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simple&#44; and accurate method to improve the diagnosis of sepsis&#46; Adrenomedullin &#40;ADM&#41; 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&#46;<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&#46; Compared with normal individuals&#44; ADM levels are 25- to 30-fold higher in patients with septic shock&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a> Thus&#44; quantification of ADM may be helpful in diagnosing and monitoring sepsis as well as establishing prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a> As ADM is rapidly cleared from the circulation&#44; the mid-region part of proadrenomedullin &#40;proADM&#41; that directly shows level of the fast degraded active peptide of ADM may be used instead of ADM as a predictor of sepsis&#46;<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&#46;</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 &#40;PRISMA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> PubMed&#44; EMBASE and The Cochrane Library were searched for trials in English&#44; and China National Knowledge Infrastructure &#40;CNKI&#41; database were searched for trials in Chinese to identify the relevant published studies for clinical data&#46; Searches were conducted separately for each literature databases up to May 2017&#46; The search terms for each database were &#40;&#8220;adrenomedullin&#8221; OR &#8220;proadrenomedullin&#8221; OR &#8220;mid-regional proadrenomedullin&#8221; OR &#8220;MR-proadrenomedullin&#8221;&#41; AND &#40;&#8220;sepsis&#8221; OR &#8220;septicemia&#8221; OR &#8220;septicaemia&#8221; OR &#8220;septic&#8221; OR &#8220;septic shock&#8221;&#41;&#46; In addition to our computerized search&#44; the bibliographies of all articles were reviewed to look for other potential articles with eligible data for the meta-analysis&#46; The corresponding authors or first authors of the publications were contacted if additional information was needed&#44; results were unclear&#44; or relevant data were not reported&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies were considered eligible for the systematic review ad meta-analysis if they fulfilled the following criteria&#58; 1&#41; data was from an original&#44; peer-reviewed study rather than review articles or meeting abstracts&#59; 2&#41; patients with sepsis or septic shock&#59; 3&#41; studies that provided mortality or diagnostic characteristics&#44; that is&#44; the area under the receiver operating characteristic &#40;ROC&#41; curve &#40;AUC&#41;&#44; or sensitivity and specificity&#46; We excluded studies that were animal studies or duplicate studies&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Article screening</span><p id="par0030" class="elsevierStylePara elsevierViewall">After deduplication&#44; references were screened based on their titles and abstracts against a set of pre-defined eligibility criteria&#46; Only one reviewer was involved in this round of review and the criteria was relative wide&#46; If any uncertainty on inclusion existed&#44; a second reviewer would join to assess and reach a consensus&#46; Then&#44; the full texts of retained references after first-round screening were obtained and reviewed by two reviewers against stringent inclusion criteria&#46; Disagreements were resolved through discussion&#44; and consensus was reached through a third party&#46; All papers included after completion of the full text review were retained for data extraction and quality assessment&#46;</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&#58; first author&#44; publication year&#44; country of origin&#44; setting&#44; sample size&#44; gender distribution&#44; mean ages&#44; mortality rate&#44; test methods&#44; and diagnostic performances &#40;AUC&#44; cut-off value&#44; sensitivity&#44; and specificity&#41;&#46;</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 &#40;QUADAS-2&#41;&#46;<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&#39;s Kappa statistic&#46; Any disagreement in data extraction and quality assessment was resolved by discussion&#46;</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 &#40;REVMAN&#41; 5&#46;3 Copenhagen &#40;The Nordic Cochrane Centre&#44; The Cochrane Collaboration&#44; 2014&#41; and STATA &#40;version 14&#59; Stata Corp&#46;&#44; College Station&#44; Texas&#44; USA&#41;&#46; Reported values are 2-tailed&#44; and hypothesis-testing results were considered statistically significant at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Relative risk &#40;RR&#41; was used to assess the predictive value of ADM and proADM for mortality&#46; We tested heterogeneity with Cochran&#39;s <span class="elsevierStyleItalic">Q</span> statistic&#44; with <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;10 indicating heterogeneity&#44; 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&#46; In case of significant heterogeneity between studies&#44; DerSimonian and Laird random effects model was used&#59; otherwise&#44; the fixed effects model was performed&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> Publication bias was tested using Deek&#39;s funnel plot&#46;</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&#46; If no threshold effect existed&#44; a bivariate random effects regression model<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> was used to calculate the pooled sensitivity&#44; specificity&#44; diagnostic odds ratio &#40;DOR&#41;&#44; positive likelihood ratio &#40;PLR&#41;&#44; and negative likelihood ratio &#40;NLR&#41;&#46; We also constructed a summary receiver operator characteristic &#40;SROC&#41; curve by plotting the individual and summary points of sensitivity and specificity to assess the overall diagnostic accuracy&#46;<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&#44; 13 articles were eventually included after examining the initial searched 279 articles&#46; The process of study selection and the final results of the search were illustrated in the Flow Diagram &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Thirteen studies involving 2556 patients were published from 1999 to 2017&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#8211;25</span></a> Five studies reported the prognostic values of ADM and eight reported the proADM &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All studies were published in English&#46; The mean age of patients varied between 60&#46;0 and 72&#46;0 years and the proportion of men ranged from 58&#46;6&#37; to 74&#46;2&#37;&#46; Eight studies were performed in ICUs&#44; two in EDs and three in both departments&#46; Follow-up periods differed across studies&#44; including 28-days mortality &#40;5 studies&#41;&#44; 90-days mortality &#40;1 study&#41;&#44; and in-hospital mortality &#40;7 studies&#41;&#46; The mortality rate varied from 23&#46;5&#37; to 47&#46;6&#37;&#46;</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&#46; 2</a> summarizes the methodological quality assessment with the QUADAS-2 tool of the thirteen included studies&#46; Three studies were labeled as unclear in the patient selection domain as there is no report on whether patients were consecutive &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; For the index text domain&#44; there is no cutoff value in three studies which has been labeled as unclear&#46; 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&#46; Seven studies were labeled as unclear because whether ADM or proADM were measured in a blinded fashion is unknown&#46; There is neither risk in flow timing nor application concerns in all these thirteen studies &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The Cohen&#39;s Kappa statistic for inter-rater agreement of assessment of quality between two reviewers was 0&#46;84&#46;</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&#44; with RR ranging from 1&#46;58 to 12&#46;67&#46; Due to the substantial heterogeneity between studies &#40;<span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#37;&#44; <span class="elsevierStyleItalic">Tau</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;30&#44; Cochran&#39;s <span class="elsevierStyleItalic">Q</span> statistic <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; a random-effects model was used to pool RR estimates &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The pooled RR in all the 13 studies was 3&#46;31 &#40;95&#37;CI&#44; 2&#46;31&#8211;4&#46;75&#41;&#46; Subgroup analyses indicated the pooled RRs were 3&#46;12 &#40;95&#37;CI&#44; 1&#46;75&#8211;5&#46;56&#41; and 3&#46;43 &#40;95&#37;CI&#44; 2&#46;21&#8211;5&#46;31&#41; for ADM and proADM&#44; respectively&#46; To explore the source of between-study heterogeneity&#44; further analyses was performed &#40;data not shown&#41;&#44; showing that the pooled RRs comparing high with low level of proADM were 2&#46;96 &#40;95&#37;CI&#44; 2&#46;12&#8211;4&#46;13&#41; for in-hospital mortality and 5&#46;21 &#40;95&#37;CI&#44; 3&#46;10&#8211;8&#46;77&#41; for 28-day mortality&#46; The definition of cutoff value may also bring about heterogeneity as the pooled RRs were 3&#46;18 &#40;95&#37;CI&#44; 2&#46;21&#8211;4&#46;56&#41; for high cutoff value &#40;&#8805;4<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#41; and 5&#46;43 &#40;95&#37;CI&#44; 3&#46;13&#8211;9&#46;40&#41; for low cutoff value &#40;&#60;4<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#41;&#46;</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 &#40;Spearman correlation coefficient<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;071&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;74&#41;&#46; Totally ten studies were included for assessing the diagnostic accuracy of ADM and proADM for mortality in patients with sepsis&#46; As shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#44; the pooled sensitivity and specificity of included 10 studies were 0&#46;72 &#40;95&#37;CI&#44; 0&#46;64&#8211;0&#46;78&#41; and 0&#46;77 &#40;95&#37;CI&#44; 0&#46;69&#8211;0&#46;83&#41;&#44; respectively&#46; The PLR and NLR were 3&#46;1 &#40;95&#37;CI&#44; 2&#46;3&#8211;4&#46;1&#41; and 0&#46;37 &#40;95&#37;CI&#44; 0&#46;29&#8211;0&#46;47&#41;&#44; respectively &#40;data not shown&#41;&#46; The DOR was 8&#46;11 &#40;95&#37;CI&#44; 5&#46;25&#8211;12&#46;54&#41; &#40;data not shown&#41;&#46; The overall area under the SROC curve was 0&#46;80 &#40;95&#37;CI&#44; 0&#46;77&#8211;0&#46;84&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</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&#39;s funnel plot of the included studies showed that publication bias was not statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;24&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</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&#46; 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&#44;<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&#46; 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&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Studies conducted by Chen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> and Akpinar et al&#46;<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 &#40;SIRS&#41;&#44; sepsis&#44; severe sepsis and septic shock&#46; Moreover&#44; ADM is regarded as an independent predictor of in-hospital mortality for sepsis in the multivariate logistic regressions&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">14&#44;19</span></a> A similar positive association of proADM with short-term mortality in patients with community-acquired pneumonia &#40;CAP&#41; has been reported in a prior meta-analysis by Cavallazzi et al&#46;<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&#44; reaching 0&#46;72 and 0&#46;77&#44; respectively&#46; Generally&#44; there is a trade-off between sensitivity and specificity in a test of diagnostic accuracy&#46; That is&#44; an increase in sensitivity &#40;the true positive rate&#41; is usually accompanied by a reduction in specificity &#40;the true negative rate&#41;&#46; Thus&#44; the AUC should be a comprehensive index&#46; The present study found that the AUC for sROC was 0&#46;80 &#40;95&#37;CI&#44; 0&#46;77&#8211;0&#46;84&#41;&#44; which was greater than the results of published meta-analyses of procalcitonin&#44;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a> A study reported by Ara-Somohano evaluated eight biomarkers &#40;ProADM&#44; proANP&#44; pro-endothelin&#44; copeptin&#44; amino-terminal pro-B-type Natriuretic Peptide&#44; troponin&#44; C-reactive protein&#44; procalcitonin&#41; to predict short-term mortality in patients with sepsis&#44; among which ProADM &#40;AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;731&#59; 95&#37;CI&#58; 0&#46;658&#8211;0&#46;804&#41; presented the best accuracy&#46; All the results revealed that ADM and proADM should be a strong predictor for sepsis mortality&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In view of the complexity of the sepsis response&#44; a great number of researchers have attempted to combine the comprehensive but subjective and time-consuming severity scoring systems with biomarkers&#46; The prognostic ability of the combination of ADM with Mortality in Emergency Department Sepsis &#40;MEDS&#41; score was superior to either ADM or MEDS score alone&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> In addition&#44; the combination of Sequential Organ Failure Assessment &#40;SOFA&#41;&#44; Acute Physiological and Chronic Health Evaluation &#40;APACHE&#41; II scores&#44; and MR-proADM was efficient to predict prognosis and mortality rate in severe sepsis or septic shock patients&#46;<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&#46;</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&#46; It is sometimes not clear how the investigators selected the subjects &#40;consecutively&#44; randomly&#44; or neither&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#44;16&#44;24</span></a> If the subjects were not recruited either consecutively or randomly&#44; this may introduce selection bias&#46; The thresholds used in the studies were not always pre-specified&#44; which may also introduce bias&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;16&#44;24</span></a> In addition&#44; a limitation inherent to the meta-analysis is the potential heterogeneity among studies that might lead to inaccurate conclusions&#46; This may relate to the fact that the definition of mortality and cutoff values were inconsistent across the trials&#46; Moreover&#44; 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 &#40;SPESIS-3&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> which may cause a potential limitation on the reproducibility of the results&#46;</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&#46; Further systematic reviews need to be performed to assess the accuracy of combination of ADM&#47;proADM with severity scoring systems or other biomarkers&#46;</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&#46; QL&#44; BW&#44; LY&#44; CP&#44; LM and CC design the experiment&#44; collect data and write this article&#59; QL and BW perform the analysis&#46;</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&#46;</p></span></span>"
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      "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 &#40;ADM&#41; and proadrenomedullin &#40;proADM&#41; to predict mortality in sepsis patients&#46;</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&#44; EMBASE&#44; Cochrane and China National Knowledge Infrastructure &#40;CNKI&#41; databases before May 2017&#44; supplemented by manual searches of references&#46; A meta-analysis of high-quality clinical studies was subsequently performed to assess the association between ADM&#47;proADM and mortality risk among patients with sepsis&#46;</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&#46;</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&#44; extracted data&#44; assessed quality and cross-checked the results&#46; The predictive values of ADM and proADM referred to mortality were assessed by relative risk &#40;RR&#41;&#46; The overall diagnostic accuracy of ADM and proADM in application to sepsis was pooled according to a bivariate model&#46; Publication bias was assessed using Deek&#39;s funnel plot asymmetry test&#46;</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 &#40;pooled RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;31&#59; 95&#37;CI 2&#46;31&#8211;4&#46;75&#41;&#46; Subgroup analyses indicated the pooled RRs were 3&#46;12 &#40;95&#37;CI 1&#46;75&#8211;5&#46;56&#41; and 3&#46;43 &#40;95&#37;CI 2&#46;21&#8211;5&#46;31&#41; for ADM and proADM&#44; respectively&#46; The pooled sensitivity and specificity were 0&#46;72 &#40;95&#37;CI 0&#46;64&#8211;0&#46;78&#41; and 0&#46;77 &#40;95&#37;CI 0&#46;69&#8211;0&#46;83&#41;&#44; respectively&#46; The overall area under the summary receiver operating characteristic &#40;SROC&#41; curve was 0&#46;80 &#40;95&#37;CI 0&#46;77&#8211;0&#46;84&#41;&#46; Publication bias was not statistically significant&#46;</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&#46;</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 &#40;ADM&#41; y la proadrenomedulina &#40;proADM&#41; para predecir la mortalidad en pacientes s&#233;pticos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo una b&#250;squeda sistem&#225;tica de la literatura cient&#237;fica en las bases de datos PubMed&#44; EMBASE&#44; Cochrane y China National Knowledge Infrastructure &#40;CNKI&#41; antes de mayo de 2017&#44; complementada con b&#250;squedas manuales de referencia&#46; Posteriormente&#44; se realiz&#243; un metaan&#225;lisis de estudios cl&#237;nicos de alta calidad para evaluar la asociaci&#243;n entre ADM&#47;proADM y el riesgo de mortalidad en pacientes con sepsis&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En este an&#225;lisis se incluyeron 30 estudios en los que particip&#243; un total de 2&#46;556 pacientes&#46;</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 art&#237;culos&#44; extrajeron los datos&#44; evaluaron la calidad y realizaron verificaciones cruzadas de los resultados&#46; Se evalu&#243; el valor de ADM y proADM como factor pron&#243;stico de mortalidad a partir del riesgo relativo &#40;RR&#41;&#46; La precisi&#243;n global del diagn&#243;stico con ADM y proADM en pacientes con sepsis se agrup&#243; utilizando un modelo de 2 variables&#46; Se evalu&#243; el sesgo de publicaci&#243;n utilizando una prueba de Deek para asimetr&#237;a de gr&#225;fico en embudo&#46;</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 &#40;RR agrupado&#58; 3&#44;31&#59; IC del 95&#37;&#58; 2&#44;31-4&#44;75&#41;&#46; Los an&#225;lisis por subgrupos indicaron que los RR agrupados eran de 3&#44;12 &#40;IC del 95&#37;&#58; 1&#44;75-5&#44;56&#41; y 3&#44;43 &#40;IC del 95&#37;&#58; 2&#44;21-5&#44;31&#41; para ADM y proADM&#44; respectivamente&#46; La sensibilidad y especificidad agrupadas fueron 0&#44;72 &#40;IC del 95&#37;&#58; 0&#44;64-0&#44;78&#41; y 0&#44;77 &#40;IC del 95&#37;&#58; 0&#44;69-0&#44;83&#41;&#44; respectivamente&#46; El &#225;rea global bajo la curva &#40;SROC&#41; fue de 0&#44;80 &#40;IC del 95&#37;&#58; 0&#44;77-0&#44;84&#41;&#46; El sesgo de publicaci&#243;n no fue estad&#237;sticamente relevante&#46;</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 &#250;tiles para predecir el pron&#243;stico de pacientes con sepsis&#46;</p></span>"
        "secciones" => array:6 [
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            "identificador" => "abst0035"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Pacientes"
          ]
          3 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Intervenciones"
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            "identificador" => "abst0055"
            "titulo" => "Resultados"
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            "identificador" => "abst0060"
            "titulo" => "Conclusiones"
          ]
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Contributed equally&#46;</p>"
        "identificador" => "fn0005"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Flowchart of study selection&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Quality assessment &#40;QUADAS-2&#41; summary of 13 studies &#40;A&#41; and quality assessment &#40;QUADAS-2&#41; for each included study &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Forest plot of ADM or proADM to predict mortality in sepsis&#46;</p>"
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Summary receiver operating characteristic of ADM or proADM for the predicting of mortality in patients with sepsis&#46;</p>"
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      5 => array:7 [
        "identificador" => "fig0030"
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Deek&#39;s funnel plot asymmetry test for publication bias&#46;</p>"
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      6 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">ADM&#58; adrenomedullin&#59; proADM&#58; proadrenomedullin&#59; ICU&#58; intensive care unit&#59; ED&#58; emergence department&#59; SEN&#58; sensitivity&#59; SPE&#58; specificity&#46;</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">&nbsp;\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&nbsp;\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&nbsp;\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&nbsp;\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&nbsp;\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>&nbsp;\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&nbsp;\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 &#40;&#37;&#41;&nbsp;\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&nbsp;\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&nbsp;\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 &#40;nmol&#47;l&#41;&nbsp;\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 &#40;&#37;&#41;&nbsp;\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 &#40;&#37;&#41;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1999&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&#47;ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;76&#46;1&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">684&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72 &#40;56&#8211;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">419 &#40;61&#46;3&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;49<span class="elsevierStyleHsp" style=""></span>ng&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;8&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78 &#40;72&#8211;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;60&#46;4&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">956&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">561 &#40;58&#46;7&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">237&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110 &#40;63&#46;6&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switzerland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;8&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67 &#40;54&#8211;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;58&#46;6&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#46;0&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;0&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;67&#46;3&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;0&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&#47;ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;65&#46;7&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;7&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69 &#40;41&#8211;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;61&#46;9&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#46;7&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Turkey&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;8&#177;17&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;74&#46;2&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;3&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&#47;ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Characteristics of included studies&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
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                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&#46;S&#46; Martin"
                            1 => "D&#46;M&#46; Mannino"
                            2 => "S&#46; Eaton"
                            3 => "M&#46; Moss"
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                        ]
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                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa022139"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2003"
                        "volumen" => "348"
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                        "paginaFinal" => "1554"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12700374"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data&#44; 2009&#8211;2014"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Rhee"
                            1 => "R&#46; Dantes"
                            2 => "L&#46; Epstein"
                            3 => "D&#46;J&#46; Murphy"
                            4 => "C&#46;W&#46; Seymour"
                            5 => "T&#46;J&#46; Iwashyna"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2017.13836"
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                      "titulo" => "Diagnostic accuracy of lipopolysaccharide-binding protein as biomarker for sepsis in adult patients&#58; a systematic review and meta-analysis"
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                            2 => "J&#46;Y&#46; Jiang"
                            3 => "H&#46;W&#46; Yu"
                            4 => "Y&#46;H&#46; Meng"
                            5 => "W&#46;C&#46; Tang"
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                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0153188"
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                        "tituloSerie" => "PLOS ONE"
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Original
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
Q. Li1, B.S. Wang1, L. Yang, C. Peng, L.B. Ma, C. Chai
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3rd Department of General Surgery, First Hospital of Lanzhou University, Lanzhou 730000, China
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sepsis&#44; a syndrome with physiologic&#44; pathologic&#44; and biochemical abnormalities triggered by infection&#44; is a major challenge in intensive care units &#40;ICUs&#41; and emergency departments &#40;EDs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> Despite advances in antibiotic therapy and modern life support in past decade&#44; the in-hospital mortality rate of US patients with sepsis has remained as high as 15&#37;&#44; posing a heavy burden to critically ill populations&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> It is therefore necessary and urgent to develop a rapid&#44; simple&#44; and accurate method to improve the diagnosis of sepsis&#46; Adrenomedullin &#40;ADM&#41; 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&#46;<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&#46; Compared with normal individuals&#44; ADM levels are 25- to 30-fold higher in patients with septic shock&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;6</span></a> Thus&#44; quantification of ADM may be helpful in diagnosing and monitoring sepsis as well as establishing prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a> As ADM is rapidly cleared from the circulation&#44; the mid-region part of proadrenomedullin &#40;proADM&#41; that directly shows level of the fast degraded active peptide of ADM may be used instead of ADM as a predictor of sepsis&#46;<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&#46;</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 &#40;PRISMA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> PubMed&#44; EMBASE and The Cochrane Library were searched for trials in English&#44; and China National Knowledge Infrastructure &#40;CNKI&#41; database were searched for trials in Chinese to identify the relevant published studies for clinical data&#46; Searches were conducted separately for each literature databases up to May 2017&#46; The search terms for each database were &#40;&#8220;adrenomedullin&#8221; OR &#8220;proadrenomedullin&#8221; OR &#8220;mid-regional proadrenomedullin&#8221; OR &#8220;MR-proadrenomedullin&#8221;&#41; AND &#40;&#8220;sepsis&#8221; OR &#8220;septicemia&#8221; OR &#8220;septicaemia&#8221; OR &#8220;septic&#8221; OR &#8220;septic shock&#8221;&#41;&#46; In addition to our computerized search&#44; the bibliographies of all articles were reviewed to look for other potential articles with eligible data for the meta-analysis&#46; The corresponding authors or first authors of the publications were contacted if additional information was needed&#44; results were unclear&#44; or relevant data were not reported&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies were considered eligible for the systematic review ad meta-analysis if they fulfilled the following criteria&#58; 1&#41; data was from an original&#44; peer-reviewed study rather than review articles or meeting abstracts&#59; 2&#41; patients with sepsis or septic shock&#59; 3&#41; studies that provided mortality or diagnostic characteristics&#44; that is&#44; the area under the receiver operating characteristic &#40;ROC&#41; curve &#40;AUC&#41;&#44; or sensitivity and specificity&#46; We excluded studies that were animal studies or duplicate studies&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Article screening</span><p id="par0030" class="elsevierStylePara elsevierViewall">After deduplication&#44; references were screened based on their titles and abstracts against a set of pre-defined eligibility criteria&#46; Only one reviewer was involved in this round of review and the criteria was relative wide&#46; If any uncertainty on inclusion existed&#44; a second reviewer would join to assess and reach a consensus&#46; Then&#44; the full texts of retained references after first-round screening were obtained and reviewed by two reviewers against stringent inclusion criteria&#46; Disagreements were resolved through discussion&#44; and consensus was reached through a third party&#46; All papers included after completion of the full text review were retained for data extraction and quality assessment&#46;</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&#58; first author&#44; publication year&#44; country of origin&#44; setting&#44; sample size&#44; gender distribution&#44; mean ages&#44; mortality rate&#44; test methods&#44; and diagnostic performances &#40;AUC&#44; cut-off value&#44; sensitivity&#44; and specificity&#41;&#46;</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 &#40;QUADAS-2&#41;&#46;<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&#39;s Kappa statistic&#46; Any disagreement in data extraction and quality assessment was resolved by discussion&#46;</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 &#40;REVMAN&#41; 5&#46;3 Copenhagen &#40;The Nordic Cochrane Centre&#44; The Cochrane Collaboration&#44; 2014&#41; and STATA &#40;version 14&#59; Stata Corp&#46;&#44; College Station&#44; Texas&#44; USA&#41;&#46; Reported values are 2-tailed&#44; and hypothesis-testing results were considered statistically significant at <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Relative risk &#40;RR&#41; was used to assess the predictive value of ADM and proADM for mortality&#46; We tested heterogeneity with Cochran&#39;s <span class="elsevierStyleItalic">Q</span> statistic&#44; with <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;10 indicating heterogeneity&#44; 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&#46; In case of significant heterogeneity between studies&#44; DerSimonian and Laird random effects model was used&#59; otherwise&#44; the fixed effects model was performed&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> Publication bias was tested using Deek&#39;s funnel plot&#46;</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&#46; If no threshold effect existed&#44; a bivariate random effects regression model<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> was used to calculate the pooled sensitivity&#44; specificity&#44; diagnostic odds ratio &#40;DOR&#41;&#44; positive likelihood ratio &#40;PLR&#41;&#44; and negative likelihood ratio &#40;NLR&#41;&#46; We also constructed a summary receiver operator characteristic &#40;SROC&#41; curve by plotting the individual and summary points of sensitivity and specificity to assess the overall diagnostic accuracy&#46;<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&#44; 13 articles were eventually included after examining the initial searched 279 articles&#46; The process of study selection and the final results of the search were illustrated in the Flow Diagram &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Thirteen studies involving 2556 patients were published from 1999 to 2017&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#8211;25</span></a> Five studies reported the prognostic values of ADM and eight reported the proADM &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All studies were published in English&#46; The mean age of patients varied between 60&#46;0 and 72&#46;0 years and the proportion of men ranged from 58&#46;6&#37; to 74&#46;2&#37;&#46; Eight studies were performed in ICUs&#44; two in EDs and three in both departments&#46; Follow-up periods differed across studies&#44; including 28-days mortality &#40;5 studies&#41;&#44; 90-days mortality &#40;1 study&#41;&#44; and in-hospital mortality &#40;7 studies&#41;&#46; The mortality rate varied from 23&#46;5&#37; to 47&#46;6&#37;&#46;</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&#46; 2</a> summarizes the methodological quality assessment with the QUADAS-2 tool of the thirteen included studies&#46; Three studies were labeled as unclear in the patient selection domain as there is no report on whether patients were consecutive &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; For the index text domain&#44; there is no cutoff value in three studies which has been labeled as unclear&#46; 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&#46; Seven studies were labeled as unclear because whether ADM or proADM were measured in a blinded fashion is unknown&#46; There is neither risk in flow timing nor application concerns in all these thirteen studies &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The Cohen&#39;s Kappa statistic for inter-rater agreement of assessment of quality between two reviewers was 0&#46;84&#46;</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&#44; with RR ranging from 1&#46;58 to 12&#46;67&#46; Due to the substantial heterogeneity between studies &#40;<span class="elsevierStyleItalic">I</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#37;&#44; <span class="elsevierStyleItalic">Tau</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;30&#44; Cochran&#39;s <span class="elsevierStyleItalic">Q</span> statistic <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; a random-effects model was used to pool RR estimates &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The pooled RR in all the 13 studies was 3&#46;31 &#40;95&#37;CI&#44; 2&#46;31&#8211;4&#46;75&#41;&#46; Subgroup analyses indicated the pooled RRs were 3&#46;12 &#40;95&#37;CI&#44; 1&#46;75&#8211;5&#46;56&#41; and 3&#46;43 &#40;95&#37;CI&#44; 2&#46;21&#8211;5&#46;31&#41; for ADM and proADM&#44; respectively&#46; To explore the source of between-study heterogeneity&#44; further analyses was performed &#40;data not shown&#41;&#44; showing that the pooled RRs comparing high with low level of proADM were 2&#46;96 &#40;95&#37;CI&#44; 2&#46;12&#8211;4&#46;13&#41; for in-hospital mortality and 5&#46;21 &#40;95&#37;CI&#44; 3&#46;10&#8211;8&#46;77&#41; for 28-day mortality&#46; The definition of cutoff value may also bring about heterogeneity as the pooled RRs were 3&#46;18 &#40;95&#37;CI&#44; 2&#46;21&#8211;4&#46;56&#41; for high cutoff value &#40;&#8805;4<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#41; and 5&#46;43 &#40;95&#37;CI&#44; 3&#46;13&#8211;9&#46;40&#41; for low cutoff value &#40;&#60;4<span class="elsevierStyleHsp" style=""></span>nmol&#47;l&#41;&#46;</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 &#40;Spearman correlation coefficient<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;071&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;74&#41;&#46; Totally ten studies were included for assessing the diagnostic accuracy of ADM and proADM for mortality in patients with sepsis&#46; As shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#44; the pooled sensitivity and specificity of included 10 studies were 0&#46;72 &#40;95&#37;CI&#44; 0&#46;64&#8211;0&#46;78&#41; and 0&#46;77 &#40;95&#37;CI&#44; 0&#46;69&#8211;0&#46;83&#41;&#44; respectively&#46; The PLR and NLR were 3&#46;1 &#40;95&#37;CI&#44; 2&#46;3&#8211;4&#46;1&#41; and 0&#46;37 &#40;95&#37;CI&#44; 0&#46;29&#8211;0&#46;47&#41;&#44; respectively &#40;data not shown&#41;&#46; The DOR was 8&#46;11 &#40;95&#37;CI&#44; 5&#46;25&#8211;12&#46;54&#41; &#40;data not shown&#41;&#46; The overall area under the SROC curve was 0&#46;80 &#40;95&#37;CI&#44; 0&#46;77&#8211;0&#46;84&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</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&#39;s funnel plot of the included studies showed that publication bias was not statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;24&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</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&#46; 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&#44;<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&#46; 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&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Studies conducted by Chen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> and Akpinar et al&#46;<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 &#40;SIRS&#41;&#44; sepsis&#44; severe sepsis and septic shock&#46; Moreover&#44; ADM is regarded as an independent predictor of in-hospital mortality for sepsis in the multivariate logistic regressions&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">14&#44;19</span></a> A similar positive association of proADM with short-term mortality in patients with community-acquired pneumonia &#40;CAP&#41; has been reported in a prior meta-analysis by Cavallazzi et al&#46;<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&#44; reaching 0&#46;72 and 0&#46;77&#44; respectively&#46; Generally&#44; there is a trade-off between sensitivity and specificity in a test of diagnostic accuracy&#46; That is&#44; an increase in sensitivity &#40;the true positive rate&#41; is usually accompanied by a reduction in specificity &#40;the true negative rate&#41;&#46; Thus&#44; the AUC should be a comprehensive index&#46; The present study found that the AUC for sROC was 0&#46;80 &#40;95&#37;CI&#44; 0&#46;77&#8211;0&#46;84&#41;&#44; which was greater than the results of published meta-analyses of procalcitonin&#44;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">30</span></a> A study reported by Ara-Somohano evaluated eight biomarkers &#40;ProADM&#44; proANP&#44; pro-endothelin&#44; copeptin&#44; amino-terminal pro-B-type Natriuretic Peptide&#44; troponin&#44; C-reactive protein&#44; procalcitonin&#41; to predict short-term mortality in patients with sepsis&#44; among which ProADM &#40;AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;731&#59; 95&#37;CI&#58; 0&#46;658&#8211;0&#46;804&#41; presented the best accuracy&#46; All the results revealed that ADM and proADM should be a strong predictor for sepsis mortality&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In view of the complexity of the sepsis response&#44; a great number of researchers have attempted to combine the comprehensive but subjective and time-consuming severity scoring systems with biomarkers&#46; The prognostic ability of the combination of ADM with Mortality in Emergency Department Sepsis &#40;MEDS&#41; score was superior to either ADM or MEDS score alone&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> In addition&#44; the combination of Sequential Organ Failure Assessment &#40;SOFA&#41;&#44; Acute Physiological and Chronic Health Evaluation &#40;APACHE&#41; II scores&#44; and MR-proADM was efficient to predict prognosis and mortality rate in severe sepsis or septic shock patients&#46;<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&#46;</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&#46; It is sometimes not clear how the investigators selected the subjects &#40;consecutively&#44; randomly&#44; or neither&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#44;16&#44;24</span></a> If the subjects were not recruited either consecutively or randomly&#44; this may introduce selection bias&#46; The thresholds used in the studies were not always pre-specified&#44; which may also introduce bias&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;16&#44;24</span></a> In addition&#44; a limitation inherent to the meta-analysis is the potential heterogeneity among studies that might lead to inaccurate conclusions&#46; This may relate to the fact that the definition of mortality and cutoff values were inconsistent across the trials&#46; Moreover&#44; 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 &#40;SPESIS-3&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> which may cause a potential limitation on the reproducibility of the results&#46;</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&#46; Further systematic reviews need to be performed to assess the accuracy of combination of ADM&#47;proADM with severity scoring systems or other biomarkers&#46;</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&#46; QL&#44; BW&#44; LY&#44; CP&#44; LM and CC design the experiment&#44; collect data and write this article&#59; QL and BW perform the analysis&#46;</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&#46;</p></span></span>"
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              "titulo" => "Association of ADM and proADM with mortality"
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              "titulo" => "Diagnostic accuracy of ADM and proADM for mortality"
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              "titulo" => "Publication bias"
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    "fechaRecibido" => "2017-08-11"
    "fechaAceptado" => "2017-10-26"
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            0 => "Adrenomedullin"
            1 => "Proadrenomedullin"
            2 => "Sepsis"
            3 => "Mortality"
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            0 => "Adrenomedulina"
            1 => "Proadrenomedulina"
            2 => "Sepsis"
            3 => "Mortalidad"
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        "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 &#40;ADM&#41; and proadrenomedullin &#40;proADM&#41; to predict mortality in sepsis patients&#46;</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&#44; EMBASE&#44; Cochrane and China National Knowledge Infrastructure &#40;CNKI&#41; databases before May 2017&#44; supplemented by manual searches of references&#46; A meta-analysis of high-quality clinical studies was subsequently performed to assess the association between ADM&#47;proADM and mortality risk among patients with sepsis&#46;</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&#46;</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&#44; extracted data&#44; assessed quality and cross-checked the results&#46; The predictive values of ADM and proADM referred to mortality were assessed by relative risk &#40;RR&#41;&#46; The overall diagnostic accuracy of ADM and proADM in application to sepsis was pooled according to a bivariate model&#46; Publication bias was assessed using Deek&#39;s funnel plot asymmetry test&#46;</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 &#40;pooled RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;31&#59; 95&#37;CI 2&#46;31&#8211;4&#46;75&#41;&#46; Subgroup analyses indicated the pooled RRs were 3&#46;12 &#40;95&#37;CI 1&#46;75&#8211;5&#46;56&#41; and 3&#46;43 &#40;95&#37;CI 2&#46;21&#8211;5&#46;31&#41; for ADM and proADM&#44; respectively&#46; The pooled sensitivity and specificity were 0&#46;72 &#40;95&#37;CI 0&#46;64&#8211;0&#46;78&#41; and 0&#46;77 &#40;95&#37;CI 0&#46;69&#8211;0&#46;83&#41;&#44; respectively&#46; The overall area under the summary receiver operating characteristic &#40;SROC&#41; curve was 0&#46;80 &#40;95&#37;CI 0&#46;77&#8211;0&#46;84&#41;&#46; Publication bias was not statistically significant&#46;</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&#46;</p></span>"
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        "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 &#40;ADM&#41; y la proadrenomedulina &#40;proADM&#41; para predecir la mortalidad en pacientes s&#233;pticos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo una b&#250;squeda sistem&#225;tica de la literatura cient&#237;fica en las bases de datos PubMed&#44; EMBASE&#44; Cochrane y China National Knowledge Infrastructure &#40;CNKI&#41; antes de mayo de 2017&#44; complementada con b&#250;squedas manuales de referencia&#46; Posteriormente&#44; se realiz&#243; un metaan&#225;lisis de estudios cl&#237;nicos de alta calidad para evaluar la asociaci&#243;n entre ADM&#47;proADM y el riesgo de mortalidad en pacientes con sepsis&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En este an&#225;lisis se incluyeron 30 estudios en los que particip&#243; un total de 2&#46;556 pacientes&#46;</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 art&#237;culos&#44; extrajeron los datos&#44; evaluaron la calidad y realizaron verificaciones cruzadas de los resultados&#46; Se evalu&#243; el valor de ADM y proADM como factor pron&#243;stico de mortalidad a partir del riesgo relativo &#40;RR&#41;&#46; La precisi&#243;n global del diagn&#243;stico con ADM y proADM en pacientes con sepsis se agrup&#243; utilizando un modelo de 2 variables&#46; Se evalu&#243; el sesgo de publicaci&#243;n utilizando una prueba de Deek para asimetr&#237;a de gr&#225;fico en embudo&#46;</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 &#40;RR agrupado&#58; 3&#44;31&#59; IC del 95&#37;&#58; 2&#44;31-4&#44;75&#41;&#46; Los an&#225;lisis por subgrupos indicaron que los RR agrupados eran de 3&#44;12 &#40;IC del 95&#37;&#58; 1&#44;75-5&#44;56&#41; y 3&#44;43 &#40;IC del 95&#37;&#58; 2&#44;21-5&#44;31&#41; para ADM y proADM&#44; respectivamente&#46; La sensibilidad y especificidad agrupadas fueron 0&#44;72 &#40;IC del 95&#37;&#58; 0&#44;64-0&#44;78&#41; y 0&#44;77 &#40;IC del 95&#37;&#58; 0&#44;69-0&#44;83&#41;&#44; respectivamente&#46; El &#225;rea global bajo la curva &#40;SROC&#41; fue de 0&#44;80 &#40;IC del 95&#37;&#58; 0&#44;77-0&#44;84&#41;&#46; El sesgo de publicaci&#243;n no fue estad&#237;sticamente relevante&#46;</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 &#250;tiles para predecir el pron&#243;stico de pacientes con sepsis&#46;</p></span>"
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                  <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">&nbsp;\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&nbsp;\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&nbsp;\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&nbsp;\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&nbsp;\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>&nbsp;\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&nbsp;\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 &#40;&#37;&#41;&nbsp;\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&nbsp;\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&nbsp;\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 &#40;nmol&#47;l&#41;&nbsp;\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 &#40;&#37;&#41;&nbsp;\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 &#40;&#37;&#41;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1999&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&#47;ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;76&#46;1&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">684&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72 &#40;56&#8211;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">419 &#40;61&#46;3&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;49<span class="elsevierStyleHsp" style=""></span>ng&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;8&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78 &#40;72&#8211;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;60&#46;4&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">956&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">561 &#40;58&#46;7&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">237&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110 &#40;63&#46;6&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switzerland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;8&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67 &#40;54&#8211;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;58&#46;6&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#46;0&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;0&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;67&#46;3&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;0&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&#47;ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;65&#46;7&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;7&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69 &#40;41&#8211;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;61&#46;9&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#46;7&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Turkey&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;8&#177;17&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;74&#46;2&#37;&#41;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;3&nbsp;\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>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ED&#47;ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Characteristics of included studies&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
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                            0 => "G&#46;S&#46; Martin"
                            1 => "D&#46;M&#46; Mannino"
                            2 => "S&#46; Eaton"
                            3 => "M&#46; Moss"
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                        ]
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                    0 => array:2 [
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                            "web" => "Medline"
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                          "etal" => true
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                            0 => "C&#46; Rhee"
                            1 => "R&#46; Dantes"
                            2 => "L&#46; Epstein"
                            3 => "D&#46;J&#46; Murphy"
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                            1 => "C&#46;H&#46; Chaou"
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                        0 => array:2 [
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                            0 => "Y&#46; Hirata"
                            1 => "C&#46; Mitaka"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1210/jcem.81.4.8636349"
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                        0 => array:2 [
                          "etal" => true
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                            0 => "K&#46; Nishio"
                            1 => "Y&#46; Akai"
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                  "host" => array:1 [
                    0 => array:1 [
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                            0 => "J&#46; Struck"
                            1 => "C&#46; Tao"
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                  ]
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                0 => array:2 [
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                            0 => "D&#46; Moher"
                            1 => "A&#46; Liberati"
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                    0 => array:1 [
                      "Revista" => array:5 [
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                  "contribucion" => array:1 [
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