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Assessment of adrenomedullin and proadrenomedullin as predictors of mortality in septic patients: A systematic review and meta-analysis
Evaluación de adrenomedulina y proadrenomedulina como factores pronóstico de la mortalidad en pacientes sépticos: revisión sistemática y metaanálisis
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González de Molina Ortiz, F. Gordo Vidal, A. Estella García, P. Morrondo Valdeolmillos, J.F. Fernández Ortega, J. Caballero López, P.V. Pérez Villares, M.A. Ballesteros Sanz, C. de Haro López, J.A. Sanchez-Izquierdo Riera, A. Serrano Lázaro, M.P. Fuset Cabanes, L.J. Terceros Almanza, X. Nuvials Casals, J. Baldirà Martínez de Irujo" "autores" => array:16 [ 0 => array:2 [ "nombre" => "F.J." "apellidos" => "González de Molina Ortiz" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Gordo Vidal" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Estella García" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Morrondo Valdeolmillos" ] 4 => array:2 [ "nombre" => "J.F." "apellidos" => "Fernández Ortega" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Caballero López" ] 6 => array:2 [ "nombre" => "P.V." "apellidos" => "Pérez Villares" ] 7 => array:2 [ "nombre" => "M.A." "apellidos" => "Ballesteros Sanz" ] 8 => array:2 [ "nombre" => "C." 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Li, B.S. Wang, L. Yang, C. Peng, L.B. Ma, C. Chai" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Q." "apellidos" => "Li" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] 1 => array:3 [ "nombre" => "B.S." "apellidos" => "Wang" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Yang" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Peng" ] 4 => array:2 [ "nombre" => "L.B." "apellidos" => "Ma" ] 5 => array:4 [ "nombre" => "C." "apellidos" => "Chai" "email" => array:2 [ 0 => "chasechai@gmail.com" 1 => "cd4971@163.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "3rd Department of General Surgery, First Hospital of Lanzhou University, Lanzhou 730000, China" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de adrenomedulina y proadrenomedulina como factores pronóstico de la mortalidad en pacientes sépticos: revisión sistemática y metaanálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2211 "Ancho" => 3167 "Tamanyo" => 315281 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Sensitivity and specificity of ADM or proADM for the predicting of mortality in patients with sepsis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sepsis, a syndrome with physiologic, pathologic, and biochemical abnormalities triggered by infection, is a major challenge in intensive care units (ICUs) and emergency departments (EDs).<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> Despite advances in antibiotic therapy and modern life support in past decade, the in-hospital mortality rate of US patients with sepsis has remained as high as 15%, posing a heavy burden to critically ill populations.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">One the most important reasons why first-line clinical physicians fail to provide timely and accurate treatment to sepsis patients is the lack of rapid and accurate diagnostic tools.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> It is therefore necessary and urgent to develop a rapid, simple, and accurate method to improve the diagnosis of sepsis. Adrenomedullin (ADM) is a 52-amino-acid peptide which can act as a hormone and is produced and secreted by multiple mammalian tissues during physiologic and infectious stress.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> Several clinical trials have demonstrated that ADM increases significantly in patients with sepsis and is positively associated with disease severity. Compared with normal individuals, ADM levels are 25- to 30-fold higher in patients with septic shock.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5,6</span></a> Thus, quantification of ADM may be helpful in diagnosing and monitoring sepsis as well as establishing prognosis.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a> As ADM is rapidly cleared from the circulation, the mid-region part of proadrenomedullin (proADM) that directly shows level of the fast degraded active peptide of ADM may be used instead of ADM as a predictor of sepsis.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The present systematic review and meta-analysis aims to evaluate the prognostic value of ADM and proADM for mortality of patients with sepsis and assess their diagnostic accuracy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Search strategy</span><p id="par0020" class="elsevierStylePara elsevierViewall">This systematic review and meta-analysis was performed and reported in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> PubMed, EMBASE and The Cochrane Library were searched for trials in English, and China National Knowledge Infrastructure (CNKI) database were searched for trials in Chinese to identify the relevant published studies for clinical data. Searches were conducted separately for each literature databases up to May 2017. The search terms for each database were (“adrenomedullin” OR “proadrenomedullin” OR “mid-regional proadrenomedullin” OR “MR-proadrenomedullin”) AND (“sepsis” OR “septicemia” OR “septicaemia” OR “septic” OR “septic shock”). In addition to our computerized search, the bibliographies of all articles were reviewed to look for other potential articles with eligible data for the meta-analysis. The corresponding authors or first authors of the publications were contacted if additional information was needed, results were unclear, or relevant data were not reported.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies were considered eligible for the systematic review ad meta-analysis if they fulfilled the following criteria: 1) data was from an original, peer-reviewed study rather than review articles or meeting abstracts; 2) patients with sepsis or septic shock; 3) studies that provided mortality or diagnostic characteristics, that is, the area under the receiver operating characteristic (ROC) curve (AUC), or sensitivity and specificity. We excluded studies that were animal studies or duplicate studies.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Article screening</span><p id="par0030" class="elsevierStylePara elsevierViewall">After deduplication, references were screened based on their titles and abstracts against a set of pre-defined eligibility criteria. Only one reviewer was involved in this round of review and the criteria was relative wide. If any uncertainty on inclusion existed, a second reviewer would join to assess and reach a consensus. Then, the full texts of retained references after first-round screening were obtained and reviewed by two reviewers against stringent inclusion criteria. Disagreements were resolved through discussion, and consensus was reached through a third party. All papers included after completion of the full text review were retained for data extraction and quality assessment.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Data extraction and quality assessment</span><p id="par0035" class="elsevierStylePara elsevierViewall">The following information was extracted from the eligible studies: first author, publication year, country of origin, setting, sample size, gender distribution, mean ages, mortality rate, test methods, and diagnostic performances (AUC, cut-off value, sensitivity, and specificity).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Two investigators independently assessed the quality of eligible studies using the revised Quality Assessment for Studies of Diagnostic Accuracy tool (QUADAS-2).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> Agreement between the two reviewers for assessment of methodological quality was evaluated using the Cohen's Kappa statistic. Any disagreement in data extraction and quality assessment was resolved by discussion.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The analyses were performed with Review Manager (REVMAN) 5.3 Copenhagen (The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and STATA (version 14; Stata Corp., College Station, Texas, USA). Reported values are 2-tailed, and hypothesis-testing results were considered statistically significant at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Relative risk (RR) was used to assess the predictive value of ADM and proADM for mortality. We tested heterogeneity with Cochran's <span class="elsevierStyleItalic">Q</span> statistic, with <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.10 indicating heterogeneity, and quantified the degree of heterogeneity using the <span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span> and <span class="elsevierStyleItalic">tau</span><span class="elsevierStyleSup">2</span> statistic. In case of significant heterogeneity between studies, DerSimonian and Laird random effects model was used; otherwise, the fixed effects model was performed.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> Publication bias was tested using Deek's funnel plot.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The presence of a threshold effect on the prognostic accuracy of ADM and proADM in patients with sepsis was evaluated with the Spearman correlation coefficient between the logits of sensitivity and specificity. If no threshold effect existed, a bivariate random effects regression model<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> was used to calculate the pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). We also constructed a summary receiver operator characteristic (SROC) curve by plotting the individual and summary points of sensitivity and specificity to assess the overall diagnostic accuracy.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Literature search and study characteristics</span><p id="par0060" class="elsevierStylePara elsevierViewall">Eventually, 13 articles were eventually included after examining the initial searched 279 articles. The process of study selection and the final results of the search were illustrated in the Flow Diagram (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Thirteen studies involving 2556 patients were published from 1999 to 2017.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13–25</span></a> Five studies reported the prognostic values of ADM and eight reported the proADM (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All studies were published in English. The mean age of patients varied between 60.0 and 72.0 years and the proportion of men ranged from 58.6% to 74.2%. Eight studies were performed in ICUs, two in EDs and three in both departments. Follow-up periods differed across studies, including 28-days mortality (5 studies), 90-days mortality (1 study), and in-hospital mortality (7 studies). The mortality rate varied from 23.5% to 47.6%.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Quality assessment</span><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> summarizes the methodological quality assessment with the QUADAS-2 tool of the thirteen included studies. Three studies were labeled as unclear in the patient selection domain as there is no report on whether patients were consecutive (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). For the index text domain, there is no cutoff value in three studies which has been labeled as unclear. The reference standard domain of two studies were labeled as high risk as the ADM or proADM levels were calculated before the endpoint was revealed. Seven studies were labeled as unclear because whether ADM or proADM were measured in a blinded fashion is unknown. There is neither risk in flow timing nor application concerns in all these thirteen studies (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The Cohen's Kappa statistic for inter-rater agreement of assessment of quality between two reviewers was 0.84.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Association of ADM and proADM with mortality</span><p id="par0075" class="elsevierStylePara elsevierViewall">All studies showed that an elevated ADM or proADM levels were associated with a higher risk of death, with RR ranging from 1.58 to 12.67. Due to the substantial heterogeneity between studies (<span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>82%, <span class="elsevierStyleItalic">Tau</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.30, Cochran's <span class="elsevierStyleItalic">Q</span> statistic <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01), a random-effects model was used to pool RR estimates (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The pooled RR in all the 13 studies was 3.31 (95%CI, 2.31–4.75). Subgroup analyses indicated the pooled RRs were 3.12 (95%CI, 1.75–5.56) and 3.43 (95%CI, 2.21–5.31) for ADM and proADM, respectively. To explore the source of between-study heterogeneity, further analyses was performed (data not shown), showing that the pooled RRs comparing high with low level of proADM were 2.96 (95%CI, 2.12–4.13) for in-hospital mortality and 5.21 (95%CI, 3.10–8.77) for 28-day mortality. The definition of cutoff value may also bring about heterogeneity as the pooled RRs were 3.18 (95%CI, 2.21–4.56) for high cutoff value (≥4<span class="elsevierStyleHsp" style=""></span>nmol/l) and 5.43 (95%CI, 3.13–9.40) for low cutoff value (<4<span class="elsevierStyleHsp" style=""></span>nmol/l).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Diagnostic accuracy of ADM and proADM for mortality</span><p id="par0080" class="elsevierStylePara elsevierViewall">There is no statistically significant difference when exploring for threshold effect (Spearman correlation coefficient<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.071; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.74). Totally ten studies were included for assessing the diagnostic accuracy of ADM and proADM for mortality in patients with sepsis. As shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>, the pooled sensitivity and specificity of included 10 studies were 0.72 (95%CI, 0.64–0.78) and 0.77 (95%CI, 0.69–0.83), respectively. The PLR and NLR were 3.1 (95%CI, 2.3–4.1) and 0.37 (95%CI, 0.29–0.47), respectively (data not shown). The DOR was 8.11 (95%CI, 5.25–12.54) (data not shown). The overall area under the SROC curve was 0.80 (95%CI, 0.77–0.84) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Publication bias</span><p id="par0085" class="elsevierStylePara elsevierViewall">The Deek's funnel plot of the included studies showed that publication bias was not statistically significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.24) (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Early prognosis and risk assessment after sepsis may provide timely and accurate treatment for patients. Since it is dominated by major peripheral vasodilation and other cardiovascular system alternations during the first hours after the onset of sepsis or septic shock,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> the measurement of the biomarkers including vasodilator and vasoconstrictor may be of great interest as they play vital roles in the homeostasis of the system. Our present systematic review and meta-analysis involving 13 high-quality clinical studies illustrates that both ADM and proADM are positively associated with the mortality risk for patients with sepsis.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Studies conducted by Chen et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> and Akpinar et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> show that ADM and proADM levels in survivors are significantly lower than those in non-survivors in patients with systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Moreover, ADM is regarded as an independent predictor of in-hospital mortality for sepsis in the multivariate logistic regressions.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">14,19</span></a> A similar positive association of proADM with short-term mortality in patients with community-acquired pneumonia (CAP) has been reported in a prior meta-analysis by Cavallazzi et al.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The pooled sensitivity and specificity in this study were optimal, reaching 0.72 and 0.77, respectively. Generally, there is a trade-off between sensitivity and specificity in a test of diagnostic accuracy. That is, an increase in sensitivity (the true positive rate) is usually accompanied by a reduction in specificity (the true negative rate). Thus, the AUC should be a comprehensive index. The present study found that the AUC for sROC was 0.80 (95%CI, 0.77–0.84), which was greater than the results of published meta-analyses of procalcitonin,<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> troponins<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a> and lactate clearance.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a> A study reported by Ara-Somohano evaluated eight biomarkers (ProADM, proANP, pro-endothelin, copeptin, amino-terminal pro-B-type Natriuretic Peptide, troponin, C-reactive protein, procalcitonin) to predict short-term mortality in patients with sepsis, among which ProADM (AUC<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.731; 95%CI: 0.658–0.804) presented the best accuracy. All the results revealed that ADM and proADM should be a strong predictor for sepsis mortality.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In view of the complexity of the sepsis response, a great number of researchers have attempted to combine the comprehensive but subjective and time-consuming severity scoring systems with biomarkers. The prognostic ability of the combination of ADM with Mortality in Emergency Department Sepsis (MEDS) score was superior to either ADM or MEDS score alone.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> In addition, the combination of Sequential Organ Failure Assessment (SOFA), Acute Physiological and Chronic Health Evaluation (APACHE) II scores, and MR-proADM was efficient to predict prognosis and mortality rate in severe sepsis or septic shock patients.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> These data indicate that combined use of severity scoring systems and biomarkers is more effective in risk stratification and prognosis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Flaws in the design of these studies should be considered when interpreting the results of the present systematic review and meta-analysis. It is sometimes not clear how the investigators selected the subjects (consecutively, randomly, or neither).<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13,16,24</span></a> If the subjects were not recruited either consecutively or randomly, this may introduce selection bias. The thresholds used in the studies were not always pre-specified, which may also introduce bias.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15,16,24</span></a> In addition, a limitation inherent to the meta-analysis is the potential heterogeneity among studies that might lead to inaccurate conclusions. This may relate to the fact that the definition of mortality and cutoff values were inconsistent across the trials. Moreover, most studies included in this meta-analysis are performed prior to the publication of the updated definitions and clinical criteria of sepsis and septic shock (SPESIS-3),<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> which may cause a potential limitation on the reproducibility of the results.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The present systematic review indicates that ADM and proADM are effective biomarkers for the prediction of mortality risk in patients with sepsis. Further systematic reviews need to be performed to assess the accuracy of combination of ADM/proADM with severity scoring systems or other biomarkers.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">All authors have approved the final article. QL, BW, LY, CP, LM and CC design the experiment, collect data and write this article; QL and BW perform the analysis.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1088221" "titulo" => "Abstract" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Interventions" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1032011" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1088222" "titulo" => "Resumen" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0040" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0045" "titulo" => "Pacientes" ] 3 => array:2 [ "identificador" => "abst0050" "titulo" => "Intervenciones" ] 4 => array:2 [ "identificador" => "abst0055" "titulo" => "Resultados" ] 5 => array:2 [ "identificador" => "abst0060" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1032012" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Search strategy" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Article screening" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data extraction and quality assessment" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Literature search and study characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Quality assessment" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Association of ADM and proADM with mortality" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Diagnostic accuracy of ADM and proADM for mortality" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Publication bias" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Contributions" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack369450" "titulo" => "Acknowledgement" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-11" "fechaAceptado" => "2017-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1032011" "palabras" => array:4 [ 0 => "Adrenomedullin" 1 => "Proadrenomedullin" 2 => "Sepsis" 3 => "Mortality" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1032012" "palabras" => array:4 [ 0 => "Adrenomedulina" 1 => "Proadrenomedulina" 2 => "Sepsis" 3 => "Mortalidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To ascertain the ability of adrenomedullin (ADM) and proadrenomedullin (proADM) to predict mortality in sepsis patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A systematic literature search was made of the PubMed, EMBASE, Cochrane and China National Knowledge Infrastructure (CNKI) databases before May 2017, supplemented by manual searches of references. A meta-analysis of high-quality clinical studies was subsequently performed to assess the association between ADM/proADM and mortality risk among patients with sepsis.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirteen studies involving 2556 patients were included in the study.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Interventions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Two reviewers independently identified articles, extracted data, assessed quality and cross-checked the results. The predictive values of ADM and proADM referred to mortality were assessed by relative risk (RR). The overall diagnostic accuracy of ADM and proADM in application to sepsis was pooled according to a bivariate model. Publication bias was assessed using Deek's funnel plot asymmetry test.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Elevated ADM or proADM levels were associated with increased mortality (pooled RR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.31; 95%CI 2.31–4.75). Subgroup analyses indicated the pooled RRs were 3.12 (95%CI 1.75–5.56) and 3.43 (95%CI 2.21–5.31) for ADM and proADM, respectively. The pooled sensitivity and specificity were 0.72 (95%CI 0.64–0.78) and 0.77 (95%CI 0.69–0.83), respectively. The overall area under the summary receiver operating characteristic (SROC) curve was 0.80 (95%CI 0.77–0.84). Publication bias was not statistically significant.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Both ADM and proADM might serve as useful markers for predicting the prognosis of sepsis.</p></span>" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Interventions" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Establecer la capacidad de la adrenomedulina (ADM) y la proadrenomedulina (proADM) para predecir la mortalidad en pacientes sépticos.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diseño</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se llevó a cabo una búsqueda sistemática de la literatura científica en las bases de datos PubMed, EMBASE, Cochrane y China National Knowledge Infrastructure (CNKI) antes de mayo de 2017, complementada con búsquedas manuales de referencia. Posteriormente, se realizó un metaanálisis de estudios clínicos de alta calidad para evaluar la asociación entre ADM/proADM y el riesgo de mortalidad en pacientes con sepsis.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En este análisis se incluyeron 30 estudios en los que participó un total de 2.556 pacientes.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Intervenciones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dos revisores identificaron de forma independiente los artículos, extrajeron los datos, evaluaron la calidad y realizaron verificaciones cruzadas de los resultados. Se evaluó el valor de ADM y proADM como factor pronóstico de mortalidad a partir del riesgo relativo (RR). La precisión global del diagnóstico con ADM y proADM en pacientes con sepsis se agrupó utilizando un modelo de 2 variables. Se evaluó el sesgo de publicación utilizando una prueba de Deek para asimetría de gráfico en embudo.</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Las concentraciones elevadas de ADM o proADM se asociaron a un aumento de la mortalidad (RR agrupado: 3,31; IC del 95%: 2,31-4,75). Los análisis por subgrupos indicaron que los RR agrupados eran de 3,12 (IC del 95%: 1,75-5,56) y 3,43 (IC del 95%: 2,21-5,31) para ADM y proADM, respectivamente. La sensibilidad y especificidad agrupadas fueron 0,72 (IC del 95%: 0,64-0,78) y 0,77 (IC del 95%: 0,69-0,83), respectivamente. El área global bajo la curva (SROC) fue de 0,80 (IC del 95%: 0,77-0,84). El sesgo de publicación no fue estadísticamente relevante.</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Tanto ADM como proADM pueden ser marcadores útiles para predecir el pronóstico de pacientes con sepsis.</p></span>" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0040" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0045" "titulo" => "Pacientes" ] 3 => array:2 [ "identificador" => "abst0050" "titulo" => "Intervenciones" ] 4 => array:2 [ "identificador" => "abst0055" "titulo" => "Resultados" ] 5 => array:2 [ "identificador" => "abst0060" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Contributed equally.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1297 "Ancho" => 1503 "Tamanyo" => 127599 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Flowchart of study selection.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3029 "Ancho" => 2257 "Tamanyo" => 430773 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Quality assessment (QUADAS-2) summary of 13 studies (A) and quality assessment (QUADAS-2) for each included study (B).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2025 "Ancho" => 3163 "Tamanyo" => 435042 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Forest plot of ADM or proADM to predict mortality in sepsis.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2211 "Ancho" => 3167 "Tamanyo" => 315281 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Sensitivity and specificity of ADM or proADM for the predicting of mortality in patients with sepsis.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1565 "Ancho" => 1583 "Tamanyo" => 118746 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Summary receiver operating characteristic of ADM or proADM for the predicting of mortality in patients with sepsis.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1196 "Ancho" => 1583 "Tamanyo" => 65564 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Deek's funnel plot asymmetry test for publication bias.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">ADM: adrenomedullin; proADM: proadrenomedullin; ICU: intensive care unit; ED: emergence department; SEN: sensitivity; SPE: specificity.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Setting \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Male (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortality rate \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cutoff value (nmol/l) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SEN (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SPE (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">ADM</td><td class="td" title="table-entry " align="left" valign="top">Ueda<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1999 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ED/ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (76.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chen<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ED \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">684 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 (56–78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">419 (61.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34.49<span class="elsevierStyleHsp" style=""></span>ng/l \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Marino<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ED \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78 (72–83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (60.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Caironi<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">956 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">561 (58.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charles<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">237 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">110 (63.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="8" align="left" valign="top">ProADM</td><td class="td" title="table-entry " align="left" valign="top">Christ-Crain<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">18</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Switzerland \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Guignant<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67 (54–76) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (58.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wang<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">China \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.8<span class="elsevierStyleHsp" style=""></span>ng/ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suberviola<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (67.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suberviola<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ED/ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">137 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (65.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pezzilli<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">23</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 (41–85) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (61.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Akpinar<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Turkey \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.8±17.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (74.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ara-Somohano<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ED/ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">116 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.143 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1859573.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Characteristics of included studies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0160" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of sepsis in the United States from 1979 through 2000" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 4 | 7 |
| 2024 October | 39 | 40 | 79 |
| 2024 September | 53 | 39 | 92 |
| 2024 August | 49 | 42 | 91 |
| 2024 July | 99 | 31 | 130 |
| 2024 June | 50 | 43 | 93 |
| 2024 May | 37 | 25 | 62 |
| 2024 April | 51 | 37 | 88 |
| 2024 March | 51 | 31 | 82 |
| 2024 February | 44 | 44 | 88 |
| 2024 January | 29 | 23 | 52 |
| 2023 December | 22 | 34 | 56 |
| 2023 November | 30 | 33 | 63 |
| 2023 October | 30 | 36 | 66 |
| 2023 September | 41 | 40 | 81 |
| 2023 August | 34 | 15 | 49 |
| 2023 July | 39 | 32 | 71 |
| 2023 June | 35 | 18 | 53 |
| 2023 May | 58 | 34 | 92 |
| 2023 April | 35 | 11 | 46 |
| 2023 March | 57 | 44 | 101 |
| 2023 February | 49 | 46 | 95 |
| 2023 January | 48 | 32 | 80 |
| 2022 December | 75 | 35 | 110 |
| 2022 November | 76 | 42 | 118 |
| 2022 October | 66 | 49 | 115 |
| 2022 September | 64 | 39 | 103 |
| 2022 August | 45 | 35 | 80 |
| 2022 July | 34 | 36 | 70 |
| 2022 June | 39 | 28 | 67 |
| 2022 May | 38 | 32 | 70 |
| 2022 April | 41 | 40 | 81 |
| 2022 March | 43 | 51 | 94 |
| 2022 February | 30 | 40 | 70 |
| 2022 January | 36 | 35 | 71 |
| 2021 December | 45 | 47 | 92 |
| 2021 November | 65 | 47 | 112 |
| 2021 October | 50 | 76 | 126 |
| 2021 September | 48 | 32 | 80 |
| 2021 August | 29 | 33 | 62 |
| 2021 July | 22 | 36 | 58 |
| 2021 June | 34 | 22 | 56 |
| 2021 May | 49 | 62 | 111 |
| 2021 April | 167 | 93 | 260 |
| 2021 March | 81 | 33 | 114 |
| 2021 February | 64 | 30 | 94 |
| 2021 January | 62 | 22 | 84 |
| 2020 December | 54 | 13 | 67 |
| 2020 November | 55 | 34 | 89 |
| 2020 October | 49 | 27 | 76 |
| 2020 September | 99 | 17 | 116 |
| 2020 August | 38 | 29 | 67 |
| 2020 July | 35 | 30 | 65 |
| 2020 June | 31 | 25 | 56 |
| 2020 May | 25 | 12 | 37 |
| 2020 April | 31 | 9 | 40 |
| 2020 March | 18 | 7 | 25 |
| 2020 February | 61 | 25 | 86 |
| 2020 January | 44 | 33 | 77 |
| 2019 December | 26 | 17 | 43 |
| 2019 November | 31 | 42 | 73 |
| 2019 October | 31 | 21 | 52 |
| 2019 September | 23 | 24 | 47 |
| 2019 August | 33 | 21 | 54 |
| 2019 July | 32 | 25 | 57 |
| 2019 June | 63 | 17 | 80 |
| 2019 May | 52 | 45 | 97 |
| 2019 April | 21 | 15 | 36 |
| 2019 March | 40 | 24 | 64 |
| 2019 February | 22 | 28 | 50 |
| 2019 January | 1 | 5 | 6 |
| 2018 October | 3 | 1 | 4 |
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