, and post-traumatic stress
disorder (PTSD). Results Ninety-nine participants were enrolled (median LF/HF ratio, 0.92
[interquartile range, 0.64–1.38]). Of 92 participants who completed the
3-month follow-up, 29 (32%) had persistent anxiety. Logistic regression
showed that LF/HF ratio (odds ratio [OR] 0.85, 95% confidence interval [CI]
0.43, 1.53) was not associated with 3-month outcomes. In an exploratory
analysis, DFA α (OR 0.93, 95% CI 0.87, 0.99), α1 (OR 0.97, 95% CI
0.94, 0.99), and α2 (OR 0.94, 95% CI 0.88, 0.99) scaling
components were associated with PTSD development. Conclusion Almost one-third of family members experienced anxiety at three months after
enrollment. HRV, measured by LF/HF ratio, was not a predictor of psychologic
distress, however, exploratory analyses indicated that DFA may be associated
with PTSD outcomes.
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Affiliation(s)
- Benjamin Re Harris
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sarah J Beesley
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Psychology Department and Neuroscience Center, 6756Brigham Young University, Brigham Young University, Provo, UT, USA
| | - Eliotte L Hirshberg
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Emily Wilson
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jorie Butler
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Geriatrics and Psychology, University of Utah and Salt Lake City Veterans Administration Hospital, Salt Lake City, UT, USA
| | - Thomas A Oniki
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Care Transformation Information Systems, 7061Intermountain Healthcare, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Kathryn G Kuttler
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Care Transformation Information Systems, 7061Intermountain Healthcare, Intermountain Healthcare, Salt Lake City, UT, USA
| | - James F Orme
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samuel M Brown
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Sun Y, Kaur R, Gupta S, Paul R, Das R, Cho SJ, Anand S, Boutilier JJ, Saria S, Palma J, Saluja S, McAdams RM, Kaur A, Yadav G, Singh H. Development and validation of high definition phenotype-based mortality prediction in critical care units. JAMIA Open 2021; 4:ooab004. [PMID: 33796821 PMCID: PMC7991779 DOI: 10.1093/jamiaopen/ooab004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives The objectives of this study are to construct the high definition phenotype (HDP), a novel time-series data structure composed of both primary and derived parameters, using heterogeneous clinical sources and to determine whether different predictive models can utilize the HDP in the neonatal intensive care unit (NICU) to improve neonatal mortality prediction in clinical settings. Materials and Methods A total of 49 primary data parameters were collected from July 2018 to May 2020 from eight level-III NICUs. From a total of 1546 patients, 757 patients were found to contain sufficient fixed, intermittent, and continuous data to create HDPs. Two different predictive models utilizing the HDP, one a logistic regression model (LRM) and the other a deep learning long–short-term memory (LSTM) model, were constructed to predict neonatal mortality at multiple time points during the patient hospitalization. The results were compared with previous illness severity scores, including SNAPPE, SNAPPE-II, CRIB, and CRIB-II. Results A HDP matrix, including 12 221 536 minutes of patient stay in NICU, was constructed. The LRM model and the LSTM model performed better than existing neonatal illness severity scores in predicting mortality using the area under the receiver operating characteristic curve (AUC) metric. An ablation study showed that utilizing continuous parameters alone results in an AUC score of >80% for both LRM and LSTM, but combining fixed, intermittent, and continuous parameters in the HDP results in scores >85%. The probability of mortality predictive score has recall and precision of 0.88 and 0.77 for the LRM and 0.97 and 0.85 for the LSTM. Conclusions and Relevance The HDP data structure supports multiple analytic techniques, including the statistical LRM approach and the machine learning LSTM approach used in this study. LRM and LSTM predictive models of neonatal mortality utilizing the HDP performed better than existing neonatal illness severity scores. Further research is necessary to create HDP–based clinical decision tools to detect the early onset of neonatal morbidities.
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Affiliation(s)
- Yao Sun
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Ravneet Kaur
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Shubham Gupta
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Rahul Paul
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Ritu Das
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Su Jin Cho
- Department of Pediatrics, College of Medicine, Ewha Womans University Seoul, Seoul, Korea
| | - Saket Anand
- Department of Computer Science, Indraprastha Institute of Information Technology, New Delhi, India
| | - Justin J Boutilier
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Wisconsin, USA
| | - Suchi Saria
- Machine Learning and Healthcare Lab, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Applied Math & Statistics, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Health Policy & Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Palma
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Satish Saluja
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Avneet Kaur
- Department of Neonatology, Apollo Cradle Hospitals, New Delhi, India
| | - Gautam Yadav
- Department of Pediatrics, Kalawati Hospital, Rewari, India
| | - Harpreet Singh
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
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Durand M, Louis H, Fritz C, Levy B, Kimmoun A. β-bloquants dans la prise en charge du choc septique. Méd Intensive Réa 2019. [DOI: 10.3166/rea-2019-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les adrénorécepteurs α et en particulier β sont les principales cibles de l’adrénaline et de la noradrénaline libérées par le système sympathique activé. Durant le choc septique, la dysautonomie est une stimulation prolongée à un haut niveau d’intensité du système nerveux sympathique à l’origine d’une altération de la contractilité, de la vasoréactivité et d’une immunodépression. Ainsi, l’administration précoce d’un traitement β-bloquant lors du choc septique pourrait pondérer les effets délétères de cette surstimulation sympathique. Néanmoins, si les preuves expérimentales sont en faveur de cette approche, l’accumulation des preuves cliniques reste encore insuffisante.
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Berlin R, Gruen R, Best J. Systems Medicine Disease: Disease Classification and Scalability Beyond Networks and Boundary Conditions. Front Bioeng Biotechnol 2018; 6:112. [PMID: 30131956 PMCID: PMC6090066 DOI: 10.3389/fbioe.2018.00112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/18/2018] [Indexed: 12/26/2022] Open
Abstract
In order to accommodate the forthcoming wealth of health and disease related information, from genome to body sensors to population and the environment, the approach to disease description and definition demands re-examination. Traditional classification methods remain trapped by history; to provide the descriptive features that are required for a comprehensive description of disease, systems science, which realizes dynamic processes, adaptive response, and asynchronous communication channels, must be applied (Wolkenhauer et al., 2013). When Disease is viewed beyond the thresholds of lines and threshold boundaries, disease definition is not only the result of reductionist, mechanistic categories which reluctantly face re-composition. Disease is process and synergy as the characteristics of Systems Biology and Systems Medicine are included. To capture the wealth of information and contribute meaningfully to medical practice and biology research, Disease classification goes beyond a single spatial biologic level or static time assignment to include the interface of Disease process and organism response (Bechtel, 2017a; Green et al., 2017).
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Affiliation(s)
- Richard Berlin
- Department of Computer Science, University of Illinois, Urbana, IL, United States
| | - Russell Gruen
- Department of Surgery, Nanyang Institute of Technology in Health and Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - James Best
- Lee Kong China School of Medicine, Nanyang Technological University, Singapore, Singapore
- Imperial College, London, United Kingdom
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