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Alhamdan F, Koutsogiannaki S, Yuki K. The landscape of immune dysregulation in pediatric sepsis at a single-cell resolution. Clin Immunol 2024; 262:110175. [PMID: 38460893 PMCID: PMC11009045 DOI: 10.1016/j.clim.2024.110175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 03/11/2024]
Abstract
Recognizing immune dysregulation as a hallmark of sepsis pathophysiology, leukocytes have attracted major attention of investigation. While adult and pediatric sepsis are clinically distinct, their immunological delineation remains limited. Single cell technologies facilitated the characterization of immune signatures. We tackled to delineate immunological profiles of pediatric sepsis at a single-cell level by analyzing blood samples from six septic children, at both acute and recovery phases, and four healthy children. 16 single-cell transcriptomic datasets were analyzed and compared to adult sepsis dataset. We showed a unique shift in neutrophil subpopulations and functions between acute and recovery phases, along with the regulatory role of resistin. Neutrophil signatures were comparable between adult and pediatric sepsis. Innate-like CD4 T cells were predominantly and uniquely observed in acute phase of pediatric sepsis. Our study serves as a rich source of information about the phenotypic diversity and trajectory of circulating immune cells during pediatric sepsis.
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Affiliation(s)
- Fahd Alhamdan
- Department of Anesthesiology, Critical Care, and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, USA; Department of Immunology and Anaesthesia, Harvard Medical School, USA; Broad Institute of MIT and Harvard, USA
| | - Sophia Koutsogiannaki
- Department of Anesthesiology, Critical Care, and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, USA; Department of Immunology and Anaesthesia, Harvard Medical School, USA; Broad Institute of MIT and Harvard, USA.
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care, and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, USA; Department of Immunology and Anaesthesia, Harvard Medical School, USA; Broad Institute of MIT and Harvard, USA.
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Xiao YP, Cheng YC, Chen C, Xue HM, Yang M, Lin C. Identification of the Shared Gene Signatures of HCK, NOG, RNF125 and Biological Mechanism in Pediatric Acute Lymphoblastic Leukaemia and Pediatric Sepsis. Mol Biotechnol 2023:10.1007/s12033-023-00979-6. [PMID: 38123749 DOI: 10.1007/s12033-023-00979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023]
Abstract
The shared mechanisms between pediatric acute lymphoblastic leukaemia (ALL) and pediatric sepsis are currently unclear. This study was aimed to explore the shared key genes of pediatric ALL and pediatric sepsis. The datasets involved were downloaded from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) between disease and control samples in GSE13904 and GSE79533 were intersected. The least absolute shrinkage and selection operator (LASSO) and the boruta analyses were performed in GSE13904 and GSE79533 separately based on shared DEGs, and shared key genes were obtained by taking the intersection of sepsis-related key genes and ALL-related key genes. Three shared key genes (HCK, NOG, RNF125) were obtained, that have a good diagnostic value for both sepsis and ALL. The correlation between shared key genes and differentially expressed immune cells was higher in GSE13904 and conversely, the correlation of which was lower in GSE79533. Suggesting that the sharing key genes had a different impact on the immune environment in pediatric ALL and pediatric sepsis. We make the case that this study provides a new perspective to study the relationship between pediatric ALL and pediatric sepsis.
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Affiliation(s)
- Ying-Ping Xiao
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Yu-Cai Cheng
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Chun Chen
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Hong-Man Xue
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Mo Yang
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
- Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
| | - Chao Lin
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
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Marassi C, Socia D, Larie D, An G, Cockrell RC. Children are small adults (when properly normalized): Transferrable/generalizable sepsis prediction. Surg Open Sci 2023; 16:77-81. [PMID: 37818461 PMCID: PMC10561114 DOI: 10.1016/j.sopen.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 06/16/2023] [Revised: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 10/12/2023] Open
Abstract
Background Though governed by the same underlying biology, the differential physiology of children causes the temporal evolution from health to a septic/diseased state to follow trajectories that are distinct from adult cases. As pediatric sepsis data sets are less readily available than for adult sepsis, we aim to leverage this shared underlying biology by normalizing pediatric physiological data such that it would be directly comparable to adult data, and then develop machine-learning (ML) based classifiers to predict the onset of sepsis in the pediatric population. We then externally validated the classifiers in an independent adult dataset. Methods Vital signs and laboratory observables were obtained from the Pediatric Intensive Care (PIC) database. These data elements were normalized for age and placed on a continuous scale, termed the Continuous Age-Normalized SOFA (CAN-SOFA) score. The XGBoost algorithm was used to classify pediatric patients that are septic. We tested the trained model using adult data from the MIMIC-IV database. Results On the pediatric population, the sepsis classifier has an accuracy of 0.84 and an F1-Score of 0.867. On the adult population, the sepsis classifier has an accuracy of 0.80 and an F1-score of 0.88; when tested on the adult population, the model showed similar performance degradation ("data drift") as in the pediatric population. Conclusions In this work, we demonstrate that, using a straightforward age-normalization method, EHR's can be generalizable compared (at least in the context of sepsis) between the pediatric and adult populations.
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Affiliation(s)
- Caitlin Marassi
- Department of Surgery, University of Vermont, 89 Beaumont Ave, Given D319, Burlington, VT 05405, United States of America
| | - Damien Socia
- Department of Surgery, University of Vermont, 89 Beaumont Ave, Given D319, Burlington, VT 05405, United States of America
| | - Dale Larie
- Department of Surgery, University of Vermont, 89 Beaumont Ave, Given D319, Burlington, VT 05405, United States of America
| | - Gary An
- Department of Surgery, University of Vermont, 89 Beaumont Ave, Given D319, Burlington, VT 05405, United States of America
| | - R. Chase Cockrell
- Department of Surgery, University of Vermont, 89 Beaumont Ave, Given D319, Burlington, VT 05405, United States of America
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Nguyen TM, Poh KL, Chong SL, Loh SW, Heng YCK, Lee JH. The use of probabilistic graphical models in pediatric sepsis: a feasibility and scoping review. Transl Pediatr 2023; 12:2074-2089. [PMID: 38130578 PMCID: PMC10730969 DOI: 10.21037/tp-23-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023] Open
Abstract
Background Recent research has demonstrated that machine learning (ML) has the potential to improve several aspects of medical application for critical illness, including sepsis. This scoping review aims to evaluate the feasibility of probabilistic graphical model (PGM) methods in pediatric sepsis application and describe the use of pediatric sepsis definition in these studies. Methods Literature searches were conducted in PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL+), and Web of Sciences from 2000-2023. Keywords included "pediatric", "neonates", "infants", "machine learning", "probabilistic graphical model", and "sepsis". Results A total of 3,244 studies were screened, and 72 were included in this scoping review. Sepsis was defined using positive microbiology cultures in 19 studies (26.4%), followed by the 2005's international pediatric sepsis consensus definition in 11 studies (15.3%), and Sepsis-3 definition in seven studies (9.7%). Other sepsis definitions included: bacterial infection, the international classification of diseases, clinicians' assessment, and antibiotic administration time. Among the most common ML approaches used were logistic regression (n=27), random forest (n=24), and Neural Network (n=18). PGMs were used in 13 studies (18.1%), including Bayesian classifiers (n=10), and the Markov Model (n=3). When applied on the same dataset, PGMs show a relatively inferior performance to other ML models in most cases. Other aspects of explainability and transparency were not examined in these studies. Conclusions Current studies suggest that the performance of probabilistic graphic models is relatively inferior to other ML methods. However, its explainability and transparency advantages make it a potentially viable method for several pediatric sepsis studies and applications.
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Affiliation(s)
- Tuong Minh Nguyen
- Department of Industrial Systems Engineering and Management, College of Design and Engineering, National University of Singapore, SG, Singapore
| | - Kim Leng Poh
- Department of Industrial Systems Engineering and Management, College of Design and Engineering, National University of Singapore, SG, Singapore
| | - Shu-Ling Chong
- Children’s Emergency, KK Women’s and Children’s Hospital, SG, Singapore
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, SG, Singapore
| | - Sin Wee Loh
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, SG, Singapore
| | | | - Jan Hau Lee
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, SG, Singapore
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, SG, Singapore
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Hermans E, Devreese M, Zeitlinger M, Dhont E, Verougstraete N, Colman R, Vande Walle J, De Paepe P, De Cock PA. Microdialysis as a safe and feasible method to study target-site piperacillin-tazobactam disposition in septic piglets and children. Int J Antimicrob Agents 2023; 62:106970. [PMID: 37716576 DOI: 10.1016/j.ijantimicag.2023.106970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/17/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVES Knowledge on the tissue penetration of piperacillin-tazobactam in children with sepsis is lacking. In this study, the feasibility and performance of microdialysis experiments were explored in septic piglets and children as part of a translational research project. METHODS Multiple-day microdialysis investigations were performed in muscle tissue of 22 piglets (of which 11 were septic) and 6 children with sepsis. An in vitro experiment preceded the (pre)clinical trials to derive optimal experimental settings and calibration technique. Linear mixed-effects models quantified the impact of sepsis on relative recovery (RR) and intercatheter, interindividual, interoccasion, and residual variability. RESULTS In vivo microdialysis was well tolerated in piglets and children, with no significant adverse events reported. Using identical experimental settings, lower RR values were recorded in healthy and septic piglets (range: piperacillin, 17.2-29.1% and tazobactam, 23.5-29.1%) compared with the in vitro experiment (piperacillin, 43.3% and tazobactam, 55.3%), and there were unacceptably low values in children with sepsis (<10%). As a result, methodological changes were made in the pediatric trial. Realistic tissue concentration-time curves were derived in piglets and children. In piglets, sepsis reduced the RR. The greatest contributors to RR variability were residual (>40%) and interoccasion (>30%) variability. The internal standard method was the preferred calibration technique in both piglets and children. CONCLUSIONS Microdialysis is a safe and applicable method for the measurement of tissue drug concentrations in piglets and children. This study demonstrated the impact of experimental settings, sepsis, and target population on individual RR.
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Affiliation(s)
- Eline Hermans
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium; Department of Pediatrics, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Mathias Devreese
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | - Evelyn Dhont
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Nick Verougstraete
- Department of Laboratory Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pediatric Nephrology, SafePeDrug, Erknet center, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Peter De Paepe
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Emergency Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Pieter A De Cock
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pharmacy, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
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Li ECK, Tagoola A, Komugisha C, Nabweteme AM, Pillay Y, Ansermino JM, Khowaja AR. Cost-effectiveness analysis of Smart Triage, a data-driven pediatric sepsis triage platform in Eastern Uganda. BMC Health Serv Res 2023; 23:932. [PMID: 37653477 PMCID: PMC10468891 DOI: 10.1186/s12913-023-09977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Sepsis, characterized by organ dysfunction due to presumed or proven infection, has a case-fatality over 20% in severe cases in low-and-middle income countries. Early diagnosis and treatment have proven benefits, prompting our implementation of Smart Triage at Jinja Regional Referral Hospital in Uganda, a program that expedites treatment through a data-driven triage platform. We conducted a cost-effectiveness analysis of Smart Triage to explore its impact on patients and inform multicenter scale up. METHODS The parent clinical trial for Smart Triage was pre-post in design, using the proportion of children receiving sepsis treatment within one hour as the primary outcome, a measure linked to mortality benefit in existing literature. We used a decision-analytic model with Monte Carlo simulation to calculate the cost per year-of-life-lost (YLL) averted of Smart Triage from societal, government, and patient perspectives. Healthcare utilization and lost work for seven days post-discharge were translated into costs and productivity losses via secondary linkage data. RESULTS In 2021 United States dollars, Smart Triage requires an annuitized program cost of only $0.05 per child, but results in $15.32 saved per YLL averted. At a willingness-to-pay threshold of only $3 per YLL averted, well below published cost-effectiveness threshold estimates for Uganda, Smart Triage approaches 100% probability of cost-effectiveness over the baseline manual triage system. This cost-effectiveness was observed from societal, government, and patient perspectives. The cost-effectiveness observed was driven by a reduction in admission that, while explainable by an improved triage mechanism, may also be partially attributable to changes in healthcare utilization influenced by the coronavirus pandemic. However, Smart Triage remains cost-effective in sensitivity analyses introducing a penalty factor of up to 50% in the reduction in admission. CONCLUSION Smart Triage's ability to both save costs and avert YLLs indicates that patients benefit both economically and clinically, while its high probability of cost-effectiveness strongly supports multicenter scale up. Areas for further research include the incorporation of years lived with disability when sepsis disability weights in low-resource settings become available and analyzing budget impact during multicenter scale up. TRIAL REGISTRATION NCT04304235 (registered on 11/03/2020, clinicaltrials.gov).
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Affiliation(s)
- Edmond C K Li
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
- Department of Anesthesiology, Royal Columbian Hospital, Vancouver, BC, Canada.
| | | | - Clare Komugisha
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kololo, Kampala, Uganda
| | | | - Yashodani Pillay
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Asif R Khowaja
- Faculty of Applied Health Sciences, Brock University, St. Catharines, ON, Canada
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Miranda M, Nadel S. Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations. Curr Pediatr Rep 2023; 11:29-39. [PMID: 37252329 PMCID: PMC10169116 DOI: 10.1007/s40124-023-00286-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/31/2023]
Abstract
Purpose of Review Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement. Recent Findings Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Summary Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.
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Affiliation(s)
- Mariana Miranda
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Simon Nadel
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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Nguyen TM, Poh KL, Chong SL, Lee JH. Effective diagnosis of sepsis in critically ill children using probabilistic graphical model. Transl Pediatr 2023; 12:538-551. [PMID: 37181015 PMCID: PMC10167381 DOI: 10.21037/tp-22-510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/26/2023] [Indexed: 05/16/2023] Open
Abstract
Background Probabilistic graphical model, a rich graphical framework in modelling associations between variables in complex domains, can be utilized to aid clinical diagnosis. However, its application in pediatric sepsis remains limited. This study aims to explore the utility of probabilistic graphical models in pediatric sepsis in the pediatric intensive care unit. Methods We conducted a retrospective study on children using the first 24-hour clinical data of the intensive care unit admission from the Pediatric Intensive Care Dataset, 2010-2019. A probabilistic graphical model method, Tree Augmented Naive Bayes, was used to build diagnosis models using combinations of four categories: vital signs, clinical symptoms, laboratory, and microbiological tests. Variables were reviewed and selected by clinicians. Sepsis cases were identified with the discharged diagnosis of sepsis or suspected infection with the systemic inflammatory response syndrome. Performance was measured by the average sensitivity, specificity, accuracy, and area under the curve of ten-fold cross-validations. Results We extracted 3,014 admissions [median age of 1.13 (interquartile range: 0.15-4.30) years old]. There were 134 (4.4%) and 2,880 (95.6%) sepsis and non-sepsis patients, respectively. All diagnosis models had high accuracy (0.92-0.96), specificity (0.95-0.99), and area under the curve (0.77-0.87). Sensitivity varied with different combinations of variables. The model that combined all four categories yielded the best performance [accuracy: 0.93 (95% confidence interval (CI): 0.916-0.936); sensitivity: 0.46 (95% CI: 0.376-0.550), specificity: 0.95 (95% CI: 0.940-0.956), area under the curve: 0.87 (95% CI: 0.826-0.906)]. Microbiological tests had low sensitivity (<0.10) with high incidence of negative results (67.2%). Conclusions We demonstrated that the probabilistic graphical model is a feasible diagnostic tool for pediatric sepsis. Future studies using different datasets should be conducted to assess its utility to aid clinicians in the diagnosis of sepsis.
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Affiliation(s)
- Tuong Minh Nguyen
- Department of Industrial Engineering and Management, National University of Singapore, Singapore, Singapore
| | - Kim Leng Poh
- Department of Industrial Engineering and Management, National University of Singapore, Singapore, Singapore
| | - Shu-Ling Chong
- Children’s Emergency, KK Women’s and Children’s Hospital, Singapore, Singapore
- Singhealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Singhealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore, Singapore
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Cui Y, Feng S, Miao H, Liu T, Shi J, Dou J, Wang C, Zhang Y. The novel biomarkers for assessing clinical benefits of continuous renal replacement therapy in pediatric sepsis: a pilot study. Clin Proteomics 2023; 20:4. [PMID: 36650427 PMCID: PMC9847018 DOI: 10.1186/s12014-023-09392-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) has been considered as an adjuvant therapy for sepsis. However, the novel biomarker to evaluate the benefits of CRRT is limited. The aim of this study was to explore the novel biomarkers involved in the impact of CRRT in pediatric sepsis. METHODS The serum proteomic profiles on the 7th day after CRRT (CRRT 7th day) compared with before CRRT (CRRT 1st day) was determined in 3 children with sepsis as a discovery set. The screened candidates were confirmed in the validation cohort including patients received CRRT (CRRT group) and without CRRT (non-CRRT group). We defined that pediatric sequential organ failure assessment score (pSOFA) in pediatric patients with sepsis decreased by 2 points or more on the CRRT 1st day compared with CRRT initiation as CRRT responders. The changes of serum biomarkers were compared between CRRT responders and CRRT non-responders. Moreover, correlation analysis was further conducted in pediatric sepsis. RESULTS A total of 145 differentially expressed proteins were found according to the serum proteomics profiles. By visualizing the interaction between the differential proteins, 6 candidates (Lysozyme C [LYZ], Leucine-rich alpha-2-glycoprotein [LRG1], Fibromodulin [FMOD], Alpha-1-antichymotrypsin [SERPINA3], L-selectin [SELL], Monocyte differentiation antigen CD14 [CD14]) were screened. In the validation cohort, serum levels of LYZ and LRG1 showed a higher trend on the CRRT 7th day than that on the 1st day in the non-CRRT group. However, the changes in levels of LYZ and LRG1 on the 7th day was significant in the CRRT group (p = 0.016, p = 0.009, respectively). Moreover, the levels of LYZ and LRG1 on the CRRT 7th day in the CRRT group were significantly higher than that in the non-CRRT group (p < 0.001, p = 0.025). Decreased levels of CD14 were associated with sepsis recovery, but not associated with CRRT. There were no significantly difference in serum FMOD, SERPINA3, and SELL levels. Importantly, serum LYZ and LRG1 levels changed in CRRT responders, but not CRRT non-responders. Further analysis indicated that serum LYZ levels were correlated to total platelet counts, aspartate aminotransferase (ALT), alanine aminotransferase (AST), and albumin levels, and serum LRG1 level were correlated to total platelet count and TBIL levels on the 1st day in the CRRT group. Protein-protein interaction network analysis displayed that serum LYZ and LRG1 were involved in the process of inflammatory response, leucocytes adhesion to vascular endothelial cell, as well as complement activation. CONCLUSION Elevated serum LYZ and LRG1 levels are associated with clinical benefits of CRRT during sepsis.
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Affiliation(s)
- Yun Cui
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, 200062 China
| | - Shuyun Feng
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China
| | - Huijie Miao
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, 200062 China
| | - Tiantian Liu
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China
| | - Jingyi Shi
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, 200062 China
| | - Jiaying Dou
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, 200062 China
| | - Chunxia Wang
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, 200062 China ,grid.415625.10000 0004 0467 3069Clinical Research Unit, Shanghai Children’s Hospital, Shanghai, 200062 China
| | - Yucai Zhang
- grid.16821.3c0000 0004 0368 8293Department of Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062 China ,grid.16821.3c0000 0004 0368 8293Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, 200062 China
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Trepatchayakorn S, Sakunpunphuk M, Samransamruajkit R. Balanced Salt Solution Versus Normal Saline in Resuscitation of Pediatric Sepsis: A Randomized, Controlled Trial. Indian J Pediatr 2021; 88:921-924. [PMID: 34110580 PMCID: PMC8189839 DOI: 10.1007/s12098-021-03808-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/10/2021] [Indexed: 11/27/2022]
Abstract
Current evidences in resuscitation of adult sepsis have pointed to the importance of types of crystalloid fluid-related complications on resuscitation outcomes, but evidences are lacking in pediatric populations. In this study, the authors aimed to compare outcomes of pediatric sepsis resuscitation with different types of crystalloid. They randomly assigned pediatric sepsis patients requiring fluid bolus into three groups to receive either normal saline solution (NSS), Ringer lactate solution (RLS), or Sterofundin as fluid bolus therapy. Forty-two patients were included in the study. Median age was 29 mo and, weight 13 kg. After fluid bolus, the complications were not different among groups. However, in the RLS group, the patients who received large dose of the fluid showed significant reduction in urinary neutrophil gelatinase-associated lipocalin (uNGAL) level. It is concluded that fluid bolus therapy with different types of crystalloid solution did not result in different outcomes but large dose of RLS was associated with greater reduction of uNGAL level, compared to other fluids.Trial Registration: Thai Clinical Trial Registry (TCTR) identification number TCTR20170605001 (retrospectively registered on 1st June 2017). https://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task20=search&task2=view1&id=2576.
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Affiliation(s)
- Sirawut Trepatchayakorn
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathum Wan, Bangkok, 10330, Thailand.
| | - Manee Sakunpunphuk
- Department of Nursing, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathum Wan, Bangkok, 10330, Thailand
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11
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Zhang X, Cui Y, Ding X, Liu S, Han B, Duan X, Zhang H, Sun T. Analysis of mRNA‑lncRNA and mRNA‑lncRNA-pathway co‑expression networks based on WGCNA in developing pediatric sepsis. Bioengineered 2021; 12:1457-1470. [PMID: 33949285 PMCID: PMC8806204 DOI: 10.1080/21655979.2021.1908029] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Pediatric sepsis is a great threat to death worldwide. However, the pathogenesis has not been clearly understood until now in sepsis. This study identified differentially expressed mRNAs and lncRNAs based on Gene Expression Omnibus (GEO) database. And the weighted gene co-expression network analysis (WGCNA) was performed to explore co-expression modules associated with pediatric sepsis. Then, Gene Ontology (GO), KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway, mRNA‑lncRNA and mRNA‑lncRNA-pathway co-expression network analysis was conducted in selected significant module. A total of 1941 mRNAs and 225 lncRNAs were used to conduct WGCNA. And turquoise module was selected as a significant module that was associated with particular traits. The mRNAs functions associated with many vital processes were also shown by GO and KEGG pathway analysis in the turquoise module. Finally, 15 mRNAs (MAPK14, ITGAM, HK3, ALOX5, CR1, HCK, NCF4, PYGL, FLOT1, CARD6, NLRC4, SH3GLB1, PGS1, RAB31, LTB4R) and 4 lncRNAs (GSEC, NONHSAT160878.1, XR_926068.1 and RARA-AS1) were selected as hub genes in mRNA‑lncRNA-Pathway co-expression network. We identified 15 mRNAs and 4 lncRNAs as diagnostic markers, which have potential functions in pediatric sepsis. Our study provides more directions to study the molecular mechanism of pediatric sepsis.Abbreviations: mRNA: messenger RNA; lncRNA: long noncoding RNAs; GEO: Gene Expression Omnibus; WGCNA: weighted gene co-expression network analysis; GO: Gene Ontology; KEGG: Kyoto Encyclopedia of Genes and Genomes; SIRS: systemic inflammatory response syndrome; TOM: topological overlap measure; BP: biological process; MF: molecular function; CC: cellular component; ROC: receiver operating characteristic curve; AUC: area under curve; MAPK14: Mitogen-activated protein kinase 14; ALI: acute lung injury; ITGAM: Integrin subunit alpha M; HK3: Hexokinase 3; LPS: lipopolysaccharide; 5-LO: 5-lipoxygenase; LTs: leukotrienes; LTB4R: leukotriene B4 receptor.
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Affiliation(s)
- Xiaojuan Zhang
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
| | - Yuqing Cui
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
| | - Xianfei Ding
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
| | - Shaohua Liu
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
| | - Bing Han
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
| | - Xiaoguang Duan
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
| | - Haibo Zhang
- Interdepartmental Division of Critical Care Medicine, Departments of Anesthesia and Physiology, University of Toronto, Toronto, Canada
| | - Tongwen Sun
- General ICU, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, the First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou, China
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12
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Yaroustovsky M, Abramyan M, Rogalskaya E, Komardina E. Selective Polymyxin Hemoperfusion in Complex Therapy of Sepsis in Children after Cardiac Surgery. Blood Purif 2020; 50:222-229. [PMID: 33242859 DOI: 10.1159/000510126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND To date, sepsis remains one of the main challenges of intensive care in pediatrics. Newborns with low birth weight and infants with chronic diseases and congenital disorders are particularly at risk. The incidence of infectious complications in pediatric cardiac surgery is known to be approximately 15-30%. The main etiological factor of sepsis is endotoxin. AIM To evaluate the efficiency and safety of polymyxin (PMX) B-immobilized column-direct hemoperfusion in complex intensive therapy of sepsis in children after cardiac surgery with cardiopulmonary bypass. DESIGN Prospective cohort study. METHODS This study enrolled 15 children, aged 9-96 months, with congenital heart diseases and with body weights of 6.2-22.5 kg. The criteria for admission were body weight >6 kg and clinical and laboratory signs of sepsis (microbiological analysis, procalcitonin [PCT] >2 ng/mL, and endotoxin activity assay [ЕАА] >0.6). Intensive care included inotropic and vasopressor support, mechanical ventilation, broad-spectrum antibiotic therapy, and PMX hemoperfusion procedures. Extracorporeal therapy was initiated within 24 h following the sepsis diagnosis. Every patient underwent 2 hemoperfusion sessions with the use of a PMX B-immobilized column; the session duration was 180 min. RESULTS We noted improvements in hemodynamic parameters, oxygenation index, and laboratory signs of sepsis, with decreases in the endotoxin concentration according to the EAA, PCT, and presepsin levels. The 28-day survival of the patients in this severely affected group was 80%. Main Conclusion: The inclusion of extracorporeal methods of blood purification, aimed at the selective elimination of circulating endotoxin, in the treatment of sepsis increases the survival rates of children after open heart surgery. Second Conclusion: The obtained results of sepsis therapy with PMX hemoperfusion in children after cardiac surgery enable us to suggest the sufficient safety and efficiency of the procedures in this category of severely affected patients.
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Affiliation(s)
- Michail Yaroustovsky
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation,
| | - Marina Abramyan
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation
| | - Ekaterina Rogalskaya
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation
| | - Ekaterina Komardina
- Federal State Budget Institution "A.N. Bakulev National Medical Research Centre for Cardiovascular Surgery" of the Ministry of Healthcare of the Russian Federation (Bakulev NMRCCS), Moscow, Russian Federation
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13
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Hermon MM, Etmayr T, Brandt JB, Sadeghi K, Burda G, Golej J. Pediatric infection and sepsis in five age subgroups: single-center registry. Wien Med Wochenschr 2021; 171:29-35. [PMID: 33108806 DOI: 10.1007/s10354-020-00787-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/28/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sepsis is, worldwide, one of the leading causes of death among infants and children. Over the past two decades, mortality rates have declined due to advanced treatment options; however, the incidence of sepsis and septic shock is still on the rise in many hospital settings. The objective of this study was to evaluate the course of this disease in pediatric intensive care patients. METHODS An evaluation of pediatric patients in the intensive care unit diagnosed with infections or sepsis between 2005 and 2015 was performed via a retrospective exploratory data analysis. RESULTS During the observational period, 201 patients were diagnosed with infection or sepsis. The study population was divided into five age subgroups. The majority of patients were newborns, infants, and toddlers. Forty percent had sepsis; 6% had septic shock. Viral infection was the most prevalent (59%). The overall survival rate was 83%; newborns and adolescents had the lowest survival rates. CONCLUSION With this registry, children divided into five age subgroups with infection or sepsis were evaluated and treatment strategies were examined. We have shown that our findings on children treated in our pediatric intensive care unit conform with current literature about pediatric sepsis. In addition to maintaining strict hygiene standards, optimal aspects of sepsis care should be stringently observed, such as the quick administration of empirical broad-spectrum antibiotics, initial adequate fluid resuscitation, and a reliable and frequent routine of source control.
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14
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Ying J, Wang Q, Xu T, Lu Z. Diagnostic potential of a gradient boosting-based model for detecting pediatric sepsis. Genomics 2020; 113:874-883. [PMID: 33096256 DOI: 10.1016/j.ygeno.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/30/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022]
Abstract
Pediatric sepsis is a major cause of mortality of children worldwide. However, there is still a lack of easy-to-use predictive tools that can accurately diagnose sepsis in children. This study aimed to develop an optimal gene model for the diagnosis of pediatric sepsis using statistics and machine learning approaches. Combining gene expression profiles from a training cohort of 364 pediatric samples with a Least Absolute Shrinkage and Selection Operator analysis produced eighteen genes as diagnostic markers. With the implementation of a Gradient Boosting algorithm, a model designated PEDSEPS-GBM, that aggregated these markers was developed with optimal performance for the diagnosis of pediatric samples in the validation and two independent cohorts. Moreover, a web calculator with a user-friendly interface was established for PEDSEPS-GBM. This study presents a diagnostic model that holds great potential for the detection of pediatric sepsis, and demonstrates the biologic and clinical relevance of this model.
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Affiliation(s)
- Jianchao Ying
- Central Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Institute of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Qian Wang
- Department of Clinical Laboratory, Wenzhou People's Hospital, The Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, China
| | - Teng Xu
- Institute of Translational Medicine, Baotou Central Hospital, Baotou, China
| | - Zhongqiu Lu
- Institute of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Emergency Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
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15
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Bai Z, Li Y, Li Y, Pan J, Wang J, Fang F. Long noncoding RNA and messenger RNA abnormalities in pediatric sepsis: a preliminary study. BMC Med Genomics 2020; 13:36. [PMID: 32151258 PMCID: PMC7063742 DOI: 10.1186/s12920-020-0698-x] [Citation(s) in RCA: 6] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/21/2020] [Indexed: 12/13/2022] Open
Abstract
Background Sepsis represents a complex disease with dysregulated inflammatory response and high mortality rate. Long noncoding RNAs (lncRNAs) have been reported to play regulatory roles in a variety of biological processes. However, studies evaluating the function of lncRNAs in pediatric sepsis are scarce, and current knowledge of the role of lncRNAs in pediatric sepsis is still limited. The present study explored the expression patterns of both lncRNAs and mRNAs between pediatric sepsis patients and healthy controls based on a comprehensive microarray analysis. Methods LncRNA and mRNA microarray was used to detect the expression of lncRNAs and mRNAs in the septic and control groups. Aberrantly expressed mRNAs and lncRNAs identified were further interpreted by enrichment analysis, receiver operating characteristic (ROC) curve analysis, co-expression network analysis, and quantitative real-time PCR (qPCR). Results A total of 1488 differetially expressed lncRNAs and 1460 differentially expressed mRNAs were identified. A co-expression network of the identified lncRNAs and mRNAs was constructed. In this network, lncRNA lnc-RP11-1220 K2.2.1–7 is correlated with mRNA CXCR1 and CLEC4D; lncRNA lnc-ANXA3–2 is correlated with mRNA CLEC4D; lncRNA lnc-TRAPPC5–1 is correlated with mRNA DYSF and HLX; lncRNA lnc-ZNF638–1 is correlated with mRNA DYSF and HLX. Significantly different expressions between pediatric sepsis patients and controls were validated by qPCR for the 4 lncRNAs and 4 co-expressed mRNAs, validating the microarray results. Conclusions Our study contributes to a comprehensive understading of the involvment of lncRNAs and mRNAs in pediatric sepsis, which may guide subsequent experimental research. Furthermore, our study may also provide potential candidate lncRNAs and mRNAs for the diagnosis and treatment of pediatric sepsis.
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Affiliation(s)
- Zhenjiang Bai
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Yiping Li
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| | - Yanhong Li
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China.,Department of Nephrology, Children's Hospital of Soochow University, Suzhou, China
| | - Jian Pan
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| | - Jian Wang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China
| | - Fang Fang
- Institute of Pediatric Research, Children's Hospital of Soochow University, Suzhou, China.
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16
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Agrawal M, Rattan A. How to Treat Sepsis in the Background of Resistance?: Role of Pharmacodynamics / Pharmacokinetics in Treating Sepsis. Indian J Pediatr 2020; 87:111-6. [PMID: 31933137 DOI: 10.1007/s12098-019-03153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
Though a decline has been seen in child mortality and morbidity over the last decades, sepsis in neonates and infants remains a major cause of death. Optimal use of antibiotics in sepsis management is a key factor which can further reduce the number of poor clinical outcomes. Selecting the right antibiotic to which the offending bacteria is susceptible and administrating the antibiotic within the first hour can save many lives. However, the pharmacokinetic profile of an antibiotic is affected by developmental changes such as capacity of drug metabolizing enzymes and maturation of organ function. This can affect antibiotic exposure and response in neonates and infants. While suspecting sepsis, the primary focus of empiric treatment during the initial phase is to assure efficacy and it must be broad based to cover all suspected pathogens. Once the bacterial etiology is confirmed as a cause of sepsis and the in vitro antibiotic susceptibility is established, targeted treatment can be started which ensures optimal balance between efficacy and safety.
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17
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Diaz DA, Anderson M, Quelly SB, Clark KD, Talbert S. Early Recognition of Pediatric Sepsis Simulation Checklist - An Exploratory Study. J Pediatr Nurs 2020; 50:25-30. [PMID: 31675548 DOI: 10.1016/j.pedn.2019.10.004] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To report on the modification and exploration of a 21-item Early Detection of Pediatric Sepsis Assessment Checklist aimed at improving nursing students' recognition of key factors that contribute to early detection of sepsis in pediatric patients through clinical simulation. DESIGN AND METHODS One hundred and thirty-one undergraduate, pre-licensure nursing students were evaluated using the adapted 21-item Early Detection of Pediatric Sepsis Assessment Checklist in simulation using high-fidelity manikins. Categorical Principle Component Analysis was used to evaluate for factor structure, with items accounting for <0.20 of the variance were dropped from the loadings. RESULTS Two factors emerged from the analysis: assessment and deterioration, accounting for 68% of the variance. Factor one, assessment, contained nine items (α = 0.77; λ = 3.36). Factor two, deterioration, contained seven items (α = 0.72; λ = 2.85). Five items did not load and were dropped from the factor structure, resulting in a 16-item checklist. CONCLUSIONS Two factors emerged from the analysis which is key to improving the early detection of pediatric sepsis. Assessment, factor one, accounted for the nursing students' central skills of recognizing baseline vital signs and timely medication administration. Deterioration, factor two, contained items reflecting the recognition of changes from baseline that require action. Conceptually, these factors reflect the most central points in the early detection of signs in pediatric patients at risk for sepsis. PRACTICE IMPLICATIONS This checklist forms a valuable tool to assess the knowledge of pre-licensure students and may possibly be extended as a tool to assess the clinical readiness and performance of new graduates through the safety and supervision allotted by simulation.
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Affiliation(s)
- Desiree A Diaz
- University of Central Florida, Orlando, FL, United States of America.
| | - Mindi Anderson
- University of Central Florida, Orlando, FL, United States of America.
| | - Susan B Quelly
- University of Central Florida, Orlando, FL, United States of America.
| | - Kristen D Clark
- University of California San Francisco, California, United States of America.
| | - Steve Talbert
- University of Central Florida, Orlando, FL, United States of America.
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18
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Stevens C, Ton E, Jones P, Shattuck B. A complicated case of bowel obstruction with sepsis and methamphetamine toxicity in a child with pica. Forensic Sci Med Pathol 2019; 15:598-602. [PMID: 31444700 DOI: 10.1007/s12024-019-00143-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 11/25/2022]
Abstract
In this report, a pediatric case of bowel obstruction with sepsis complicated by methamphetamine toxicity is described. The decedent, an eleven-year-old female with a clinical history of pica, was found unresponsive in her home and pronounced dead following unsuccessful resuscitative efforts. Radiologic imaging showed multiple radio-opaque foreign objects in the stomach and bowel. Autopsy revealed a green leafy substance, coins and other metallic items, folded paper, and plastic in her stomach and bowels. Postmortem iliac blood and urine tested positive for amphetamine and methamphetamine. While the decedent's medical history and autopsy findings provided evidence consistent with bowel obstruction with sepsis due to the ingestion of foreign materials, the high methamphetamine concentration was suggestive of concurrent methamphetamine toxicity. Unique complications associated with this case include the phenomenon that methamphetamine toxicity and bowel obstruction can present similarly in children and the reported opinion that accidental drug ingestion is uncommon in children over the age of five. This case emphasizes that the age range for suspected accidental drug ingestion should be expanded for those with pica, as these patients, despite being older, may not be able to differentiate between what they should and should not ingest. Furthermore, when treating a pediatric patient with pica that appears to present with bowel obstruction, unintentional drug ingestion should also be considered, particularly if there is a suspicion that the child lives in a household where drugs are abused, given the prospect that drug toxicity can present similarly.
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Affiliation(s)
- Christine Stevens
- Western Michigan University Homer Stryker M.D. School of Medicine, 276 Portage Street #200, Kalamazoo, MI, 49007, USA.
| | - Erinn Ton
- Western Michigan University Homer Stryker M.D. School of Medicine, 276 Portage Street #200, Kalamazoo, MI, 49007, USA
| | - Prentiss Jones
- Western Michigan University Homer Stryker M.D. School of Medicine, 276 Portage Street #200, Kalamazoo, MI, 49007, USA
| | - Brandy Shattuck
- Western Michigan University Homer Stryker M.D. School of Medicine, 276 Portage Street #200, Kalamazoo, MI, 49007, USA
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Nazir M, Wani W, Dar SA, Mir IH, Charoo BA, Ahmad QI, Wajid S. Lactate clearance prognosticates outcome in pediatric septic shock during first 24 h of intensive care unit admission. J Intensive Care Soc 2019; 20:290-298. [PMID: 31695733 DOI: 10.1177/1751143719855202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This study was undertaken to examine the clinical utility of lactate clearance as an indicator of mortality in pediatric septic shock, and to compare the performance of lactate clearance at 6, 12, and 24 h for predicting in-hospital and 60-day mortality. Pediatric patients with septic shock were prospectively studied. Vital signs, laboratory values, Pediatric Risk of Mortality Score, and pediatric logistic organ dysfunction score were obtained at presentation (hour 0), hour 6, hour 24 and over the first 72 h of hospitalization. Lactate clearance was obtained at 6, 12, and 24 h of hospital admission. Therapy received, outcome parameters of mortality, and duration of hospitalization were recorded. The primary outcome variable of 60-day mortality rate was 31.25%. Only lactate clearance at 6 and 24 h was significantly associated with mortality, with odds of 0.97 (95% CI, 0.951-981; p < 0.001) and 0.975 (95% CI, 0.964-0.986; p < 0.001), respectively. Approximately there was a 24% decrease in likelihood of mortality for each 10% increase in lactate clearance at 24 h. At a threshold value of 10% 6-h lactate clearance had a sensitivity of 0.948 and specificity of 0.571, while at a threshold of 20% 24-h lactate clearance had a sensitivity of 0.922 and specificity of 0.629. The comparison of clearance at 6 and 24 h using receiver operating characteristic showed that former was "fair" (area under the curve = 0.753) and later was "good" (area under the curve = 0.81) in predicting mortality in pediatric septic shock. Conclusion We concluded that optimal lactate clearance in pediatric septic shock both during the early presentation and after the initial "golden hours" is associated with lower in-hospital and 60-day mortality. Further, 24-h lactate clearance appears superior to 6 h lactate clearance in predicting mortality in such patients.
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Affiliation(s)
- Mudasir Nazir
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Wasim Wani
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Sheeraz Ahmad Dar
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Inamul-Haq Mir
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Bashir Ahmad Charoo
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Qazi Iqbal Ahmad
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
| | - Syed Wajid
- Department of Pediatrics and Neonatology, Sher-I-Kashmir Institute of Medical Sciences Hospital, Srinagar, India
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20
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Thakkar RK, Weiss SL, Fitzgerald JC, Keele L, Thomas NJ, Nadkarni VM, Muszynski JA, Hall MW. Risk Factors for Mortality in Pediatric Postsurgical versus Medical Severe Sepsis. J Surg Res 2019; 242:100-110. [PMID: 31075654 DOI: 10.1016/j.jss.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/20/2019] [Accepted: 04/04/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sepsis is a leading cause of morbidity and mortality after surgery. Most studies regarding sepsis do not differentiate between patients who have had recent surgery and those without. Few data exist regarding the risk factors for poor outcomes in pediatric postsurgical sepsis. Our hypothesis is pediatric postsurgical, and medical patients with severe sepsis have unique risk factors for mortality. METHODS Data were extracted from a secondary analysis of an international point prevalence study of pediatric severe sepsis. Sites included 128 pediatric intensive care units from 26 countries. Pediatric patients with severe sepsis were categorized into those who had recent surgery (postsurgical sepsis) versus those that did not (medical sepsis) before sepsis onset. Multivariable logistic regression models were used to determine risk factors for mortality. RESULTS A total of 556 patients were included: 138 with postsurgical and 418 with medical sepsis. In postsurgical sepsis, older age, admission from the hospital ward, multiple organ dysfunction syndrome at sepsis recognition, and cardiovascular and respiratory comorbidities were independent risk factors for death. In medical sepsis, resource-limited region, hospital-acquired infection, multiple organ dysfunction syndrome at sepsis recognition, higher Pediatric Index of Mortality-3 score, and malignancy were independent risk factors for death. CONCLUSIONS Pediatric patients with postsurgical sepsis had different risk factors for mortality compared with medical sepsis. This included a higher mortality risk in postsurgical patients presenting to the intensive care unit from the hospital ward. These data suggest an opportunity to develop and test early warning systems specific to pediatric sepsis in the postsurgical population.
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Affiliation(s)
- Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio.
| | - Scott L Weiss
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Luke Keele
- Center for Surgery and Economic, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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Zallocco F, Osimani P, Carloni I, Romagnoli V, Angeloni S, Cazzato S. Assessment of clinical outcome of children with sepsis outside the intensive care unit. Eur J Pediatr 2018; 177:1775-1783. [PMID: 30225636 DOI: 10.1007/s00431-018-3247-2] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 08/07/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022]
Abstract
In 2016, in order to identify adult patients with sepsis who are likely to have poor outcomes, the Third International Consensus Definitions Task Force introduced a new bedside index, called the quick Sepsis-related Organ Failure Assessment (qSOFA) score. However, these new criteria have not been validated in the pediatric population. In this study, we sought to assess the qSOFA score for children with sepsis, who are being treated outside the pediatric intensive care units. The qSOFA criteria were revised and applied to a study population of 89 pediatric patients with sepsis, admitted in a pediatric tertiary referral center from 2006 to 2016. The analysis of prognostic performance of qSOFA score for the prediction of severe sepsis showed a sensitivity of 46% (95% CI, 27-67%), a specificity of 74% (95% CI, 62-85%), a positive predictive value of 43% (95% CI, 34-52%), and a negative predictive value of 77% (95% CI, 71-82%). The area under ROC curve for qSOFA score ≥ 2 was 0.602 (95% CI 0.492-0.705).Conclusion: The qSOFA score showed a low accuracy to identify children in the pediatric ward at risk for severe sepsis. Clinical tools are needed to facilitate the diagnosis of impending organ dysfunction in pediatric infection outside of the ICU. What is Known: • One of the major challenges for clinicians is to identify and recognize children with sepsis and impending organ dysfunction, in the emergency and in the pediatric department. • In 2016, members of the Sepsis-3 task force proposed qSOFA, an empirically derived score using simple clinical criteria, to assist clinicians in identifying adult patients with sepsis at risk for poor outcome. What is New: • qSOFA demonstrated insufficient clinical value to be recommended as a screening tool for pediatric sepsis outside ICU. • D-dimer level and blood glucose may be useful biomarkers to identify children at risk for severe sepsis.
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Affiliation(s)
- Federica Zallocco
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Patrizia Osimani
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Ines Carloni
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Vittorio Romagnoli
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Silvia Angeloni
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy
| | - Salvatore Cazzato
- Pediatrics and Infectious Disease Unit, G. Salesi Children's Hospital, Ancona, Italy. .,Pediatrics and Infectious Disease Unit, Department of Mother and Child Health, G. Salesi Children's Hospital, Via Corridoni 11, 60123, Ancona, Italy.
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Vidrine R, Atreya MR, Stalets EL. Continuum of care in pediatric sepsis: a prototypical acute care delivery model. Transl Pediatr 2018; 7:253-261. [PMID: 30460176 PMCID: PMC6212391 DOI: 10.21037/tp.2018.10.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 11/06/2022] Open
Abstract
Sepsis is a burdensome public health problem and a leading cause of infant and child morbidity and mortality across the world. Few proven therapies exist to treat septic shock and the mainstay of management remains judicious fluid resuscitation and timely antibiotics. In its most recent iteration, the American College of Critical Care Medicine (ACCM) guidelines on hemodynamic support in pediatric septic shock recommends an institutional approach to the management of septic shock rather than one aimed at the individual practitioner. The acute care delivery model has been proposed as a way to guide quality improvement in emergency care and to improve care delivery. In this review, we summarize current recommendations in the management of pediatric patients with septic shock, and highlight opportunities to provide seamless care by application of the acute care model.
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Affiliation(s)
- Rhea Vidrine
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mihir R. Atreya
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Erika L. Stalets
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Li Y, Li Y, Bai Z, Pan J, Wang J, Fang F. Identification of potential transcriptomic markers in developing pediatric sepsis: a weighted gene co-expression network analysis and a case-control validation study. J Transl Med 2017; 15:254. [PMID: 29237456 DOI: 10.1186/s12967-017-1364-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/08/2017] [Indexed: 01/23/2023] Open
Abstract
Background Sepsis represents a complex disease with the dysregulated inflammatory response and high mortality rate. The goal of this study was to identify potential transcriptomic markers in developing pediatric sepsis by a co-expression module analysis of the transcriptomic dataset. Methods Using the R software and Bioconductor packages, we performed a weighted gene co-expression network analysis to identify co-expression modules significantly associated with pediatric sepsis. Functional interpretation (gene ontology and pathway analysis) and enrichment analysis with known transcription factors and microRNAs of the identified candidate modules were then performed. In modules significantly associated with sepsis, the intramodular analysis was further performed and “hub genes” were identified and validated by quantitative real-time PCR (qPCR) in this study. Results 15 co-expression modules in total were detected, and four modules (“midnight blue”, “cyan”, “brown”, and “tan”) were most significantly associated with pediatric sepsis and suggested as potential sepsis-associated modules. Gene ontology analysis and pathway analysis revealed that these four modules strongly associated with immune response. Three of the four sepsis-associated modules were also enriched with known transcription factors (false discovery rate-adjusted P < 0.05). Hub genes were identified in each of the four modules. Four of the identified hub genes (MYB proto-oncogene like 1, killer cell lectin like receptor G1, stomatin, and membrane spanning 4-domains A4A) were further validated to be differentially expressed between septic children and controls by qPCR. Conclusions Four pediatric sepsis-associated co-expression modules were identified in this study. qPCR results suggest that hub genes in these modules are potential transcriptomic markers for pediatric sepsis diagnosis. These results provide novel insights into the pathogenesis of pediatric sepsis and promote the generation of diagnostic gene sets. Electronic supplementary material The online version of this article (10.1186/s12967-017-1364-8) contains supplementary material, which is available to authorized users.
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Abstract
OBJECTIVES Oxidative stress is known to participate in the progression of sepsis. Definite data regarding the behavior of oxidative stress biomarkers in pediatric sepsis is still lacking. This study hypothesized that oxidative stress occurs in pediatric sepsis and that the magnitude of the redox derangement is associated with worse clinical progression. METHODS Forty-two previously healthy pediatric patients with sepsis and a group of control subjects were included. Oxidative stress and inflammatory activity biomarkers were determined in blood samples. Patients were prospectively followed until their discharge or death. RESULTS Patients with non-severe and severe sepsis showed higher levels of plasmatic antioxidant capacity, lower erythrocyte thiol index, lower superoxide dismutase and catalase activities, higher glutathione peroxidase activity, and higher plasmatic F2-isoprostanes concentration than controls. Patients with severe sepsis had higher NF-kappaB activation than those with non-severe sepsis. Although we observed changes in some biomarkers in patients with worse clinical evolution, the explored biomarkers did not correlate with clinical estimators of outcome. DISCUSSION Oxidative stress occurs in pediatric sepsis, resulting in oxidative damage. The explored biomarkers are not useful as outcome predictors in the studied population. The behavior of these biomarkers still needs to be addressed in broader groups of pediatric patients with sepsis.
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Affiliation(s)
- Víctor Molina
- a Pediatric Intensive Care Unit , Hospital de Niños Roberto del Río , Santiago , Chile
| | - Bettina von Dessauer
- a Pediatric Intensive Care Unit , Hospital de Niños Roberto del Río , Santiago , Chile
| | - Ramón Rodrigo
- b Laboratory of Renal Pathophysiology, Molecular and Clinical Pharmacology Program , Institute of Biomedical Sciences, Faculty of Medicine, University of Chile , Santiago , Chile
| | - Cristian Carvajal
- a Pediatric Intensive Care Unit , Hospital de Niños Roberto del Río , Santiago , Chile
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