Biomarker-guided personalised emergency medicine for all - hope for another hype?
Biomarker-guided personalised emergency medicine for all - hope for another hype?
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DOI：
10.4414/smw.2015.14079
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发表时间：
2015-02-19
影响因子：
2.9
通讯作者：
Mueller, Beat
中科院分区：
文献类型：
--
作者：
Schuetz, Philipp;Aujesky, Drahomir;Mueller, Beat
多病患者、多样化的诊断和治疗选择、更复杂的医院结构、财务激励、基准以及观念和社会变化给医生带来了压力，特别是在医疗差错出现的情况下。这对于急诊科设置尤其如此，在急诊科中，患者面临延迟或错误的初始诊断或治疗措施以及由于次优分诊而导致的昂贵的住院时间。“生物标志物”是具有更好地检测和诊断疾病、简化复杂的临床算法以及改善常规护理中的临床问题解决的潜力的任何实验室工具。它们必须嵌入临床算法中，以补充而不是取代基本的医疗技能。实验室检查的未选择顺序和测试性能和解释的缺点有助于诊断错误。测试结果可能是模糊的假阳性或假阴性结果，并产生不必要的伤害和成本。只有在结果具有临床后果的情况下，才应安排实验室检查。在研究中，我们必须超越观察报告和生物标志物诊断准确性的荟萃分析。相反，应提出具体的临界范围，并进行干预研究，以证明对患者护理的结果相关影响。本次审查的重点是举例说明在紧急情况下适当使用选定的实验室检查，随机对照干预研究已证明其临床益处。在此，我们专注于急诊科心肺疾病患者的初始患者分诊和治疗机会分配。将讨论以下五种生物标志物：肾上腺髓质素前体用于预后分诊评估和现场护理决策，心肌肌钙蛋白用于急性心肌梗死，利钠肽用于急性心力衰竭，D-二聚体用于静脉血栓栓塞，C-反应蛋白作为炎症标志物，降钙素原用于呼吸道感染和脓毒症的抗生素管理。对于这些标志物，我们提供了关于病理生理学、证据的历史演变、临床算法合理实施的优势和局限性的概述。我们批判性地讨论了导致其在临床常规和潜在的未来适应症中使用的关键干预试验的结果。使用所有这些生物标志物的合理性，首先是解决诊断模糊性和连续防御性药物，第二，延迟和次优治疗决策，第三，预后的不确定性与错误的分类和护理地点的决定都有助于浪费我们有限的卫生保健资源。从急诊入院到出院对医疗患者进行更有针对性的管理（包括生物标志物）的多方面方法将转化为更好的资源利用，缩短住院时间，降低总成本，提高患者满意度以及死亡率和再住院率方面的结果。希望本文中概述的概念能帮助读者提高诊断技能，并成为更吝啬的实验室检查请求者。
Polymorbid patients, diverse diagnostic and therapeutic options, more complex hospital structures, financial incentives, benchmarking, as well as perceptional and societal changes put pressure on medical doctors, specifically if medical errors surface. This is particularly true for the emergency department setting, where patients face delayed or erroneous initial diagnostic or therapeutic measures and costly hospital stays due to sub-optimal triage.A "biomarker" is any laboratory tool with the potential better to detect and characterise diseases, to simplify complex clinical algorithms and to improve clinical problem solving in routine care. They must be embedded in clinical algorithms to complement and not replace basic medical skills. Unselected ordering of laboratory tests and shortcomings in test performance and interpretation contribute to diagnostic errors. Test results may be ambiguous with false positive or false negative results and generate unnecessary harm and costs. Laboratory tests should only be ordered, if results have clinical consequences. In studies, we must move beyond the observational reporting and meta-analysing of diagnostic accuracies for biomarkers. Instead, specific cut-off ranges should be proposed and intervention studies conducted to prove outcome relevant impacts on patient care.The focus of this review is to exemplify the appropriate use of selected laboratory tests in the emergency setting for which randomised-controlled intervention studies have proven clinical benefit. Herein, we focus on initial patient triage and allocation of treatment opportunities in patients with cardiorespiratory diseases in the emergency department. The following five biomarkers will be discussed: proadrenomedullin for prognostic triage assessment and site-of-care decisions, cardiac troponin for acute myocardial infarction, natriuretic peptides for acute heart failure, D-dimers for venous thromboembolism, C-reactive protein as a marker of inflammation, and procalcitonin for antibiotic stewardship in infections of the respiratory tract and sepsis. For these markers we provide an overview on physiopathology, historical evolution of evidence, strengths and limitations for a rational implementation into clinical algorithms. We critically discuss results from key intervention trials that led to their use in clinical routine and potential future indications.The rational for the use of all these biomarkers, is to tackle, first, diagnostic ambiguity and consecutive defensive medicine, second, delayed and sub-optimal therapeutic decisions, and third, prognostic uncertainty with misguided triage and site-of-care decisions all contributing to the waste of our limited health care resources. A multifaceted approach for a more targeted management of medical patients from emergency admission to discharge including biomarkers, will translate into better resource use, shorter length of hospital stay, reduced overall costs, improved patients satisfaction and outcomes in terms of mortality and re-hospitalisation. Hopefully, the concepts outlined in this review will help the reader to improve their diagnostic skills and become more parsimonious laboratory test requesters.