Novel diagnostic and stratification tools for septic shock

描述(由申请人提供)：感染性休克仍然是成人和儿童的主要公共卫生问题。该领域一个重要且尚未填补的临床空白是缺乏针对感染性休克的强有力的分层和诊断工具。这项提议寻求直接解决这一差距。我们利用我们广泛的多中心感染性休克儿童基因表达数据库来识别基因签名，为临床感染性休克新的分层和诊断工具的开发提供了坚实的基础。这项建议的主要创新是能够直接利用转录dat作为临床进步的基础，这是转录学的一个经常陈述但很少实现的目标。我们提出了三个独立但高度互补的具体目标，所有这些目标都直接解决了前面提到的尚未满足的临床差距。在具体目标1中，我们将测试84个基因的信使核糖核酸表达可以提高现有的、经过验证的模型的准确性的假设，该模型可以更可靠地对感染性休克儿童的死亡或生存风险进行分层。我们已经确定了84个候选分层基因，这些基因具有预测死亡/生存的能力。利用数字化的信使核糖核酸测量平台，我们将结合这84个基因的信使核糖核酸表达数据，以增强最近开发的基于血清蛋白质生物标记物的模型的预测能力。增强的模型将在现有的300名患者队列中获得，并随后在200名预期登记的患者队列中得到验证。在特定的目标2中，我们将检验白介素27可以作为细菌感染的诊断生物标志物的假设。我们已将IL-27确定为细菌感染的候选诊断生物标志物。在一组危重儿童中，我们已经证明IL-27血清蛋白浓度可以预测细菌感染，其特异性和阳性预测值为90%。我们将在急诊科和重症监护室招募的两组患者中进一步测试血清IL-27蛋白浓度作为诊断生物标志物的能力。在特定的目标3中，我们将检验这样一种假设，即存在一组以糖皮质激素受体(GCR)表达减少为特征的感染性休克患者。我们的基因表达数据已经确定了一组感染性休克患者，他们的特点是与GCR信号通路基因对应的基因广泛抑制，与其他两组没有GCR信号通路基因抑制的患者相比，这组患者的病情严重程度和死亡率更高。这表明存在一组可识别的感染性休克患者，他们对辅助性糖皮质激素的反应相对较差。如果这是真的，这将是研究辅助皮质类固醇在感染性休克中的作用的一个主要混淆因素，这是目前该领域的一个主要争议。我们已经开发了一种基于流式细胞术的方法来直接测量感染性休克患者血液隔室中GCR的表达。我们将系统地检测GCR的表达，并将其与临床表型相关联。总而言之，这三个目标有可能大幅推进临床感染性休克的分层和诊断手段。

DESCRIPTION (provided by applicant): Septic shock continues to be a major public health problem in both adults and children. An important and unmet clinical gap in the field is the lack of robust stratification and diagnostic tools specific for septic shock. This proposal seeks to directly address this gap. We have leveraged our extensive, multi-center gene expression databank of children with septic shock to identify gene signatures that provide a strong foundation for the development of novel stratification and diagnostic tools for clinical septic shock. The major innovation of this proposal is the ability to directly leverage transcriptomic dat as a basis for clinical advancements, an often stated, but seldom achieved goal of transcriptomics. We are proposing three independent, but highly complementary Specific Aims, all of which directly address the aforementioned, unmet clinical gap. In Specific Aim 1, we will test the hypothesis that the mRNA expression of 84 genes can enhance the accuracy of an existing, validated model to stratify more reliably the risk of death or survival in children with septic shock. We have identified 84 candidate stratification genes having predictive capacity of mortality/survival. Using a digital mRNA measurement platform, we will incorporate the mRNA expression data from these 84 genes to enhance the predictive capacity of a recently developed, serum protein biomarker-based model. The enhanced model will be derived in an existing cohort of 300 patients, and subsequently validated in a prospectively enrolled cohort of 200 patients. In Specific Aim 2, we will test the hypothesis that interleukin-27 can serve as a diagnostic biomarker for bacterial infection. We have identified IL-27 as a candidate diagnostic biomarker for bacterial infection. In a cohort of critically ill children, we have demonstrated tha IL-27 serum protein concentrations can predict bacterial infection with a specificity and positive predictive value of >90%. We will further test the ability of serum IL-27 protein concentration to serve as a diagnostic biomarker in two separate cohorts of patients recruited from the Emergency Department and the Intensive Care Unit. In Specific Aim 3, we will test the hypothesis that there exists a group of patients with septic shock characterized by decreased expression of the glucocorticoid receptor (GCR). Our gene expression data have identified a group of patients with septic shock who are characterized by widespread repression of genes corresponding to the GCR signaling pathway, and this particular group of patients has higher illness severity and mortality, compare to two other groups without repression of GCR signaling pathway genes. This suggests the existence of an identifiable group of patients with septic shock who are relatively less responsive to adjunctive glucocorticoids. If this holds true, it woul represent a major confounder for studying the role of adjunctive corticosteroids for septic shock, which is currently a major controversy in the field. We have developed a flow cytometry-based protocol to directly measure GCR expression in the blood compartment of patients with septic shock. We will systematically measure GCR expression and correlate GCR expression with clinical phenotypes. Collectively, these three Aims have the potential to substantially advance the stratification and diagnostic armamentarium for clinical septic shock.