Kathrin Jähne - Academia.edu (original) (raw)
Papers by Kathrin Jähne
JAMA Network Open
IMPORTANCE Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinica... more IMPORTANCE Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship. OBJECTIVE To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments.
Background and Purpose: Thromboelastography (TEG) is often used to measure coagulation dynamics i... more Background and Purpose: Thromboelastography (TEG) is often used to measure coagulation dynamics in the setting of acute ischemic stroke and thrombolytic therapy. The stability of thrombolytics has not been investigated in TEG. We conducted an experimental series to test the effects of recombinant tissue plasminogen activator (rtPA) on fibrinolysis in normal blood samples using TEG. Methods: Freeze dried rtPA powder was reconstituted in normal saline containing 0.2% bovine serum albumin (100 mg/24 mL), divided into 1 mL aliquots, and diluted to enable using a relatively large volume for complete mixing with blood samples. Aliquots and dilutions were frozen at -20°C. The same rtPA dilution was thawed to ambient temperature before each use and refrozen until the next use over 4 testing days. Blood was drawn into 3.2% sodium citrated collection tubes. rtPA (100 μL) was added to 1 mL whole blood to achieve a 636 ng/mL rtPA TEG sample concentration. Control-whole blood and rtPA- whole blood TEG was performed for 3 h on 4 healthy human blood samples. Maximum clot amplitude (mm) and absolute clot strength (dynes/cm) were measured. Data (mean±SD) were analyzed by t-tests and significance inferred at p\u3c0.05. Results: Clot amplitude increased with thawing and refreezing (28±3, p=0.004; 35±2 p=0.01; 50±3, p=0.02; and 55±3, p=0.30; for testing cycles 1, 2, 3 and 4, respectively) compared to untreated samples (63±4). Clot strength also increased over the 4 cycles (2±0.3, p=0.007; 3±0.2, p=0.02; 5±05, p=0.01 and 6±0.7, p=0.30) compared to untreated (9±1.4). Lysis initiation time was gradually longer over the 4 tests (red arrows, Figure 1) suggesting delayed fibrinolysis. Conclusions: One repeatedly thawed and refrozen rtPA stock showed a delay in fibrinolysis in healthy human blood, suggesting a loss of potency. Thus, rtPA should be aliquoted for 1-time use for experiments using TEG. Further investigation into rtPA potency deterioration with storage after reconstitution is warranted. (Figure presented)
Introduction: Sepsis continues to be a disease with high mortality and morbidity. Pathophysiologi... more Introduction: Sepsis continues to be a disease with high mortality and morbidity. Pathophysiologic understanding continues to be limited. Research has focused in the past on freely circulating inflammatory cells, cytokines, RNAs and DNAs without yielding much insight into the complex processes of these entities in the development of multiorgan dysfunction. Cell to cell communication and organ crosstalk is not only dependent on the free circulating markers, but may be more precisely modulated by extracellular vesicles (EV) such as exosomes and microvesicles, which contain protein markers along with RNA and DNA components in a defined structure. The composition of these vesicles along with variation in their size and amount could be another important puzzle piece to understand the pathophysiology of sepsis. Hypothesis: We aimed to examine variations size distribution of extracellular vesicles in patients with sepsis at time of their presentation and compare these with healthy controls healthy controls. Methods: Blood plasma samples were obtained from 10 patients at the time of presentation to the emergency department and 6 healthy control, after informed consent (HFHS IRB 1578, IRB 11000). Plasma was immediately frozen and stored at -80°C. For EV extraction samples were defrosted once and Invitrogen™ Total Exosome Extraction kit (from plasma) was used, according to manufactures protocol. EV pellets were re-suspended in PBS. Nanoparticle tracking analysis (NTA, NanoSight NS 300) was done at a standard dilution of 1:5.000. Western blots (ALIX, CD63, CD9, HSP70) and electron microscopy was conducted to confirm presence of EVs. Results: The average size of extracellular vesicles on NTA for patients with sepsis was 82.3 ± 106.5 nm and for healthy controls 71.3 ± 30.8 nm, p = 0.03. The average size of extracellular vesicles was 79.6 ± 152.1 nm for sepsis survivors (N = 6), 86.5 ± 28.3 for sepsis nonsurvivors (N = 4) and 71.3 ± 30.8 nm for healthy controls, p = 0.05. There was no statistical difference in the particle size between sepsis survivors and sepsis non-survivors. Conclusion: Size of extracellular vesicles in patients with sepsis at the time of presentation to the emergency department differs from the size of extracellular vesicles in healthy volunteers. Outlook: Differences in extracellular vesicle size at the time of presentation potentially indicate increased cellular processes and may be used in the future to aid diagnosis of sepsis
RATIONALE: New Sepsis-3 definitions have been published, stating that sepsis is a “life-threateni... more RATIONALE: New Sepsis-3 definitions have been published, stating that sepsis is a “life-threatening organ dysfunction caused by a dysregulated host response to infection”. The Sepsis-3 authors identified that “Limitations of previous definitions included an excessive focus on inflammation and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria.” With the new definitions it was proposed that identification of septic patients with a dysregulated host response is aided by the use of a quick SOFA (qSOFA) score and not by the use of SIRS criteria. qSOFA score is considered abnormal when 2 of 3 criteria are met. These criteria include sytolic blood pressure \u3c 100mmHg, respiratory rate \u3e 24 and mental status changes. We re-examined an established data-base for patients with vasopressor dependent septic shock comparing SIRS criteria to qSOFA criteria in concern to available measured cytokine markers as indicator of a dysregulated host response. If qSOFA indicates an abnormal host response, prominent cytokine markers such as IL-1RA, IL-1α, IL-6, IL-8, IL-10 and TNF-α should show similar trends as SIRS criteria. METHODS: Re-examination of established IRB approved research data base for patients with vasopressor dependent septic shock with measured multiplex cytokine markers (Milliplex HCYTMAG-60K-PX29) as indicator of a dysregulated host response to infection in concern to SIRS criteria and newly established qSOFA score. RESULTS: For 174 patients data was re-examined. At the time of enrollment within 24 hours following shock onset the average qSOFA score was 1.47 and average SIRS criteria 2.06. Table 1 shows measured cytokine values in regard to number of either SIRS criteria or qSOFA score. The average values of measured cytokine markers increased with increasing number of SIRS criteria for IL-1RA, IL-1a, IL-6, IL-8, IL-10 and TNF-a. Similar cytokine increases in relation to the number of qSOFA score was only seen for IL-8, IL-10 and TNF-a.∗Average values shown as ng/mL (Table presented). CONCLUSION. In patients with vasopressor dependent shock increasing SIRS criteria are related to increases in measured circulating cytokine markers of inflammation. Circulating cytokine markers as indicator for an abnormal host response to infection do not increase with increasing qSOFA scores similar to the SIRS criteria and therefore may not be indicative of all aspects of this dysregulated host response
Open Forum Infectious Diseases, 2021
Background Difficulty discriminating bacterial from viral infections drives antibacterial misuse.... more Background Difficulty discriminating bacterial from viral infections drives antibacterial misuse. Host gene expression tests discriminate bacterial and viral etiologies, but their clinical utility has not been evaluated. Methods Host gene expression and procalcitonin levels were measured in 582 emergency department participants with suspected infection. We also recorded clinician diagnosis and clinician-recommended treatment. These 4 diagnostic strategies were compared with clinical adjudication as the reference. To estimate the clinical impact of host gene expression, we calculated the change in overall Net Benefit (∆NB; the difference in Net Benefit comparing 1 diagnostic strategy with a reference) across a range of prevalence estimates while factoring in the clinical significance of false-positive and -negative errors. Results Gene expression correctly classified bacterial, viral, or noninfectious illness in 74.1% of subjects, similar to the other strategies. Clinical diagnosis a...
Journal of Clinical Medicine, 2020
Background: Septic Emergency Department (ED) patients provide a unique opportunity to investigate... more Background: Septic Emergency Department (ED) patients provide a unique opportunity to investigate early sepsis. Recent work focuses on exosomes, nanoparticle-sized lipid vesicles (30–130 nm) that are released into the bloodstream to transfer its contents (RNA, miRNA, DNA, protein) to other cells. Little is known about how early changes related to exosomes may contribute to the dysregulated inflammatory septic response that leads to multi-organ dysfunction. We aimed to evaluate proteomic profiles of plasma derived exosomes obtained from septic ED patients and healthy controls. Methods: This is a prospective observational pilot study evaluating a plasma proteomic exosome profile at an urban tertiary care hospital ED using a single venipuncture blood draw, collecting 40 cc Ethylenediaminetetraacetic acid (EDTA) blood. Measurements: We recruited seven patients in the ED within 6 h of their presentation and five healthy controls. Plasma exosomes were isolated using the Invitrogen Total E...
Open Forum Infectious Diseases, 2020
Background Discriminating bacterial and viral infections remains clinically challenging. The resu... more Background Discriminating bacterial and viral infections remains clinically challenging. The resulting antibacterial misuse contributes to antimicrobial resistance. Host gene expression-based tests are a promising strategy to discriminate of bacterial and viral infections, but their potential clinical utility has not yet been evaluated. Methods A host gene expression biosignature was measured using either qRT-PCR or microarray in 683 ED subjects with suspected infection. Based on chart reviews, we recorded clinical diagnosis as defined both by the provider assessment and by the provider treatment plan. The biosignature, diagnosis, treatment plan, and procalcitonin were compared to clinical adjudication as the reference standard. With this as a baseline, we then calculated average weighted accuracy (AWA) and change in overall net benefit (∆NB), weighting bacterial false negatives four times more seriously than false positives. Results Gene expression correctly classified the three po...
Journal of Clinical Medicine, 2020
The approach to shock resuscitation focuses on all components of oxygen delivery, including prelo... more The approach to shock resuscitation focuses on all components of oxygen delivery, including preload, afterload, contractility, hemoglobin, and oxygen saturation. Resuscitation focused solely on preload and fluid responsiveness minimizes other key elements, resulting in suboptimal patient care. This review will provide a physiologic and practical approach for the optimization of oxygen delivery utilizing available hemodynamic monitoring technologies. Venous oxygen saturation (SvO2) and lactate will be discussed as indicators of shock states and endpoints of resuscitation within the framework of resolving oxygen deficit and oxygen debt.
Surgical Innovation, 2020
Introduction. Patients presenting with symptoms of gastroesophageal reflux disease (GERD) are usu... more Introduction. Patients presenting with symptoms of gastroesophageal reflux disease (GERD) are usually evaluated by gastroenterologists who perform the diagnostic workup and determine when to refer for surgical consideration. The multiple diagnostic studies can be overwhelming, and this leads to dropouts. In a rural setting, without gastroenterology services, the surgeon can diagnose GERD and perform antireflux procedures. This study aimed to assess the completion of the required diagnostic studies and progression to surgical intervention. Methods. This is a retrospective chart review of patients who presented with GERD symptoms between August 2015 and January 2018. Standardized workup included the upper gastrointestinal study and esophagogastroduodenoscopy with concomitant wireless pH placement. High-resolution impedance manometry and the gastric emptying scan were selectively utilized. Results. 429 patients were evaluated. Proton pump inhibitors were used by 82.2% of patients. The ...
Biomarkers, 2020
Clinical significance: Sepsisis defined as life threatening organ-dysfunction caused by the dysre... more Clinical significance: Sepsisis defined as life threatening organ-dysfunction caused by the dysregulated host response to an infection. The diagnosis can be cryptic and mimic other disease states. Early administration of antibiotics, restoration of tissue perfusion, and source control are paramount to treatment. Biomarkers associated with disease presence or that predict poor outcomes prior to definitive diagnostics would have great utility. Our data reveal a linear relationship between F-actin levels and qSOFA scores in patients at risk for sepsis in the Emergency Department. Increased F-actin levels are also associated with Intensive Care Unit admission and presence of positive urine cultures.
EBioMedicine, 2019
Background: Distinguishing bacterial and viral respiratory infections is challenging. Novel diagn... more Background: Distinguishing bacterial and viral respiratory infections is challenging. Novel diagnostics based on differential host gene expression patterns are promising but have not been translated to a clinical platform nor extensively tested. Here, we validate a microarray-derived host response signature and explore performance in microbiology-negative and coinfection cases. Methods: Subjects with acute respiratory illness were enrolled in participating emergency departments. Reference standard was an adjudicated diagnosis of bacterial infection, viral infection, both, or neither. An 87-transcript signature for distinguishing bacterial, viral, and noninfectious illness was measured from peripheral blood using RT-PCR. Performance characteristics were evaluated in subjects with confirmed bacterial, viral, or noninfectious illness. Subjects with bacterial-viral coinfection and microbiologicallynegative suspected bacterial infection were also evaluated. Performance was compared to procalcitonin. Findings: 151 subjects with microbiologically confirmed, single-etiology illness were tested, yielding AU-ROCs 0•85-0•89 for bacterial, viral, and noninfectious illness. Accuracy was similar to procalcitonin (88% vs 83%, p = 0•23) for bacterial vs. non-bacterial infection. Whereas procalcitonin cannot distinguish viral from non-infectious illness, the RT-PCR test had 81% accuracy in making this determination. Bacterialviral coinfection was subdivided. Among 19 subjects with bacterial superinfection, the RT-PCR test identified 95% as bacterial, compared to 68% with procalcitonin (p = 0•13). Among 12 subjects with bacterial infection superimposed on chronic viral infection, the RT-PCR test identified 83% as bacterial, identical to procalcitonin. 39 subjects had suspected bacterial infection; the RT-PCR test identified bacterial infection more frequently than procalcitonin (82% vs 64%, p = 0•02). Interpretation: The RT-PCR test offered similar diagnostic performance to procalcitonin in some subgroups but offered better discrimination in others such as viral vs. non-infectious illness and bacterial/viral coinfection. Gene expression-based tests could impact decision-making for acute respiratory illness as well as a growing number of other infectious and non-infectious diseases.
Journal of Intensive Care, 2018
Background: Sepsis biomarker panels that provide diagnostic and prognostic discrimination in seps... more Background: Sepsis biomarker panels that provide diagnostic and prognostic discrimination in sepsis patients would be transformative to patient care. We assessed the mortality prediction and diagnostic discriminatory accuracy of two biomarkers reflective of cell death (apoptosis), circulating cell-free DNA (cfDNA), and nucleosomes. Methods: The cfDNA and nucleosome levels were assayed in plasma samples acquired in patients admitted from four emergency departments with suspected sepsis. Subjects with non-infectious systemic inflammatory response syndrome (SIRS) served as controls. Samples were acquired at enrollment (T0) and 24 h later (T24). We assessed diagnostic (differentiating SIRS from sepsis) and prognostic (28-day mortality) predictive power. Models incorporating procalcitonin (diagnostic prediction) and APACHE II scores (mortality prediction) were generated. Results: Two hundred three subjects were included (107 provided procalcitonin measurements). Four subjects exhibited uncomplicated sepsis, 127 severe sepsis, 35 septic shock, and 24 had non-infectious SIRS. There were 190-survivors and 13 non-survivors. Mortality prediction models using cfDNA, nucleosomes, or APACHEII yielded AUC values of 0.61, 0.75, and 0.81, respectively. A model combining nucleosomes with the APACHE II score improved the AUC to 0.84. Diagnostic models distinguishing sepsis from SIRS using procalcitonin, cfDNA(T0), or nucleosomes(T0) yielded AUC values of 0.64, 0.65, and 0.63, respectively. The three parameter model yielded an AUC of 0.74. Conclusions: To our knowledge, this is the first head-to-head comparison of cfDNA and nucleosomes in diagnosing sepsis and predicting sepsis-related mortality. Both cfDNA and nucleosome concentrations demonstrated a modest ability to distinguish sepsis survivors and non-survivors and provided additive diagnostic predictive accuracy in differentiating sepsis from non-infectious SIRS when integrated into a diagnostic prediction model including PCT and APACHE II. A sepsis biomarker strategy incorporating measures of the apoptotic pathway may serve as an important component of a sepsis diagnostic and mortality prediction tool.
SAGE open medical case reports, 2017
Jehovah's Witness patients pose a unique surgical challenge due to their refusal of transfusi... more Jehovah's Witness patients pose a unique surgical challenge due to their refusal of transfusion of whole blood or major blood products. One of the surgical strategies is to offer the least invasive approach with the least likelihood of losing blood. In the context of surgical treatment of gastroesophageal reflux disease, endoluminal approaches such as transoral incisionless fundoplication represent an appropriate approach for Jehovah's Witness patients. This patient is a devout Jehovah's Witness who was troubled with gastroesophageal reflux disease for many years which was refractory to proton pump inhibitor therapy. Her standard preoperative workup showed that she was a candidate for transoral incisionless fundoplication. Surgery was performed by a transoral incisionless fundoplication certified surgeon and this patient was his second case. Patient had no immediate or long-term complications. She was successfully weaned off proton pump inhibitors. Transoral incisionless...
Annals of emergency medicine, Jan 26, 2017
Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose o... more Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose of this investigation is to examine the prevalence of baseline abnormal lactate levels and to evaluate the effects of hemodialysis on serum lactate levels. This was a prospective observational cohort study performed at an outpatient dialysis facility at an urban tertiary care hospital. The study consisted of 226 patients with end-stage renal disease who were receiving long-term hemodialysis and were enrolled during a 2-day period at the beginning of December 2015. Blood drawn for lactate levels was immediately analyzed before and after hemodialysis sessions. All patients completed their hemodialysis sessions. The prevalence of an abnormal lactate level (greater than 1.8 mmol/L) before hemodialysis was 17.7% (n=40). Overall, lactate levels decreased by 27% (SD 35%) after hemodialysis, with a decrease of 37% (SD 31%) for subgroups with a lactate level of 1.9 to 2.4 mmol/L, and 62% (SD 14%) ...
Critical Care Medicine, 2016
Dr. Jaehne received funding from Henry Ford Hospital (part-time employee) and ASPIRUS Hospital Ir... more Dr. Jaehne received funding from Henry Ford Hospital (part-time employee) and ASPIRUS Hospital Iron River, MI (part-time employee). Dr. Rivers disclosed other support. He currently conducts research for Abbott Laboratories, Alere, Spectral Diagnostics, and the National Institutes of Health. The early goal-directed therapy study was performed without extra mural (academic or industry) funding. All catheters used and equipment in the study were paid by Henry Ford Hospital to Edwards Lifesciences.
Science translational medicine, Jan 20, 2016
Acute respiratory infections caused by bacterial or viral pathogens are among the most common rea... more Acute respiratory infections caused by bacterial or viral pathogens are among the most common reasons for seeking medical care. Despite improvements in pathogen-based diagnostics, most patients receive inappropriate antibiotics. Host response biomarkers offer an alternative diagnostic approach to direct antimicrobial use. This observational cohort study determined whether host gene expression patterns discriminate noninfectious from infectious illness and bacterial from viral causes of acute respiratory infection in the acute care setting. Peripheral whole blood gene expression from 273 subjects with community-onset acute respiratory infection (ARI) or noninfectious illness, as well as 44 healthy controls, was measured using microarrays. Sparse logistic regression was used to develop classifiers for bacterial ARI (71 probes), viral ARI (33 probes), or a noninfectious cause of illness (26 probes). Overall accuracy was 87% (238 of 273 concordant with clinical adjudication), which was ...
Biomarkers : biochemical indicators of exposure, response, and susceptibility to chemicals, Jan 12, 2016
To compare plasma levels of F-actin, G-actin and thymosin beta 4 (TB4) in humans with septic shoc... more To compare plasma levels of F-actin, G-actin and thymosin beta 4 (TB4) in humans with septic shock, noninfectious systemic inflammatory response syndrome (SIRS) and healthy controls. F-actin was significantly elevated in septic shock as compared with noninfectious SIRS and healthy controls. G-actin levels were greatest in the noninfectious SIRS group but significantly elevated in septic shock as compared with healthy controls. TB4 was not detectable in the septic shock or noninfectious SIRS group above the assay's lowest detection range (78 ng/ml). F-actin is significantly elevated in patients with septic shock as compared with noninfectious SIRS. F-actin and the F:G-actin ratio are potential biomarkers for the diagnosis of septic shock.
Current Opinion in Critical Care, 2015
The purpose of this study is to review the recent literature examining the clinical utility of ma... more The purpose of this study is to review the recent literature examining the clinical utility of markers of systemic oxygen extraction and perfusion in the diagnosis, treatment and prognosis of severe sepsis and septic shock. When sepsis is accompanied by conditions in which systemic oxygen delivery does not meet tissue oxygen demands, tissue hypoperfusion begins. Tissue hypoperfusion leads to oxygen debt, cellular injury, organ dysfunction and death. Tissue hypoperfusion can be characterized using markers of tissue perfusion (central venous oxygen saturation and lactate), which reflect the interaction between systemic oxygen delivery and demands. For the last two decades, studies and quality initiatives incorporating the early detection and interruption of tissue hypoperfusion have been shown to improve mortality and altered sepsis care. Three recent trials, while confirming an all-time improvement in sepsis mortality, challenged the concept that rapid normalization of markers of perfusion confers outcome benefit. By defining and comparing haemodynamic phenotypes using markers of tissue perfusion, we may better understand which patients are more likely to benefit from early goal-directed haemodynamic optimization. The phenotypic haemodynamic characterization of patients using perfusion markers has diagnostic, therapeutic and outcome implications in severe sepsis and septic shock. However, irrespective of haemodynamic phenotype, the outcome reflects the quality of care provided at the point of presentation. Utilizing these principles may allow more objective interpretation of resuscitation trials and translate these findings into current practice.
Kidney international, Jan 20, 2015
A systems biology approach was used to comprehensively examine the impact of renal disease and he... more A systems biology approach was used to comprehensively examine the impact of renal disease and hemodialysis (HD) on patient response during critical illness. To achieve this, we examined the metabolome, proteome, and transcriptome of 150 patients with critical illness, stratified by renal function. Quantification of plasma metabolites indicated greater change as renal function declined, with the greatest derangements in patients receiving chronic HD. Specifically, 6 uremic retention molecules, 17 other protein catabolites, 7 modified nucleosides, and 7 pentose phosphate sugars increased as renal function declined, consistent with decreased excretion or increased catabolism of amino acids and ribonucleotides. Similarly, the proteome showed increased levels of low-molecular-weight proteins and acute-phase reactants. The transcriptome revealed a broad-based decrease in mRNA levels among patients on HD. Systems integration revealed an unrecognized association between plasma RNASE1 and s...
JAMA Network Open
IMPORTANCE Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinica... more IMPORTANCE Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship. OBJECTIVE To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments.
Background and Purpose: Thromboelastography (TEG) is often used to measure coagulation dynamics i... more Background and Purpose: Thromboelastography (TEG) is often used to measure coagulation dynamics in the setting of acute ischemic stroke and thrombolytic therapy. The stability of thrombolytics has not been investigated in TEG. We conducted an experimental series to test the effects of recombinant tissue plasminogen activator (rtPA) on fibrinolysis in normal blood samples using TEG. Methods: Freeze dried rtPA powder was reconstituted in normal saline containing 0.2% bovine serum albumin (100 mg/24 mL), divided into 1 mL aliquots, and diluted to enable using a relatively large volume for complete mixing with blood samples. Aliquots and dilutions were frozen at -20°C. The same rtPA dilution was thawed to ambient temperature before each use and refrozen until the next use over 4 testing days. Blood was drawn into 3.2% sodium citrated collection tubes. rtPA (100 μL) was added to 1 mL whole blood to achieve a 636 ng/mL rtPA TEG sample concentration. Control-whole blood and rtPA- whole blood TEG was performed for 3 h on 4 healthy human blood samples. Maximum clot amplitude (mm) and absolute clot strength (dynes/cm) were measured. Data (mean±SD) were analyzed by t-tests and significance inferred at p\u3c0.05. Results: Clot amplitude increased with thawing and refreezing (28±3, p=0.004; 35±2 p=0.01; 50±3, p=0.02; and 55±3, p=0.30; for testing cycles 1, 2, 3 and 4, respectively) compared to untreated samples (63±4). Clot strength also increased over the 4 cycles (2±0.3, p=0.007; 3±0.2, p=0.02; 5±05, p=0.01 and 6±0.7, p=0.30) compared to untreated (9±1.4). Lysis initiation time was gradually longer over the 4 tests (red arrows, Figure 1) suggesting delayed fibrinolysis. Conclusions: One repeatedly thawed and refrozen rtPA stock showed a delay in fibrinolysis in healthy human blood, suggesting a loss of potency. Thus, rtPA should be aliquoted for 1-time use for experiments using TEG. Further investigation into rtPA potency deterioration with storage after reconstitution is warranted. (Figure presented)
Introduction: Sepsis continues to be a disease with high mortality and morbidity. Pathophysiologi... more Introduction: Sepsis continues to be a disease with high mortality and morbidity. Pathophysiologic understanding continues to be limited. Research has focused in the past on freely circulating inflammatory cells, cytokines, RNAs and DNAs without yielding much insight into the complex processes of these entities in the development of multiorgan dysfunction. Cell to cell communication and organ crosstalk is not only dependent on the free circulating markers, but may be more precisely modulated by extracellular vesicles (EV) such as exosomes and microvesicles, which contain protein markers along with RNA and DNA components in a defined structure. The composition of these vesicles along with variation in their size and amount could be another important puzzle piece to understand the pathophysiology of sepsis. Hypothesis: We aimed to examine variations size distribution of extracellular vesicles in patients with sepsis at time of their presentation and compare these with healthy controls healthy controls. Methods: Blood plasma samples were obtained from 10 patients at the time of presentation to the emergency department and 6 healthy control, after informed consent (HFHS IRB 1578, IRB 11000). Plasma was immediately frozen and stored at -80°C. For EV extraction samples were defrosted once and Invitrogen™ Total Exosome Extraction kit (from plasma) was used, according to manufactures protocol. EV pellets were re-suspended in PBS. Nanoparticle tracking analysis (NTA, NanoSight NS 300) was done at a standard dilution of 1:5.000. Western blots (ALIX, CD63, CD9, HSP70) and electron microscopy was conducted to confirm presence of EVs. Results: The average size of extracellular vesicles on NTA for patients with sepsis was 82.3 ± 106.5 nm and for healthy controls 71.3 ± 30.8 nm, p = 0.03. The average size of extracellular vesicles was 79.6 ± 152.1 nm for sepsis survivors (N = 6), 86.5 ± 28.3 for sepsis nonsurvivors (N = 4) and 71.3 ± 30.8 nm for healthy controls, p = 0.05. There was no statistical difference in the particle size between sepsis survivors and sepsis non-survivors. Conclusion: Size of extracellular vesicles in patients with sepsis at the time of presentation to the emergency department differs from the size of extracellular vesicles in healthy volunteers. Outlook: Differences in extracellular vesicle size at the time of presentation potentially indicate increased cellular processes and may be used in the future to aid diagnosis of sepsis
RATIONALE: New Sepsis-3 definitions have been published, stating that sepsis is a “life-threateni... more RATIONALE: New Sepsis-3 definitions have been published, stating that sepsis is a “life-threatening organ dysfunction caused by a dysregulated host response to infection”. The Sepsis-3 authors identified that “Limitations of previous definitions included an excessive focus on inflammation and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria.” With the new definitions it was proposed that identification of septic patients with a dysregulated host response is aided by the use of a quick SOFA (qSOFA) score and not by the use of SIRS criteria. qSOFA score is considered abnormal when 2 of 3 criteria are met. These criteria include sytolic blood pressure \u3c 100mmHg, respiratory rate \u3e 24 and mental status changes. We re-examined an established data-base for patients with vasopressor dependent septic shock comparing SIRS criteria to qSOFA criteria in concern to available measured cytokine markers as indicator of a dysregulated host response. If qSOFA indicates an abnormal host response, prominent cytokine markers such as IL-1RA, IL-1α, IL-6, IL-8, IL-10 and TNF-α should show similar trends as SIRS criteria. METHODS: Re-examination of established IRB approved research data base for patients with vasopressor dependent septic shock with measured multiplex cytokine markers (Milliplex HCYTMAG-60K-PX29) as indicator of a dysregulated host response to infection in concern to SIRS criteria and newly established qSOFA score. RESULTS: For 174 patients data was re-examined. At the time of enrollment within 24 hours following shock onset the average qSOFA score was 1.47 and average SIRS criteria 2.06. Table 1 shows measured cytokine values in regard to number of either SIRS criteria or qSOFA score. The average values of measured cytokine markers increased with increasing number of SIRS criteria for IL-1RA, IL-1a, IL-6, IL-8, IL-10 and TNF-a. Similar cytokine increases in relation to the number of qSOFA score was only seen for IL-8, IL-10 and TNF-a.∗Average values shown as ng/mL (Table presented). CONCLUSION. In patients with vasopressor dependent shock increasing SIRS criteria are related to increases in measured circulating cytokine markers of inflammation. Circulating cytokine markers as indicator for an abnormal host response to infection do not increase with increasing qSOFA scores similar to the SIRS criteria and therefore may not be indicative of all aspects of this dysregulated host response
Open Forum Infectious Diseases, 2021
Background Difficulty discriminating bacterial from viral infections drives antibacterial misuse.... more Background Difficulty discriminating bacterial from viral infections drives antibacterial misuse. Host gene expression tests discriminate bacterial and viral etiologies, but their clinical utility has not been evaluated. Methods Host gene expression and procalcitonin levels were measured in 582 emergency department participants with suspected infection. We also recorded clinician diagnosis and clinician-recommended treatment. These 4 diagnostic strategies were compared with clinical adjudication as the reference. To estimate the clinical impact of host gene expression, we calculated the change in overall Net Benefit (∆NB; the difference in Net Benefit comparing 1 diagnostic strategy with a reference) across a range of prevalence estimates while factoring in the clinical significance of false-positive and -negative errors. Results Gene expression correctly classified bacterial, viral, or noninfectious illness in 74.1% of subjects, similar to the other strategies. Clinical diagnosis a...
Journal of Clinical Medicine, 2020
Background: Septic Emergency Department (ED) patients provide a unique opportunity to investigate... more Background: Septic Emergency Department (ED) patients provide a unique opportunity to investigate early sepsis. Recent work focuses on exosomes, nanoparticle-sized lipid vesicles (30–130 nm) that are released into the bloodstream to transfer its contents (RNA, miRNA, DNA, protein) to other cells. Little is known about how early changes related to exosomes may contribute to the dysregulated inflammatory septic response that leads to multi-organ dysfunction. We aimed to evaluate proteomic profiles of plasma derived exosomes obtained from septic ED patients and healthy controls. Methods: This is a prospective observational pilot study evaluating a plasma proteomic exosome profile at an urban tertiary care hospital ED using a single venipuncture blood draw, collecting 40 cc Ethylenediaminetetraacetic acid (EDTA) blood. Measurements: We recruited seven patients in the ED within 6 h of their presentation and five healthy controls. Plasma exosomes were isolated using the Invitrogen Total E...
Open Forum Infectious Diseases, 2020
Background Discriminating bacterial and viral infections remains clinically challenging. The resu... more Background Discriminating bacterial and viral infections remains clinically challenging. The resulting antibacterial misuse contributes to antimicrobial resistance. Host gene expression-based tests are a promising strategy to discriminate of bacterial and viral infections, but their potential clinical utility has not yet been evaluated. Methods A host gene expression biosignature was measured using either qRT-PCR or microarray in 683 ED subjects with suspected infection. Based on chart reviews, we recorded clinical diagnosis as defined both by the provider assessment and by the provider treatment plan. The biosignature, diagnosis, treatment plan, and procalcitonin were compared to clinical adjudication as the reference standard. With this as a baseline, we then calculated average weighted accuracy (AWA) and change in overall net benefit (∆NB), weighting bacterial false negatives four times more seriously than false positives. Results Gene expression correctly classified the three po...
Journal of Clinical Medicine, 2020
The approach to shock resuscitation focuses on all components of oxygen delivery, including prelo... more The approach to shock resuscitation focuses on all components of oxygen delivery, including preload, afterload, contractility, hemoglobin, and oxygen saturation. Resuscitation focused solely on preload and fluid responsiveness minimizes other key elements, resulting in suboptimal patient care. This review will provide a physiologic and practical approach for the optimization of oxygen delivery utilizing available hemodynamic monitoring technologies. Venous oxygen saturation (SvO2) and lactate will be discussed as indicators of shock states and endpoints of resuscitation within the framework of resolving oxygen deficit and oxygen debt.
Surgical Innovation, 2020
Introduction. Patients presenting with symptoms of gastroesophageal reflux disease (GERD) are usu... more Introduction. Patients presenting with symptoms of gastroesophageal reflux disease (GERD) are usually evaluated by gastroenterologists who perform the diagnostic workup and determine when to refer for surgical consideration. The multiple diagnostic studies can be overwhelming, and this leads to dropouts. In a rural setting, without gastroenterology services, the surgeon can diagnose GERD and perform antireflux procedures. This study aimed to assess the completion of the required diagnostic studies and progression to surgical intervention. Methods. This is a retrospective chart review of patients who presented with GERD symptoms between August 2015 and January 2018. Standardized workup included the upper gastrointestinal study and esophagogastroduodenoscopy with concomitant wireless pH placement. High-resolution impedance manometry and the gastric emptying scan were selectively utilized. Results. 429 patients were evaluated. Proton pump inhibitors were used by 82.2% of patients. The ...
Biomarkers, 2020
Clinical significance: Sepsisis defined as life threatening organ-dysfunction caused by the dysre... more Clinical significance: Sepsisis defined as life threatening organ-dysfunction caused by the dysregulated host response to an infection. The diagnosis can be cryptic and mimic other disease states. Early administration of antibiotics, restoration of tissue perfusion, and source control are paramount to treatment. Biomarkers associated with disease presence or that predict poor outcomes prior to definitive diagnostics would have great utility. Our data reveal a linear relationship between F-actin levels and qSOFA scores in patients at risk for sepsis in the Emergency Department. Increased F-actin levels are also associated with Intensive Care Unit admission and presence of positive urine cultures.
EBioMedicine, 2019
Background: Distinguishing bacterial and viral respiratory infections is challenging. Novel diagn... more Background: Distinguishing bacterial and viral respiratory infections is challenging. Novel diagnostics based on differential host gene expression patterns are promising but have not been translated to a clinical platform nor extensively tested. Here, we validate a microarray-derived host response signature and explore performance in microbiology-negative and coinfection cases. Methods: Subjects with acute respiratory illness were enrolled in participating emergency departments. Reference standard was an adjudicated diagnosis of bacterial infection, viral infection, both, or neither. An 87-transcript signature for distinguishing bacterial, viral, and noninfectious illness was measured from peripheral blood using RT-PCR. Performance characteristics were evaluated in subjects with confirmed bacterial, viral, or noninfectious illness. Subjects with bacterial-viral coinfection and microbiologicallynegative suspected bacterial infection were also evaluated. Performance was compared to procalcitonin. Findings: 151 subjects with microbiologically confirmed, single-etiology illness were tested, yielding AU-ROCs 0•85-0•89 for bacterial, viral, and noninfectious illness. Accuracy was similar to procalcitonin (88% vs 83%, p = 0•23) for bacterial vs. non-bacterial infection. Whereas procalcitonin cannot distinguish viral from non-infectious illness, the RT-PCR test had 81% accuracy in making this determination. Bacterialviral coinfection was subdivided. Among 19 subjects with bacterial superinfection, the RT-PCR test identified 95% as bacterial, compared to 68% with procalcitonin (p = 0•13). Among 12 subjects with bacterial infection superimposed on chronic viral infection, the RT-PCR test identified 83% as bacterial, identical to procalcitonin. 39 subjects had suspected bacterial infection; the RT-PCR test identified bacterial infection more frequently than procalcitonin (82% vs 64%, p = 0•02). Interpretation: The RT-PCR test offered similar diagnostic performance to procalcitonin in some subgroups but offered better discrimination in others such as viral vs. non-infectious illness and bacterial/viral coinfection. Gene expression-based tests could impact decision-making for acute respiratory illness as well as a growing number of other infectious and non-infectious diseases.
Journal of Intensive Care, 2018
Background: Sepsis biomarker panels that provide diagnostic and prognostic discrimination in seps... more Background: Sepsis biomarker panels that provide diagnostic and prognostic discrimination in sepsis patients would be transformative to patient care. We assessed the mortality prediction and diagnostic discriminatory accuracy of two biomarkers reflective of cell death (apoptosis), circulating cell-free DNA (cfDNA), and nucleosomes. Methods: The cfDNA and nucleosome levels were assayed in plasma samples acquired in patients admitted from four emergency departments with suspected sepsis. Subjects with non-infectious systemic inflammatory response syndrome (SIRS) served as controls. Samples were acquired at enrollment (T0) and 24 h later (T24). We assessed diagnostic (differentiating SIRS from sepsis) and prognostic (28-day mortality) predictive power. Models incorporating procalcitonin (diagnostic prediction) and APACHE II scores (mortality prediction) were generated. Results: Two hundred three subjects were included (107 provided procalcitonin measurements). Four subjects exhibited uncomplicated sepsis, 127 severe sepsis, 35 septic shock, and 24 had non-infectious SIRS. There were 190-survivors and 13 non-survivors. Mortality prediction models using cfDNA, nucleosomes, or APACHEII yielded AUC values of 0.61, 0.75, and 0.81, respectively. A model combining nucleosomes with the APACHE II score improved the AUC to 0.84. Diagnostic models distinguishing sepsis from SIRS using procalcitonin, cfDNA(T0), or nucleosomes(T0) yielded AUC values of 0.64, 0.65, and 0.63, respectively. The three parameter model yielded an AUC of 0.74. Conclusions: To our knowledge, this is the first head-to-head comparison of cfDNA and nucleosomes in diagnosing sepsis and predicting sepsis-related mortality. Both cfDNA and nucleosome concentrations demonstrated a modest ability to distinguish sepsis survivors and non-survivors and provided additive diagnostic predictive accuracy in differentiating sepsis from non-infectious SIRS when integrated into a diagnostic prediction model including PCT and APACHE II. A sepsis biomarker strategy incorporating measures of the apoptotic pathway may serve as an important component of a sepsis diagnostic and mortality prediction tool.
SAGE open medical case reports, 2017
Jehovah's Witness patients pose a unique surgical challenge due to their refusal of transfusi... more Jehovah's Witness patients pose a unique surgical challenge due to their refusal of transfusion of whole blood or major blood products. One of the surgical strategies is to offer the least invasive approach with the least likelihood of losing blood. In the context of surgical treatment of gastroesophageal reflux disease, endoluminal approaches such as transoral incisionless fundoplication represent an appropriate approach for Jehovah's Witness patients. This patient is a devout Jehovah's Witness who was troubled with gastroesophageal reflux disease for many years which was refractory to proton pump inhibitor therapy. Her standard preoperative workup showed that she was a candidate for transoral incisionless fundoplication. Surgery was performed by a transoral incisionless fundoplication certified surgeon and this patient was his second case. Patient had no immediate or long-term complications. She was successfully weaned off proton pump inhibitors. Transoral incisionless...
Annals of emergency medicine, Jan 26, 2017
Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose o... more Patients with end-stage renal disease commonly visit the emergency department (ED). The purpose of this investigation is to examine the prevalence of baseline abnormal lactate levels and to evaluate the effects of hemodialysis on serum lactate levels. This was a prospective observational cohort study performed at an outpatient dialysis facility at an urban tertiary care hospital. The study consisted of 226 patients with end-stage renal disease who were receiving long-term hemodialysis and were enrolled during a 2-day period at the beginning of December 2015. Blood drawn for lactate levels was immediately analyzed before and after hemodialysis sessions. All patients completed their hemodialysis sessions. The prevalence of an abnormal lactate level (greater than 1.8 mmol/L) before hemodialysis was 17.7% (n=40). Overall, lactate levels decreased by 27% (SD 35%) after hemodialysis, with a decrease of 37% (SD 31%) for subgroups with a lactate level of 1.9 to 2.4 mmol/L, and 62% (SD 14%) ...
Critical Care Medicine, 2016
Dr. Jaehne received funding from Henry Ford Hospital (part-time employee) and ASPIRUS Hospital Ir... more Dr. Jaehne received funding from Henry Ford Hospital (part-time employee) and ASPIRUS Hospital Iron River, MI (part-time employee). Dr. Rivers disclosed other support. He currently conducts research for Abbott Laboratories, Alere, Spectral Diagnostics, and the National Institutes of Health. The early goal-directed therapy study was performed without extra mural (academic or industry) funding. All catheters used and equipment in the study were paid by Henry Ford Hospital to Edwards Lifesciences.
Science translational medicine, Jan 20, 2016
Acute respiratory infections caused by bacterial or viral pathogens are among the most common rea... more Acute respiratory infections caused by bacterial or viral pathogens are among the most common reasons for seeking medical care. Despite improvements in pathogen-based diagnostics, most patients receive inappropriate antibiotics. Host response biomarkers offer an alternative diagnostic approach to direct antimicrobial use. This observational cohort study determined whether host gene expression patterns discriminate noninfectious from infectious illness and bacterial from viral causes of acute respiratory infection in the acute care setting. Peripheral whole blood gene expression from 273 subjects with community-onset acute respiratory infection (ARI) or noninfectious illness, as well as 44 healthy controls, was measured using microarrays. Sparse logistic regression was used to develop classifiers for bacterial ARI (71 probes), viral ARI (33 probes), or a noninfectious cause of illness (26 probes). Overall accuracy was 87% (238 of 273 concordant with clinical adjudication), which was ...
Biomarkers : biochemical indicators of exposure, response, and susceptibility to chemicals, Jan 12, 2016
To compare plasma levels of F-actin, G-actin and thymosin beta 4 (TB4) in humans with septic shoc... more To compare plasma levels of F-actin, G-actin and thymosin beta 4 (TB4) in humans with septic shock, noninfectious systemic inflammatory response syndrome (SIRS) and healthy controls. F-actin was significantly elevated in septic shock as compared with noninfectious SIRS and healthy controls. G-actin levels were greatest in the noninfectious SIRS group but significantly elevated in septic shock as compared with healthy controls. TB4 was not detectable in the septic shock or noninfectious SIRS group above the assay's lowest detection range (78 ng/ml). F-actin is significantly elevated in patients with septic shock as compared with noninfectious SIRS. F-actin and the F:G-actin ratio are potential biomarkers for the diagnosis of septic shock.
Current Opinion in Critical Care, 2015
The purpose of this study is to review the recent literature examining the clinical utility of ma... more The purpose of this study is to review the recent literature examining the clinical utility of markers of systemic oxygen extraction and perfusion in the diagnosis, treatment and prognosis of severe sepsis and septic shock. When sepsis is accompanied by conditions in which systemic oxygen delivery does not meet tissue oxygen demands, tissue hypoperfusion begins. Tissue hypoperfusion leads to oxygen debt, cellular injury, organ dysfunction and death. Tissue hypoperfusion can be characterized using markers of tissue perfusion (central venous oxygen saturation and lactate), which reflect the interaction between systemic oxygen delivery and demands. For the last two decades, studies and quality initiatives incorporating the early detection and interruption of tissue hypoperfusion have been shown to improve mortality and altered sepsis care. Three recent trials, while confirming an all-time improvement in sepsis mortality, challenged the concept that rapid normalization of markers of perfusion confers outcome benefit. By defining and comparing haemodynamic phenotypes using markers of tissue perfusion, we may better understand which patients are more likely to benefit from early goal-directed haemodynamic optimization. The phenotypic haemodynamic characterization of patients using perfusion markers has diagnostic, therapeutic and outcome implications in severe sepsis and septic shock. However, irrespective of haemodynamic phenotype, the outcome reflects the quality of care provided at the point of presentation. Utilizing these principles may allow more objective interpretation of resuscitation trials and translate these findings into current practice.
Kidney international, Jan 20, 2015
A systems biology approach was used to comprehensively examine the impact of renal disease and he... more A systems biology approach was used to comprehensively examine the impact of renal disease and hemodialysis (HD) on patient response during critical illness. To achieve this, we examined the metabolome, proteome, and transcriptome of 150 patients with critical illness, stratified by renal function. Quantification of plasma metabolites indicated greater change as renal function declined, with the greatest derangements in patients receiving chronic HD. Specifically, 6 uremic retention molecules, 17 other protein catabolites, 7 modified nucleosides, and 7 pentose phosphate sugars increased as renal function declined, consistent with decreased excretion or increased catabolism of amino acids and ribonucleotides. Similarly, the proteome showed increased levels of low-molecular-weight proteins and acute-phase reactants. The transcriptome revealed a broad-based decrease in mRNA levels among patients on HD. Systems integration revealed an unrecognized association between plasma RNASE1 and s...