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Featured Articles
Proadrenomedullin biomarker improves risk stratification and site of care decision in pneumonia patients
Initial severity assessment of emergency department patients with lower respiratory tract infections (LRTI) remains a clinical challenge. IHE spoke to Dr Philipp Schuetz, associate professor of internal medicine of the Medical University Clinic in Aarau, Switzerland, about his experience with ProADM, a new biomarker that has great potential to improve the current triage practice and thus site of care decisions.
Q. Is the risk assessment of patients who suffer from lower respiratory tract infection (LRTI) still a clinical need in hospitals?
Yes, LRTI is a serious condition associated with a significant rate of morbidity and long-term mortality. Additionally, LRTI has a major impact on the use of resources and healthcare expenditure. Although most patients are treated on an outpatient basis, the costs for hospitalized pneumonia patients can be 25 times higher [1]. Therefore, whether or not to hospitalize a patient is clinically of outmost importance and a very costly decision. Severity scores such as Pneumonia Severity Index (PSI) and/or the CURB65 were developed to aid the site of care decision and safely assess the risk of pneumonia patients. However, these scores have significant shortcomings which limit their applicability in routine care. First of all, they focus on mortality only, rather than on other complications, Secondly, they are static and do not include changes of the condition over time. Finally, they perform sub-optimally which should be improved to be able to make safe decisions for individual patients. Thus, there is still room to improve the current risk assessment tools and blood biomarkers like Proadrenomedullin (ProADM) which seems to show great potential in filling this gap [2-5].
Q. What is ProADM? How does it improve risk assessment in LRTI patients?
ProADM (mid-regional proAdrenomedullin) is a stable surrogate marker for Adrenomedullin (ADM). ADM belongs to the family of Calcitonin related peptides, similar to Procalcitonin (PCT). ADM is the most potent vasodilator and is activated in different stages of severe illness, such as sepsis and systemic infections. Unlike PCT, ADM is not specific to infections, but increases in different conditions that correlate with severity and adverse outcome across different medical diseases. Therefore, ProADM is not a diagnostic marker for sepsis, but has prognostic abilities. Importantly, proADM is also dynamic over time and the levels decrease when a patient improves; it also correlates with the risk of adverse events.
In several studies, ProADM showed a high correlation with the severity of LRTI; it was better than other commonly used parameters (WBC, PCT and CRP) and as powerful as PSI and CURB-65. Interestingly, when ProADM was used in addition to clinical risk scores, the accuracy of PSI and CURB-65 for risk prediction was improved for both short-term and long-term mortality.
Q. What is the benefit of adding ProADM to clinical risk assessment?
ProADM allows physicians to objectively estimate a patient
Private hospitals in China and India: medical equipment demand to soar
Depending on who is speaking, the rise of China and India is seen as an opportunity, a threat or a mix of both. Measured by purchasing power, the World Bank lists the two Asian giants as the world
Scientific literature review: MR
The number of peer-reviewed papers covering the field of magnetic resonance (MR) is huge, to such an extent that it is frequently difficult for healthcare professionals to keep up with the literature. As a special service to our readers, International Hospital presents a few key literature abstracts from the clinical and scientific literature chosen by our editorial board as being particularly worthy of attention.
Clinical MRI of acute ischemic stroke
Gilberto Gonz
Scientific literature: mechanical ventilation
As a special service to our readers, International Hospital presents a few recent literature abstracts chosen by our editorial board as being particularly worthy of attention.
A review of oral preventative strategies to reduce ventilator-associated pneumonia.
Andrews T, Steen C. Nurs Crit Care 2013; May18(3):116-22. Epub 2013 Jan 30.
This article evaluates the evidence for and efficacy of the use of mechanical hygiene and chlorhexidine in the prevention of ventilator-associated pneumonia (VAP). Search strategies included primary research articles; randomized controlled trials; systematic reviews and excluded quasi-experimental trials and opinion articles. VAP is the commonest infection found in critically ill patients who are mechanically ventilated. It is associated with increased mortality, increased length of stay in intensive care and increased costs. VAP is a health care-associated infection consistent with the presence of an endotracheal tube and mechanical ventilation for greater than 48 h. Efforts aimed at reducing infection rates include oral decontamination and mechanical hygiene to control the bacteria responsible, since there is an association between changes in bacteria found in the oropharynx and its development. Tooth brushing and the use of an oral antiseptic such as chlorhexidine gluconate are increasingly recommended in ventilator care bundles.
While there have been a number of studies conducted evaluating the efficacy of both approaches, there is limited evidence to support their use. The frequency of oral decontamination and mechanical hygiene interventions have not been established and chlorhexidine 2% seems to be more effective compared to weaker concentrations, but data is mainly confined to patients following cardiothoracic surgery.
Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma.
Lim WJ, Mohammed Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA, Rowe BH, Smith BJ. Cochrane Database Syst Rev. 2012; Dec 12:12:CD004360.
Because of sub-optimal long-term care and delays in obtaining help during acute exacerbations, the mortality and morbidity related to asthma is still a major health concern. There is reason to believe that non-invasive positive pressure ventilation (NPPV) could be beneficial to patients with severe acute asthma; however, the evidence surrounding the efficacy of NPPV is unclear, despite its common use in clinical practice.
The objectives were to determine the efficacy of NPPV in adults with severe acute asthma in comparison to usual medical care with respect to mortality, tracheal intubation, changes in blood gases and hospital length of stay.
The search method consisted of a search in the Cochrane Airways Group Specialized Register of trials (July 2012). Following this, the bibliographies of included studies and review articles were searched for additional studies (July 2012). Included were randomized controlled trials of adults with severe acute asthma as the primary reason for presentation to the emergency department or for admission to hospital. Asthma diagnosis was defined by internationally accepted criteria. Studies were included if the intervention was usual medical care for the management of severe acute asthma plus NPPV applied through a nasal or facemask compared to usual medical care alone. Studies including patients with features of chronic obstructive pulmonary disease (COPD) were excluded unless data were provided separately for patients with asthma in studies recruiting both COPD and asthmatic patients. Five studies on 206 participants contributed data, while one study was available in abstract form only and was not fully incorporated into this review. For the primary outcome of endotracheal intubation there were two studies that contributed data: two intubations were needed in 45 participants on NPPV and no intubations in 41 control patients (risk ratio 4.48; 95% CI 0.23 to 89.13). There were no deaths in either of these studies. Length of hospital stay was reported in two studies, though meta-analysis was not possible. Hospitalisation was reported in one small study, in which there were three admissions out of 17 on NPPV and 10 admissions out of 16 in control patients (RR 0.28, 95% CI 0.09, 0.84).
This review of studies has highlighted the paucity of data that exist to support the use of NPPV in patients in status asthmaticus. As such this course of treatment remains controversial despite its continued use in current clinical practice. Larger, prospective randomized controlled trials of rigorous methodological design are needed to determine the role of NPPV in patients with asthma.
Protein catalysed capture agents for molecular imaging
There is a growing need for affinity agents for targeted molecular imaging of disease biomarkers. Protein catalysed capture agents (PCC agents) are assembled through target-guided in situ click chemistry and display low nanomolar affinity and specificity. The iterative design process, architecture, and composition of the resulting multi-ligands make this a promising technology for imaging agent development.
by Dr Steven W. Millward, Dr Heather D. Agnew, Dr Suresh Pitram, Dr Bert T. Lai, Dr Rosemary D. Rohde and Dr Norman Hardman
Personalized medicine is increasingly becoming a major component of cancer treatment and management. Many of the advances in personalized medicine have come from high throughput genomic sequencing and multiplexed proteomic analysis of tumour and tissue specimens. While these technologies have dramatically increased our understanding of cancer and cancer heterogeneity at the molecular level, translation of this knowledge into clinical imaging agents to non-invasively characterize tumour phenotypes in vivo has lagged behind. While small molecules (e.g. FDG) have proven very useful for clinical measurement of metabolic activity, molecular imaging of cell surface and secreted biomarkers overexpressed in cancer (e.g. IGFR, EGFR, etc.) is largely confined to the preclinical and early clinical trial setting.
While groundbreaking work to determine the biological and therapeutic roles of these proteins has produced a wealth of high affinity antibodies, antibody fragments, and peptides, attempts to translate them into radiotracers for molecular imaging have produced mixed results. Antibody-based imaging agents suffer from three disadvantages in this setting:
1) Their long serum half-lives, while advantageous for therapeutic applications, result in high background signal in perfused tissue and lengthen the time between agent administration and image acquisition.
2) Antibody-based radiotracers often show accumulation and metabolic processing in the liver, increasing nonspecific signal and potentially obscuring critical tumour-specific signal in the abdominal cavity.
3) Antibodies are biologicals, and as such their high production costs and regulatory burdens are significant economic barriers to commercialization and clinical translation. Linear peptides derived from phage display represent a second class of potential imaging agents, however their rapid degradation in vivo typically results in nonspecific background signal and poor tumour uptake. An ideal targeted molecular imaging agent would combine the affinity and specificity of antibodies with the high bio-stability, tumour uptake, and clearance of small molecules.
PCC agent design
Protein catalysed capture (PCC) agent technology represents a novel approach to rapidly design ligands with high affinity and specificity that can be potentially adapted to a variety of research and in vivo clinical applications including molecular imaging. This technology was built upon the observation by K. Barry Sharpless and co-workers at The Scripps Research Institute that the azide-alkyne cycloaddition (a
Ultrasound ? ec(h)oes of the future
COCIR (European Co-ordination Committee of the Radiological, Electromedical and Healthcare IT Industry) has just released their third edition of its annual report on the Self-Regulatory Initiative (SRI) on the ecodesign of medical devices. The Initiative has been supported and officially acknowledged by the European Commission at the end of 2012.
The COCIR committee was founded in 1959 as a voice for the medical technology industry in Europe with members consisting of key players in the development of healthcare in Europe and worldwide. They seek to promote the development of harmonized international standards and regulatory control respecting the quality and effectiveness of medical devices and healthcare IT systems, without compromising the safety of patients or users. One of the main goals of COCIR is to be pro-active in Green Technology (Eco-Design) and with this in mind the COCIR companies proactively committed with the European Commission to develop a self-regulatory initiative under the Echodesign Directive to reduce the environmental impact of medical imaging equipment. The project was presented to the European Commission in 2008. The first version of the SRI methodology was submitted for comment during 2009 which led to the submission of a new SRI 2 methodology to the EU Commission in February 2012. During November 2012, the commission acknowledged the initiative recognizing the benefits for society and healthcare. Each year a Status Report is published reporting on the progress and achievements of the initiative. This report is the third annual SRI Status report, the first after acknowledgement of the European Commission. The current status report has focused on CT (computer tomography), after having covered ultrasound and magnetic resonance modalities in 2010 and 2011 respectively.
Based on a consensus reached among themselves on a set of ecodesign targets, COCIR
