Pro-ADM for prognosis of trauma-related complications in polytrauma patients

Abstract

To provide methods, kits and further means for diagnosis, prognosis, prediction, risk assessment and / or risk stratification of a subsequent trauma-related complication in a polytrauma patient on the basis of adrenomedullin (ADM) levels, in particular proADM or MR-proADM, determined in a sample from a patient.SOLUTION: The invention relates to a method for the diagnosis, prognosis, prediction, risk assessment and / or risk stratification of a subsequent trauma-related complication in a polytrauma patient, comprising providing a sample of said patient, wherein the sample is isolated from the patient after the polytrauma, determining a level of proADM or fragment(s) thereof in the sample, where the level of proADM or fragment(s) thereof correlates with the likelihood of a subsequent trauma-related complication.SELECTED DRAWING: None

Description

[Technical field]

[0001] explanation The present invention relates to a method for the diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent trauma-related complications in polytrauma patients, comprising providing a patient sample, which is isolated from the patient following polytrauma, and determining a level of proADM or a fragment(s) thereof in the sample, wherein the level of proADM or a fragment(s) thereof correlates with the likelihood of subsequent trauma-related complications. [Background technology]

[0002] Treating severely injured patients after multiple trauma represents an increasing and significant burden for healthcare providers [1-3], and the subsequent development of systemic inflammation makes early identification of sepsis problematic [4, 5]. Despite a decline in mortality due to the initial trauma, the incidence of sepsis as a subsequent complication remains unchanged, potentially resulting in longer intensive care time and higher mortality [3]. Thus, early and accurate identification of the likelihood that a patient will develop subsequent sepsis may be of significant clinical value. Conversely, excluding sepsis onset is equally important in terms of withholding antibiotics or performing additional sepsis-related investigations such as focus cleaning.

[0003] Moreover, polytrauma patients are prone to further trauma-related complications not necessarily related to infection, including rhabdomyolysis and organ failure, which may lead to prolonged intensive care treatment and increased mortality. Regarding such non-infection-related complications, methods for early identification of polytrauma patients at risk of developing such complications are also urgently needed.

[0004] The use of biomarkers to distinguish between the presence of significant systemic inflammation and early stages of sepsis development or non-infection-related complications may allow the initiation of personalized treatment strategies, such as early initiation of antibiotic therapy. While biomarkers such as C-reactive protein (CRP), procalcitonin (PCT), and interleukin (IL)-6 have been incorporated into routine clinical use [6, 7], other biomarkers and clinical scores, such as lactate, the Sequential Organ Failure Assessment (SOFA) score, and the recently proposed Quick SOFA score, form an integral part of the recently revised definition of sepsis [8]. Despite the existence of these established biomarkers and scores, there remains a clinical requirement for faster and more accurate tools to help predict and identify the development of infections and non-infection-related complications in critically injured patients, especially in polytrauma patients.

[0005] Therefore, in the field of treating severely injured patients, such as polytrauma patients, additional means for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent trauma-related complications are needed.

[0006] The inclusion of proADM represents one such measure, particularly mid-regional pro-adrenomedullin (MR-proADM): Recent studies have shown that concentrations are elevated early in patients developing sepsis after burns [9] and neurological injury

[10] , and extensive evidence for its use in discriminating disease severity in already infected patients has been previously published [11-13].

[0007] Wang et al. (Chinese Journal Of Traumatology (English Edition), vol. 13, no. 3, 1 June 2010, pages 152-157) show that proADM can be used as a marker of sepsis severity and mortality in ICU patients. However, Wang et al. do not mention the use of proADM to predict sepsis in a specific subgroup of multiple trauma patients, and therefore the specific cut-off value for this patient population is not investigated. Furthermore, WO2018 / 029214A1 describes a method for predicting complications in subjects, which can be, for example, healthy subjects or subjects suffering from respiratory disease, urinary tract infection, or malignant tumors.

[0008] Therefore, previous studies have not addressed the performance of proADM in severe post-traumatic patients, such as those with an Injury Severity Score (ISS) of 17 or higher or those with multiple trauma. However, the selection of specific subgroups of patients can have a profound effect on the performance of a biomarker such as proADM, and as a result, the predictive impact of a particular level of a biomarker depends on the reference group of patients.

[0009] US Patent Application Nos. US2013 / 203612(A1) and US2012 / 094314(A1) refer to methods for predicting sepsis in polytrauma patients, but using markers other than proADM. US2013 / 203612(A1) relates to the use of pancreatic stone proteins, and US2012 / 094314(A1) describes the use of NT-CNP. Both of these biomarkers are completely independent of proADM, and there is no indication that proADM can be used as a replacement for these markers in a manner similar to that described in these disclosures.

[0010] The data disclosed herein includes comparing the performance of MR-proADM with established biomarkers (PCT, CRP, and lactate) and the Clinical Severity of Events Score (SOFA) to (i) compare concentrations immediately following trauma, (ii) evaluate the performance to identify patients at risk of developing infection-related complications, (iii) identify patients at low risk of any subsequent sepsis development, and (iv) identify patients at risk of developing non-infection-related complications. Summary of the Invention

[0011] In light of the difficulties in the prior art, the technical problem underlying the present invention is to provide a means for the diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent trauma-related complications in polytrauma patients.

[0012] The present invention therefore aims to provide methods, kits and further means for the diagnosis, prognosis, prediction, risk assessment and / or risk stratification of subsequent trauma-related complications in polytrauma patients based on adrenomedullin (ADM) levels, particularly proADM or MR-proADM, determined in samples from patients.One object of the present invention is therefore the use of a biomarker or combination of biomarkers to distinguish polytrauma patients who are likely or have a high risk of subsequent trauma-related complications, such as sepsis or rhabdomyolysis, from polytrauma patients who are at low risk of subsequent trauma-related complications.

[0013] The solutions to the technical problem of the present invention are provided in the independent claims. Preferred embodiments of the invention are provided in the dependent claims.

[0014] Accordingly, the present invention provides a method for the diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent trauma-related complications in polytrauma patients, comprising: providing a sample of said patient, the sample being isolated from the patient following multiple trauma; - determining the level of proADM or a fragment(s) thereof in said sample, - the level of proADM or a fragment(s) thereof correlates with the likelihood of subsequent trauma-related complications.

[0015] The present invention provides a novel, rapid and reliable test for medical personnel, such as doctors, nurses, emergency department personnel, etc., to rapidly assess the risk of multiple trauma patients developing trauma-related complications, such as sepsis. Due to the non-specific increase in many inflammatory markers and other signs of inflammation after multiple trauma, it is difficult for medical personnel to distinguish between inflammation and the development of trauma-related complications, which may also be associated with signs of inflammation, such as infection, sepsis, organ failure, shock, and rhabdomyolysis. Surprisingly, the present invention provides a means for identifying patients at increased or high risk of developing trauma-related complications, and also provides a means for identifying patients who are less likely to develop such complications or who can practically exclude the development of such complications by determining the level of proADM or a fragment thereof in a sample isolated from the patient.

[0016] In an embodiment of the invention, the patient may be a severely injured patient, rather than a polytrauma patient. In an embodiment of the invention, the severely injured patient may be a polytrauma patient. In an embodiment of the invention, the polytrauma patient may be considered to be severely injured. In accordance with the invention, trauma-related complications may be considered to be adverse events in the patient's health.

[0017] This is a major advantage, as it allows for early isolation of samples after polytrauma occurrence, providing medical personnel with early guidance regarding the progression of the patient's condition, thereby allowing for directed and improved therapeutic decisions, for example regarding the administration of specific drugs of therapeutic procedure. A further advantage is that proADM levels can also be determined at later time points after polytrauma, thus allowing for monitoring of the patient's health status.

[0018] In an embodiment of the invention, the sample is isolated from the patient within 48 hours, preferably within 24 hours, more preferably within 6 hours after multiple trauma.

[0019] In embodiments, the sample is isolated from the patient about 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours, 12 hours, 14 hours, 16 hours, 18 hours, 20 hours, 22 hours, 24 hours, 30 hours, 36 hours, 42 hours, 48 ​​hours, 60 hours, 72 hours, 84 hours, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, or 28 days after polytrauma.

[0020] In an embodiment of the invention, more than one sample may be isolated from the patient to determine proADM or a fragment thereof at multiple time points following polytrauma.

[0021] In a further embodiment of the present invention, the patient, who may be a severely injured and / or polytrauma patient, has an Injury Severity Score (ISS) of 17 or more. In a preferred embodiment, the polytrauma patient has an ISS of 17 or more. The method of the present invention has been shown to be particularly accurate in severely injured patients with an ISS of 17 or more, which is very useful since such patients are particularly unstable and trauma-related complications may be detrimental to the health status of these patients. Thus, the method of the present invention allows for improved management of the patient, focusing on the actual needs, while being able to exclude potentially occurring complications. By excluding potentially occurring complications, certain therapies can be adjusted or discontinued to avoid the development of severe side effects that polytrauma patients may face.

[0022] Furthermore, in some embodiments, the group of severely injured and / or polytraumatized patients relevant to the method of the invention does not include patients with an ISS of less than 15, less than 16, less than 17, less than 18, less than 19, or less than 20. Furthermore, in some embodiments, the patients of the invention may not include burn patients with a burn total body surface area (TBSA) of less than 40%, 39%, 38%, 37%, 36%, or 35%. Furthermore, trauma patients with an ISS of 9, 10, 11, 12, 13, or 14 may be excluded from the method of the invention in some embodiments. In embodiments of the invention, the method relates to patients with an ISS of 15 or more, 16 or more, 17 or more, 18 or more, 19 or more, or 20 or more.

[0023] The severity of trauma, such as burns, may affect the level of proADM and its predictive value for trauma-related complications, so that selecting the right group of polytrauma patients is a determining factor for the successful implementation of the method of the present invention. Thus, implementing the method on patients who have trauma but do not qualify as polytrauma patients in the sense of the present invention may lead to erroneous or misleading results. However, polytrauma patients in the sense of the present invention do not necessarily have to suffer from multiple injuries, e.g., two or more injuries in at least two areas of the body, or a condition with multiple injuries, i.e., two or more severe injuries in one body area. Polytrauma patients may also suffer from only one severe injury that is considered polytrauma, such as a burn of 40% or more of the TBSA.

[0024] In a preferred embodiment of the invention, a level of proADM or a fragment(s) thereof of 1.54 nmol / l ± 20% or more, preferably 1.54 nmol / l ± 10% or more, more preferably 1.54 nmol / l or more, is indicative of subsequent trauma-related complications.

[0025] In a further embodiment, a level of proADM or fragment(s) thereof of less than 1.54 nmol / l ± 20%, preferably less than 1.54 nmol / l ± 10%, more preferably less than 1.54 nmol / l indicates the absence of subsequent trauma-related complications.

[0026] It is a great advantage of the method of the present invention that by using a cut-off value of 1.54 nmol / l ± 20%, it is possible to identify patients at high risk of developing trauma-related complications and / or to identify patients who are unlikely to develop such complications or who can practically exclude such complications, regardless of the specific time point or time of the limited window of sample isolation after the occurrence of polytrauma and regardless of the specific trauma-related complications.

[0027] According to the present invention, the term "indicative" in the context of "indicative of a subsequent adverse event," "indicative of a subsequent trauma-related complication," "indicative of the absence of a subsequent adverse event," and "indicative of the absence of subsequent trauma-related complications" is intended as a measure of risk and / or likelihood. Preferably, an "indication" of the presence or absence of an adverse event is intended as a risk assessment and is typically not interpreted in a restrictive manner to specifically refer to the absolute presence or absence of the event.

[0028] Thus, the terms "indicating a subsequent adverse event", "indicating a subsequent trauma-related complication", "indicating the absence of a subsequent adverse event", and "indicating the absence of a subsequent trauma-related complication" can be understood as indicating a low or high risk of occurrence of an adverse event / trauma-related complication, respectively. In some embodiments, low risk refers to a low risk compared to proADM levels detected above the indicated value. In some embodiments, high risk refers to a high risk compared to proADM levels detected below the indicated value.

[0029] However, with the above in mind, the determination of high and low severity levels of proADM is highly reliable with respect to determining the subsequent presence or absence of adverse events, using the cut-off values ​​disclosed herein, such that the assessment of risk allows appropriate action by medical professionals.

[0030] It was quite surprising that the level of proADM or a fragment thereof can be correlated with the possibility of subsequent trauma-related complications in the context of polytrauma patients.The proADM level in the sample from polytrauma patients of the present invention can preferably be assigned to at least two different severity levels of proADM (high and low).A high level of proADM indicates a high severity level, and a low level indicates a low severity level.The respective concentrations that determine the cut-off values ​​that can be used to assign each severity level can depend on several parameters, such as the time of sample isolation after polytrauma, the trauma-related complications to be evaluated by the method, and the method used to determine the level of proADM or a fragment thereof in the sample.

[0031] The cut-off value disclosed herein refers to the measurement of the protein level of proADM or its fragments in blood sample, preferably whole blood sample, or plasma or serum sample obtained from patient by means of Thermo Scientific BRAHMS KRYPTOR assay.Therefore, the value disclosed herein may vary to some extent depending on the detection / measurement method used, and the specific value disclosed herein is also intended to read the corresponding value determined by other methods.

[0032] In an embodiment of the present invention, the limit or cut-off value of proADM or its fragment(s) that may define the transition from a low severity level to a high severity level may be any value in the range of 0.1 nmol / l to 4 nmol / l. Any value within this range may be considered as a suitable cut-off value for high and low proADM severity levels. Furthermore, values ​​below such cut-off values ​​may indicate the absence of trauma-related complications, and values ​​equal to or greater than such cut-off values ​​may indicate trauma-related complications. Suitable cut-off levels that may be used in the context of the present invention include, but are not limited to, 0.1, 0.15, 0.2, 0.25, 0.3, 0.35, 0.4, 0.45, 0.5, 0.55, 0.6, 0.65, 0.7, 0.75, 0.8, 0.85, 0.9, 0.95, 1.0, 1.05, 1.1, 1.15, 1.2, 1.25, 1.3, 1.35, 1.4, 1.45, 1.5, 1.55, 1.6, 1.65, 1.7, 1.75, 1.8, 1.85, 1.9 , 1.95, 2.0, 2.05, 2.1, 2.15, 2.2, 2.25, 2.3, 2.35, 2.4, 2.45, 2.5, 2.55, 2.6, 2.65, 2.7, 2.75, 2.8, 2.85, 2.9, 2.95, 3.0, 3.05, 3.1, 3.15, 3.2, 3.25, 3.3, 3.35, 3.4, 3.45, 3.5, 3.55, 3.6, 3.65, 3.7, 3.75, 3.8, 3.85, 3.9, 3.95, 4.0 nmol / l.

[0033] In embodiments of the invention deviations from these possible cut-off values ​​are also claimed, for example ±30%, 29%, 28%, 27%, 26%, 25%, 24%, 23%, 22%, 21%, 20%, 19%, 18%, 17%, 16%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, or 1%.

[0034] In certain embodiments of the methods of the present invention, the trauma-related complications include infection-related complications, such as infection, hospital-acquired infection, sepsis, and / or septic shock. In certain embodiments of the methods of the present invention, the trauma-related complications include infection, hospital-acquired infection, sepsis, and / or septic shock. In further embodiments, the trauma-related complications include infection-related complications, such as infection, hospital-acquired infection, sepsis, and / or septic shock. In an embodiment, the trauma-related complication is sepsis.

[0035] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of 0.97 nmol / l ± 20% or more, preferably 0.97 ± 10% or more, more preferably 0.97 nmol / l or more, indicates subsequent infection, hospital-acquired infection, sepsis, and / or septic shock; and / or A level of proADM or a fragment(s) thereof in a sample isolated 24-48 hours after severe injury of greater than or equal to -1.35 nmol / l ± 20%, preferably greater than or equal to 1.35 nmol / l ± 10%, more preferably greater than or equal to 1.35 nmol / l, is indicative of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock.

[0036] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of less than 0.97 nmol / l ± 20%, preferably less than 0.97 ± 10%, more preferably less than 0.97 nmol / l, indicates the absence of subsequent infection, nosocomial infection, sepsis, and / or septic shock; and / or A level of proADM or its fragment(s) in a sample isolated 24-48 hours after severe injury of less than -1.35 nmol / L ± 20%, preferably less than 1.35 nmol / L ± 10%, more preferably less than 1.35 nmol / L indicates the absence of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock.

[0037] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of 0.8 nmol / l or more, preferably 0.9 nmol / l or more, more preferably 0.97 nmol / l or more, is indicative of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock; and / or A level of proADM or a fragment(s) thereof in a sample isolated 24-48 hours after severe injury of -1.2 nmol / l or greater, preferably 1.3 nmol / l or greater, more preferably 1.35 nmol / l or greater, is indicative of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock.

[0038] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of less than 0.8 nmol / l, preferably less than 0.9 nmol / l, more preferably less than 0.97 nmol / l, indicates the absence of subsequent infection, nosocomial infection, sepsis, and / or septic shock; and / or A level of proADM or a fragment(s) thereof in a sample isolated 24-48 hours after severe injury of less than -1.2 nmol / l, preferably less than 1.3 nmol / l, more preferably less than 1.35 nmol / l, indicates the absence of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock.

[0039] It is particularly advantageous that the cut-off of proADM or its fragment(s) used in the context of the method of the present invention can be adjusted to the time of sample isolation and the trauma-related complication to be detected or excluded.Thus, the method allows a more accurate assessment of the prognosis / risk of patients depending on the situation of sample isolation and the additional information available at the time, such as the increased risk of developing certain trauma-related complications.

[0040] In further embodiments of the invention, the trauma-related complication comprises a non-infection-related complication such as rhabdomyolysis and / or organ failure. In an embodiment, the trauma-related complication is rhabdomyolysis.

[0041] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of 0.82 nmol / l ± 20% or more, preferably 0.82 nmol / l ± 10% or more, more preferably 0.82 nmol / l or more, indicates subsequent non-infection-related complications such as rhabdomyolysis and / or organ failure; and / or Levels of proADM or its fragment(s) in samples isolated 24-48 hours after severe injury of -0.97 nmol / L ± 20% or greater, preferably 0.97 nmol / L ± 10% or greater, more preferably 0.97 nmol / L or greater, indicate subsequent non-infection related complications such as rhabdomyolysis and / or organ failure.

[0042] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of less than 0.82 nmol / l ± 20%, preferably less than 0.82 nmol / l ± 10%, more preferably less than 0.82 nmol / l, indicates the absence of subsequent non-infection-related complications such as rhabdomyolysis and / or organ failure; and / or A level of proADM or its fragment(s) in a sample isolated 24-48 hours after severe injury of less than -0.97 nmol / L ± 20%, preferably less than 0.97 nmol / L ± 10%, more preferably less than 0.97 nmol / L indicates the absence of subsequent non-infection related complications such as rhabdomyolysis and / or organ failure.

[0043] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of 0.7 nmol / l or more, preferably 0.8 nmol / l or more, more preferably 0.82 nmol / l or more, indicates subsequent non-infection-related complications such as rhabdomyolysis and / or organ failure; and / or Levels of proADM or its fragment(s) in samples isolated 24-48 hours after severe injury of -0.8 nmol / l or greater, preferably 0.9 nmol / l or greater, more preferably 0.97 nmol / l or greater, indicate subsequent non-infection related complications such as rhabdomyolysis and / or organ failure.

[0044] In an embodiment of the present invention, - a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of less than 0.7 nmol / l, preferably less than 0.8 nmol / l, more preferably less than 0.82 nmol / l, indicates the absence of subsequent non-infection-related complications such as rhabdomyolysis and / or organ failure; and / or A level of proADM or its fragment(s) in a sample isolated 24-48 hours after severe injury of less than -0.8 nmol / l, preferably less than 0.9 nmol / l, more preferably less than 0.97 nmol / l indicates the absence of subsequent non-infection related complications such as rhabdomyolysis and / or organ failure.

[0045] According to a further embodiment of the method of the present invention, the trauma-related complication comprises death.In an embodiment, the trauma-related complication is death, preferably within 28 days of multiple trauma.Preferably, in the context of the method of the present invention, the trauma-related complication (predicted) will occur within 28 days of multiple trauma.

[0046] In further embodiments, the trauma-related complications (predicted) will occur within 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, or 2 days, or within 1 day, of the multiple trauma.

[0047] A major advantage of the present invention is that it not only makes it possible to estimate the risk of post-traumatic complications, but also provides a time frame for the occurrence of such complications, thereby making it possible to estimate the urgency of the need to take measures and the suitability of certain measures.

[0048] Depending on the outcome of the method of the present invention, the embodiment of the method may include subsequent therapeutic decisions and / or therapeutic actions. Such therapeutic decisions may include initiation, alteration, or modification of medical treatment. For example, if the method of the present invention indicates a subsequent trauma-related complication, suitable therapeutic measures such as initiation or alteration of a specific drug therapy, surgery, or fluid therapy may be initiated. Any of the therapies, medical treatments, or therapeutic actions disclosed herein may be used in the context of the method of the present invention as subsequent therapeutic decisions or therapeutic actions, especially when the therapeutic measures are specific to the complication, such as antibiotic treatment in the case of sepsis, or antibiotic treatment in the case of rhabdomyolysis as a trauma-related complication, intravenous fluid therapy, dialysis, management of electrolyte abnormalities (particularly potassium, calcium, and phosphorus), etc. Furthermore, sustained intensive observation and care of the patient may potentially be desirable for extended periods of time, such as days, weeks, or even months. This may include retaining or transferring the patient to an ICU and / or extending the patient's stay in the ICU.

[0049] On the other hand, if the results of the methods of the present invention indicate the absence of trauma-related complications, then specific therapeutic measures regarding such complications may not be required.

[0050] Conversely, if the methods of the invention indicate an absence of subsequent trauma-related complications, this may indicate discontinuation or modification of unnecessary medications, such as (intravenous) antibiotic therapy, and / or earlier discharge of the patient from the intensive care unit.

[0051] If the methods of the invention indicate infection, hospital acquired infection, sepsis and / or septic shock, antibiotic therapy can be initiated or ongoing antibiotic therapy can be modified or altered.

[0052] In one embodiment, the invention additionally comprises informing the patient of the results of the diagnostic methods described herein. In an embodiment of the invention, the patient is at least 18 years of age.

[0053] In a preferred embodiment of the present invention, the sample is selected from the group consisting of blood sample, serum sample, plasma sample, and / or urine sample.Determining proADM or its fragment(s) in blood, serum or plasma is particularly advantageous, since it has been shown to be particularly accurate.Moreover, these samples reflect the actual condition of the patient at a certain time very accurately.

[0054] In an embodiment of the present invention, determining the level of proADM or its fragment(s) comprises determining the level of MR-proADM in a sample. In any given embodiment described herein, it is preferred to use the determination of MR-proADM, and therefore, in the context of each embodiment, this may be taken into account. In a preferred embodiment, the "ADM fragment" may be considered to be MR-proADM.

[0055] In a further embodiment of the present invention, the level of proADM or its fragment(s) is correlated with the likelihood of subsequent trauma-related complications in the health of said patient.In a preferred embodiment, the level of proADM or its fragment(s) is positively correlated with the likelihood of subsequent trauma-related complications in said patient.In other words, the higher the level of proADM determined, the higher the likelihood of subsequent trauma-related complications.

[0056] According to a particular embodiment, the method of the present invention comprises: - determining the level of at least one additional biomarker or fragment(s) thereof in a sample from said patient, wherein the at least one additional biomarker is preferably PCT or fragment(s) thereof and / or lactate; and / or - determining at least one clinical score, which is preferably SOFA, - The level of at least one additional biomarker and / or at least one clinical score, as well as the level of proADM or a fragment(s) thereof, are indicative of subsequent trauma-related complications.

[0057] Further additional markers that may be determined in the context of the present invention include lactate and CRP. Clinical scores that may be determined in the context of the present invention include SI score (systemic inflammation score), SOFA, qSOFA, SIRS, SAPS II, APACHE II, preferably SOFA.

[0058] It has been found that the determination of proADM or a fragment(s) thereof and SOFA in the context of the methods of the present invention provides further accuracy with respect to the prediction and / or prognosis of subsequent trauma-related complications, particularly where the trauma-related complication is or includes sepsis.

[0059] In another embodiment of the method of the invention, the additional marker is lactate. Surprisingly, the combined determination of proADM and lactate in the context of the invention provides a particularly accurate prediction of subsequent non-infection-related complications, in particular rhabdomyolysis.

[0060] In further embodiments, the at least one additional biomarker is at least one marker of rhabdomyolysis, such as creatine kinase (CK), lactate dehydrogenase (LDH), creatinine, myoglobin, aldolase, troponin, carbonic anhydrase type 3, fatty acid binding protein (FABP), transaminase, or potassium.

[0061] In an embodiment of the invention, the method comprises the steps of: - determining the severity level of proADM or a fragment(s) thereof in a first sample isolated from a polytrauma patient; and / or - determining the severity level of proADM or fragment(s) thereof in a second sample isolated from the patient, the second sample being isolated after the first sample; A level of proADM or its fragment(s) less than -1.54 nmol / l ± 20% corresponds to a low severity level, and a level of proADM or its fragment(s) equal to or greater than 1.54 nmol / l ± 20% corresponds to a high severity level.

[0062] Preferably, the first sample is isolated from the polytrauma patient within 24 hours, more preferably within 6 hours, after polytrauma. The first sample may be isolated at any of the time points disclosed for sample isolation in the context of the method of the present invention.

[0063] Further, the second sample can be isolated from the patient within 24 hours after isolation of the first sample, provided that the second sample can be isolated about 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours, 12 hours, 14 hours, 16 hours, 18 hours, 20 hours, 22 hours, 24 hours, 30 hours, 36 hours, 42 hours, 48 ​​hours, 60 hours, 72 hours, 84 hours, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, or 28 days after isolation of the first sample.

[0064] In an embodiment of the invention, a high severity level of proADM or fragment(s) thereof in the second sample indicates subsequent trauma-related complications. In a further embodiment of the invention, an elevated severity level of proADM or fragment(s) thereof in the second sample compared to the first sample indicates subsequent trauma-related complications.

[0065] In a further embodiment, a low severity level of proADM or fragment(s) thereof in the first and second samples preferably indicates the absence of subsequent trauma-related complications such as sepsis and / or septic shock.

[0066] Furthermore, a low severity level of proADM or fragment(s) thereof in the second sample may preferably indicate the absence of subsequent trauma-related complications such as sepsis and / or septic shock.

[0067] In an embodiment of the present invention, a persistently low severity level of proADM or a fragment thereof (several) indicates the absence of infection-related complications, in particular sepsis, and preferably, the occurrence of sepsis (preferably within 28 days of polytrauma) can be excluded if the severity level of proADM is persistently low.

[0068] The present invention further provides a kit for carrying out the method of the present invention, comprising: - a detection reagent for determining the level of proADM or a fragment(s) thereof in a sample from a subject, and optionally for determining the level of at least one additional biomarker, such as PCT or a fragment(s) thereof and / or lactate, Reference data, such as reference levels, i. a level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of 0.97 nmol / l ± 20% or greater for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock; ii. a level of proADM or a fragment(s) thereof in a sample isolated 24-48 hours after severe injury of 1.35 nmol / l ± 20% or more for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent infection, hospital-acquired infection, sepsis, and / or septic shock; iii. A level of proADM or a fragment(s) thereof in a sample isolated within 24 hours after severe injury of 0.82 nmol / l ± 20% or more for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent non-infection related complications such as rhabdomyolysis and / or organ failure; iv. A level of proADM or a fragment(s) thereof in a sample isolated 24-48 hours after severe injury of 0.97 nmol / l ± 20% or greater for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent non-infection-related complications, such as rhabdomyolysis and / or organ failure; and / or v. reference data corresponding to high and / or low severity levels of proADM or a fragment(s) thereof, where the low severity level is less than 1.54 nmol / l ± 20% and the high severity level is equal to or greater than 1.54 nmol / l ± 20%, - the reference data is preferably stored on a computer readable medium and / or in the form of a computer executable code configured to compare the determined level of proADM or a fragment(s) thereof, and optionally the determined level of at least one additional biomarker, such as PCT or a fragment(s) thereof, with the reference data.

[0069] Detection reagents for determining the level of proADM or fragment(s) thereof, and optionally for determining the level of PCT, lactate, and / or C-reactive protein, or fragment(s) thereof, are preferably selected from those necessary to perform the method, e.g. antibodies directed against ADM, suitable labels such as fluorescent labels, preferably two separate fluorescent labels suitable for use in the KRYPTOR assay, sample collection tubes.

[0070] The embodiments and features disclosed in the context of the methods of the invention also apply to the kits of the invention, and to other methods.

[0071] In one embodiment of the methods described herein, the levels of proADM or a fragment(s) thereof, and optionally other biomarkers, such as PCT or a fragment(s) thereof, are determined using a method selected from the group consisting of mass spectrometry (MS), luminescence immunoassay (LIA), radioimmunoassay (RIA), chemiluminescence and fluorescence immunoassay, enzyme immunoassay (EIA), enzyme-linked immunoassay (ELISA), luminescence-based bead array, magnetic bead-based array, protein microarray assay, rapid test formats such as real-time immunochromatography strip tests, rare earth cryptate assays, and automated systems / analyzers.

[0072] The method according to the invention can further be embodied as a homogeneous method, in which the sandwich complex formed by the antibody / antibodies to be detected and the marker, e.g. proADM or a fragment thereof, remains suspended in a liquid phase. In this case, when two antibodies are used, it is preferred that both antibodies are labeled with part of the detection system, which leads to the generation or induction of a signal when both antibodies are integrated into a single sandwich.

[0073] Such techniques should be embodied in particular as fluorescence enhancement or fluorescence quenching detection methods. Particularly preferred embodiments relate to the use of detection reagents used in pairs, such as those described in US4882 733A, EP-B10180492, or EP-B10 539477, and the prior art cited therein. In this way, measurements are possible in which only reaction products containing both labeling components are detected directly in a single immune complex in the reaction mixture.

[0074] For example, such technology is provided under the trade name TRACE (Time Resolved Amplified Cryptate Emission), or KRYPTOR (registered trademark), which implements the teachings of the above-cited applications.Therefore, in a particularly preferred embodiment, a diagnostic device is used to carry out the method provided herein.For example, the level of proADM protein or its fragment, and / or the level of any additional marker of the method provided herein is determined.In a particularly preferred embodiment, the diagnostic device is KRYPTOR (registered trademark).

[0075] In one embodiment of the methods described herein, the method is an immunoassay, where the assay is performed in a homogeneous or heterogeneous phase.

[0076] In a further embodiment of the method described herein, the method additionally comprises a molecular analysis of a sample from said patient to detect infection. The sample used for the molecular analysis to detect infection is preferably a blood sample. In a preferred embodiment, the molecular analysis is a method aimed at detecting one or more biomolecules originating from a pathogen. The one or more biomolecules may be nucleic acids, proteins, sugars, carbohydrates, lipids, and / or combinations thereof, such as glycosylated proteins, preferably nucleic acids. The biomolecules are preferably specific for one or more pathogen(s). According to a preferred embodiment, such biomolecules are detected by one or more methods for the analysis of biomolecules selected from the group comprising nucleic acid amplification methods such as PCR, qPCR, RT-PCR, qRT-PCR, or isothermal amplification, mass spectrometry, detection of enzymatic activity, and detection methods based on immunoassays. Further methods of molecular analysis are known to the skilled person and are included in the method of the present invention.

[0077] In one embodiment of the methods described herein, the first antibody and the second antibody are present dispersed in a liquid reaction mixture, and a first label component that is part of a labeling system based on fluorescence or chemiluminescence quenching or amplification binds to the first antibody and a second label component of the labeling system binds to the second antibody, thereby generating a measurable signal that allows detection of the resulting sandwich complex in the measurement solution after binding of both antibodies to be detected to the proADM or fragment thereof.

[0078] In one embodiment of the methods described herein, the labeling system comprises a rare earth cryptate or chelate in combination with a fluorescent or chemiluminescent dye, particularly of the cyanine type.

[0079] In one embodiment of the methods described herein, the method additionally comprises comparing the determined level of proADM or a fragment thereof (s) with a reference level, threshold, and / or population average corresponding to proADM or a fragment thereof in patients diagnosed with a serious disease and under medical treatment, the comparison being performed on a computer processor using computer-executable code.

[0080] The method of the present invention can be partially computer-implemented. For example, the step of comparing the level of the detected marker, such as proADM or a fragment thereof, with a reference level can be implemented in a computer system. In the computer system, the determined level of the marker(s) can be combined with other marker levels and / or parameters of the subject to calculate a score indicated for diagnosis, prognosis, prediction, risk assessment, and / or risk stratification. For example, the determined value can be input into the computer system (either manually by a medical professional or automatically from the device(s) where the respective marker level(s) is determined). The computer system can be directly at the point-of-care (e.g., primary care, ICU, or ED) or at a remote location connected via a computer network (e.g., via the Internet, or a specialized medical cloud system, optionally combined with other IT systems or platforms such as a hospital information system (HIS)). Typically, the computer system will store values ​​(e.g., marker levels or parameters such as age, blood pressure, weight, sex, or clinical scoring systems such as SOFA, qSOFA, BMI, etc.) in a computer readable medium and calculate a score based on predefined and / or prestored reference levels or values. The resulting score will be displayed and / or printed for a user (usually a medical professional such as a physician). Alternatively or additionally, an associated prognosis, diagnosis, evaluation, treatment guidance, patient management guidance or stratification will be displayed and / or printed for a user (typically a medical professional such as a physician).

[0081] In one embodiment of the present invention, a software system can be used in which a machine learning algorithm is evident to identify hospitalized patients at risk for sepsis, severe sepsis and septic shock, preferably using data from an electronic health record (EHR). The machine learning approach can be trained with a random forest classifier using EHR data from the patient (labs, biomarker expression, vitals, demographics, etc.). Machine learning is a type of artificial intelligence that gives computers the ability to learn complex patterns of data without being explicitly programmed, unlike simple rule-based systems. Previous studies have used electronic health record data to trigger alerts to detect general clinical deterioration. In one embodiment of the present invention, the processing of proADM levels can be incorporated into appropriate software for comparison with existing data sets, for example, proADM levels can be processed with machine learning software to aid in the diagnosis or prognosis of the occurrence of adverse events.

[0082] By using the combination of proADM or its fragments in combination with another biomarker such as PCT or CRP, it can be realized either in a single multiplex assay or in two separate assays carried out on samples from patients.The samples can be related to the same sample or to different samples.The assays used for detecting and determining proADM and, for example, PCT can also be the same or different, for example, immunoassays can be used to determine one of the above markers.A more detailed description of suitable assays is provided below.

[0083] The cut-off value and other reference levels of proADM or its fragments in patients diagnosed as severe and under treatment can be determined by the above-mentioned method.For example, the method of using the coefficient of variation in evaluating the variability of quantitative assay to establish reference value and / or cut-off is known to those skilled in the art (George F.Reed et al., Clin Diagn Lab Immunol.2002;9(6):1235-1239).

[0084] In addition, the sensitivity of a functional assay can be determined to indicate a statistically significant value for use as a reference level or cutoff according to established techniques. Laboratories can independently establish the functional sensitivity of an assay by clinically relevant protocols. "Functional sensitivity" can be considered as the concentration at which the coefficient of variation (CV) yields 20% (or some other predefined %CV) and is thus a measure of the precision of the assay at low analyte levels. Thus, the CV is a standardization of the standard deviation (SD), which allows for comparison of estimates of variability regardless of the magnitude of the analyte concentration, at least in most of the valid range of the assay.

[0085] Furthermore, methods based on ROC analysis can be used to determine statistically significant differences between two clinical patient groups. Receiver operating characteristic (ROC) curves measure the efficiency of sorting the fit probability of a model to sort response levels. ROC curves can also help set benchmarks for diagnostic tests. The higher the curve from the diagonal, the better the fit. If the logistic fit has more than two response levels, a generalized ROC curve is generated. In such a plot, there is a curve for each response level, which is the ROC curve for that level relative to all other levels. Software is available that can enable this type of analysis to establish suitable reference levels and cutoffs, such as JMP12, JMP13, and Statistical Discovery from SAS.

[0086] Cut-off values ​​can be determined similarly for PCT. Literature is available to those skilled in the art to determine appropriate cut-offs, for example, Philipp Schuetz et al. (BMC Medicine. 2011; 9: 107) states that at a cut-off of 0.1 ng / mL, PCT had a very high sensitivity to exclude infection. Terence Chan et al. (Expert Rev. Mol. Diagn. 2011; 11 (5), 487.496) states that indices such as positive and negative likelihood ratios calculated based on sensitivity and specificity are also useful for evaluating the strength of diagnostic tests. Generally, values ​​are graphed as receiver operating characteristic curves for multiple cut-off values ​​(CV). The value of the area under the curve is used to determine the most diagnostically relevant CV. This literature describes the variation of CV (cut-off value due to assay and study design) and the suitable method for determining cut-off values.

[0087] The population average level of proADM or a fragment thereof can also be used as a reference value, e.g., an average proADM population value, allowing patients diagnosed with severe disease to be compared with a control population, where the control group preferably includes more than 10, 20, 30, 40, 50 or more subjects.

[0088] In one embodiment of the present invention, the cut-off level of PCT can be a value in the range of 0.01-100.00 ng / mL in serum samples, for example using the Luminex MAC Pix E-Bioscience Assay or the BRAHMS PCT-Kryptor Assay. In preferred embodiments, the cut-off level of PCT can be in the range of 0.01-100, 0.05-50, 0.1-20, or 0.1-2 ng / mL, most preferably >0.05-0.5 ng / mL. Any value within these ranges can be considered as a suitable cut-off value. For example, 0.01, 0.05, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or 100 ng / mL may be used. In some embodiments, the PCT level of healthy subjects is approximately 0.05 ng / mL. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0089] The present invention relates to a method for the diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of subsequent trauma-related complications in multiple trauma patients, comprising providing a patient sample, which is isolated from the patient following severe injury, and determining a level of proADM or a fragment(s) thereof in the sample, wherein the level of proADM or a fragment(s) thereof correlates with the likelihood of subsequent trauma-related complications.

[0090] As evident from the data presented herein, the possible presence or absence of trauma-related complications in polytrauma patients is indicated by the levels of proADM or its fragment(s).

[0091] The present invention has the advantage that the method and kit of the present invention are rapid, objective, easy to use and accurate over conventional methods.The method and kit of the present invention can determine the levels of ADM, PCT, lactate, C-reactive protein, SOFA, qSOFA, APACHE II, SAPS II in blood samples or other biological fluids obtained in a routine manner, or samples obtained from subjects, and therefore relate to markers and clinical scores that can be easily measured in a routine manner in hospitals.

[0092] As used herein, a "patient" or "subject" may be a vertebrate. In the context of the present invention, the term "subject" includes both humans and animals, particularly mammals, and other organisms.

[0093] In the sense of the present invention, a "multiple trauma patient" is a subject who is severely injured and suffers from multiple trauma. The term "multiple trauma" refers to a condition associated with multiple traumas or severe trauma. Typically, this term refers to the condition of a person who has suffered traumatic injuries, preferably multiple traumatic injuries, such as severe burns plus severe head trauma.

[0094] The term polytrauma may also refer to injuries associated with a particular Injury Severity Score (ISS), such as an ISS score of greater than 12, 13, 14, 15, 16, 17, 18, 19, 20, preferably greater than 16. Polytrauma is often associated with accidents involving high speeds that cause multiple injuries, such as motor vehicle crashes (motorcycle crashes, car crashes). Polytrauma is generally characterized by multiple head injuries, vision and hearing loss, nerve damage, multiple fractures, unhealed body wounds and infections, any of which may be life-threatening. Other injuries may include amputated limbs or spinal cord injuries, with the majority of patients experiencing some degree of traumatic brain injury.

[0095] The Injury Severity Score (ISS) is a medical score established to assess the severity of trauma and polytrauma (Baker SP et al. (1974). "The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care". The Journal of Trauma. Lippincott Williams & Wilkins. 14(3): 187-196; Copes WS et al. (1988). "The Injury Severity Score revisited". The Journal of Trauma. Lippincott Williams & Wilkins. 28(1): 69-77). It correlates with mortality, morbidity, and hospitalization time after injury. It is used to define the terms major trauma or polytrauma. Major trauma (or polytrauma) is defined as an Injury Severity Score greater than 15, preferably greater than 16. The Abbreviated Injury Index (AIS) is an anatomically based, consensus derived, global injury severity scoring system that classifies each injury in all body regions according to its relative severity on a 6-step sequence: mild-1, moderate-2, severe-3, critical-4, moribund-6, and fatal-7 (virtually untreatable). There are nine AIS chapters corresponding to nine body regions: head, face, neck, chest, abdomen, spine, upper limbs, lower limbs, and appendages.

[0096] The ISS is based on the Abbreviated Injury Index (AIS) (see below), which divides the body into six ISS body regions for the purposes of calculating an injured person's ISS: head or neck (including cervical spine), face (including facial skeleton, nose, mouth, eyes, ears), chest (thoracic spine and diaphragm), abdominal or pelvic contents (abdominal organs and lumbar spine), limbs or pelvic girdle (pelvic skeleton), and body surface. To calculate the ISS, take the highest AIS severity code in each of the three most severely injured ISS body regions, square each AIS code, and add the three squared numbers to get the ISS (ISS=AIS). 2 +B 2+C 2 , where A, B, and C are the AIS scores for the three most damaged ISS body regions). ISS scores range from 1 to 75 (i.e., the AIS score for each category is 5). If any of the three scores is 6, the score is automatically set to 75, because a score of 6 ("non-viable") indicates the futility of further medical care to sustain life.

[0097] In an embodiment of the present invention, polytrauma patients include burn patients who qualify as polytrauma patients. Such burn patients have an ISS score of 17 or more or at least one additional injury in addition to the burn. In an embodiment, polytrauma patients do not include burn patients with an ISS of less than 17 and / or burn patients without coexisting polytrauma and with a burn total body surface area (TBSA) of less than 40%, preferably less than 39%, less than 38%, less than 37%, or less than 36%.

[0098] Initial management / treatment and diagnosis of polytrauma patients are usually provided in the emergency department (ED). The time required for evaluation of a trauma patient in the ED is known as time to treatment. Upon admission to a hospital or another institution providing health care services, trauma patients should immediately undergo a thorough examination, including diagnostic x-rays of the cervical spine, chest, and pelvis (commonly known as a "trauma series") to check for any injuries that may be life-threatening. Examples include fractures of the cervical spine, severe fractures of the pelvis, and hemothorax. Once this initial investigation is completed, x-rays of the hands and feet may be taken to evaluate for other possible fractures. Also, in severe trauma, patients are often sent directly to a CT or operating room if they require emergency treatment. Less obvious signs of polytrauma include impaired attention, concentration and memory, headaches, tinnitus, lightheadedness, irritability, and impaired decision-making.

[0099] Treatment of polytrauma patients includes "damage control" orthopedic surgery, including treatment of long fractures (early reversal of the "lethal triad" of persistent metabolic acidosis, hypothermia, and coagulopathy represents the primary goal of survival), transferring the patient to the ICU at the earliest possible date after stabilization of vital functions for restoration of physiological parameters, and avoiding long-term surgical interventions to prevent a fatal "second hit" in these patients. Treatment of polytrauma patients may include four different assessment and management phases: (1) life-saving surgery for early recognition of trauma patients requiring damage control ("ground zero" recognition phase), (2) salvage surgery to control bleeding and contamination ("OR phase"), (3) intensive care management to restore physiological and immunological baseline functions ("ICU phase"), and (4) planned definitive surgery ("reconstruction phase"). Further measures for managing polytrauma patients are known to those skilled in the art and have been summarized several times in the literature, for example by Stahel PF et al. (Stahel PF et al. "Current Concepts of Polytrauma Management". European Journal of Trauma 2005;31:200-11).

[0100] In the context of the present invention, "trauma-related complications" or "adverse events" in the health of polytrauma patients refer to events that indicate complications or deterioration in the health of polytrauma patients that may be attributable to the polytrauma event. Such trauma-related complications may lead to dysfunction or injury of remote (mainly uninjured) organs and vital systems. Such adverse events include, but are not limited to, patient death and death of the patient within 28 days after polytrauma, postoperative pulmonary injury, venous thrombosis / pulmonary embolism, cellulitis or decubitus ulcers, postoperative bleeding or hematoma, postoperative pneumonia, surgical reopening of the surgical site, wound infection, postoperative infection, pneumonia / postoperative infection other than wound, postoperative GI bleeding or ulcer, postoperative stroke, postoperative AMI, postoperative cardiac abnormalities, shock or cardio-respiratory arrest, aspiration pneumonia, postoperative urinary tract complications, postoperative physical and metabolic disorders, central or peripheral nervous system, anesthetic / CNS drug-related complications.

[0101] Trauma-related complications can be divided into infection-related complications and non-infection-related complications. Further examples of adverse events and trauma-related complications include situations in which clinical deterioration indicates the need for therapeutic measures such as focal irrigation procedures, blood product infusions, colloid infusions, invasive mechanical ventilation, non-invasive mechanical ventilation, emergency surgery, organ replacement therapy such as renal or hepatic replacement, and vasopressor therapy. Infection-related complications include, but are not limited to, infection or the development of a new infection, hospital-acquired infection, sepsis, septic shock, and / or sepsis.

[0102] Non-infection-related complications include, but are not limited to, rhabdomyolysis, organ failure, and deterioration of the patient's general clinical signs or symptoms, such as hypotension or hypertension, tachycardia or bradycardia. In embodiments, the term trauma-related complication may not explicitly relate to a condition or parameter that is a result of a trauma-related complication. For example, a change in a patient's extracellular fluid volume status, fluid balance, salt balance, and / or globular volume status may not qualify as a trauma-related complication, since such a change may also represent an improvement in the patient's condition and thus is not a complication in itself. Furthermore, such a change may not be considered a complication in itself, but rather a result of a complication. For example, renal failure or infectious disease or sepsis, which may be considered a trauma-related complication in the sense of the present invention, may lead to a fluid imbalance. Thus, in embodiments, the method of the present invention does not relate to the diagnosis, prognosis, prediction, risk assessment, and / or risk stratification of a change in a patient's extracellular fluid volume status, fluid balance, salt balance, and / or globular volume status.

[0103] Rhabdomyolysis is a condition in which damaged skeletal muscle breaks down rapidly. Symptoms include muscle pain, fatigue, vomiting, confusion, dark (or "brown") urine, and / or irregular heartbeat. Some muscle breakdown products, such as the protein myoglobin, are toxic to the kidneys and can cause kidney failure.

[0104] The diagnosis of rhabdomyolysis may be suspected in individuals suffering from trauma, contusion, or prolonged immobilization, but may also be identified later due to decreased renal function (abnormally elevated or increased creatinine and urea levels, decreased urinary output), or red-brown discoloration of the urine. A reliable diagnostic test for rhabdomyolysis is the level of creatine kinase (CK) in the blood. CK is released by injured muscle, and levels above 1,000 U / L (5 times the normal limit (ULN)) indicate rhabdomyolysis, and levels above 5,000 U / L indicate severe disease, although concentrations up to 100,000 U / L are not uncommon depending on the degree of rhabdomyolysis. CK concentrations usually rise steadily for 12 hours after the initial muscle injury, remain elevated for 1–3 days, and then gradually decline. Detection of elevated myoglobin levels in the blood or urine can be used to diagnose rhabdomyolysis, and elevated myoglobin levels are associated with a higher risk of kidney dysfunction. Elevated concentrations of the enzyme lactate dehydrogenase (LDH) indicate rhabdomyolysis, as well as markers of muscle damage such as aldolase, troponin, carbonic anhydrase type 3, and fatty acid binding protein (FABP). In addition, transaminases are usually increased in rhabdomyolysis. Further diagnostic markers that can be used to detect rhabdomyolysis include high potassium levels, electrocardiogram (ECG) (which can indicate whether elevated potassium levels are affecting the cardiac conduction system), and low calcium levels.

[0105] Treatment for rhabdomyolysis may include administration of large amounts of intravenous fluids, dialysis or hemofiltration, administration of sodium bicarbonate, mannitol, calcium, insulin and / or salbutamol.

[0106] The polytrauma patients described herein may be presenting in specialized clinical settings such as emergency departments or intensive care units, or major trauma centers, or in other point-of-care settings such as emergency transport such as an ambulance, or in general practitioners who encounter patients with the condition.

[0107] The term "ICU Patient" refers to, but is not limited to, patients admitted to an intensive care unit. An intensive care unit, which may also be referred to as an intensive therapy unit, or intensive care unit (ITU), or critical care unit (CCU), is a special section of a hospital or medical facility that provides intensive care medical care. ICU patients usually suffer from severe and life-threatening illnesses and injuries and require constant close monitoring and support with specialized equipment and medicines to ensure normal bodily function. Common conditions treated in an ICU include, but are not limited to, multiple trauma, acute or adult respiratory distress syndrome (ARDS), trauma, organ failure, and sepsis.

[0108] As used herein, "diagnosis" in the context of the present invention relates to the recognition and (early) detection of a subject's clinical condition related to multiple trauma. The assessment of the severity of multiple trauma may also be encompassed by the term "diagnosis".

[0109] "Prognosis" refers to the prediction of a subject's outcome or particular risk based on multiple trauma. It can also include the estimation of the chances of recovery or chances of adverse outcome for said subject.

[0110] The method of the invention may also be used for monitoring, therapy monitoring, therapy guidance and / or therapy control. "Monitoring" refers to following the polytrauma patient and potentially occurring complications, for example analyzing the progress of the healing process or the impact of a particular treatment or therapy on the health status of the polytrauma patient.

[0111] The term "therapy monitoring" or "therapy control" in the context of the present invention refers to the monitoring and / or adjustment of the therapeutic treatment of the polytrauma patient, for example, by obtaining feedback on the efficacy of the therapy. As used herein, the term "therapy guidance" refers to the application of a particular therapy, therapeutic action, or medical intervention based on the value / level of one or more biomarkers and / or clinical parameters and / or clinical scores. This includes adjusting the therapy or discontinuing the therapy.

[0112] In the present invention, the terms "risk assessment" and "risk stratification" refer to classifying subjects into different risk groups according to further prognosis. Risk assessment also refers to stratification for applying preventive and / or therapeutic measures. The term "therapy stratification" particularly refers to grouping or classifying patients into different groups, such as risk groups or treatment groups that receive certain different therapeutic measures according to their classification. The term "therapy stratification" also refers to grouping or classifying patients with infectious disease or infectious disease symptoms into groups that do not need to receive certain therapeutic measures.

[0113] In the context of the present invention, "determining the level of proADM or its fragment(s)" and the like are understood to refer to any means of determining proADM or its fragments. The fragment may have any length, for example at least about 5, 10, 20, 30, 40, 50, or 100 amino acids, as long as the fragment allows the unambiguous determination of the level of proADM or its fragments. In a particularly preferred embodiment of the present invention, "determining the level of proADM" refers to determining the level of mid-region pro-adrenomedullin (MR-proADM). MR-proADM is a fragment and / or region of proADM.

[0114] The peptide adrenomedullin (ADM) was discovered as a 52 amino acid antihypertensive peptide isolated from human phenochromocytome (Kitamura et al., 1993). Adrenomedullin (ADM) is encoded as a precursor peptide ("preproadrenomedullin" or "preproADM") that contains 185 amino acids. An exemplary amino acid sequence of ADM is shown in SEQ ID NO:1. SEQ ID NO:1: Amino acid sequence of pre-pro-ADM: 1 MKLVSVALMY LGSLAFLGAD TARLDVASEF RKKWNKWALS RGKRELRMSS 51 SYPTGLADVK AGPAQTLIRP QDMKGASRSP EDSSPDAARI RVKRYRQSMN 101 NFQGLRSFGC RFGTCTVQKL AHQIYQFTDK DKDNVAPRSK ISPQGYGRRR 151 RRSLPEAGPG RTLVSSKPQA HGAPAPPSGS APHFL

[0115] ADM comprises positions 95-146 of the pre-proADM amino acid sequence and is a splice product thereof. "Pro-Adrenomedullin" ("proADM") refers to pre-proADM (amino acids 1-21) without the signal sequence, i.e., amino acid residues 22-185 of pre-proADM. "Mid-region pro-Adrenomedullin" ("MR-proADM") refers to amino acids 42-95 of pre-proADM. An exemplary amino acid sequence of MR-proADM is shown in SEQ ID NO:2. SEQ ID NO: 2: Amino acid sequence of MR-pro-ADM (AS45-92 of pre-pro-ADM): ELRMSSSYPT GLADVKAGPA QTLIRPQDMK GASRSPEDSS PDAARIRV

[0116] It is also contemplated herein that peptides of pre-proADM or MR-proADM and fragments thereof can be used in the methods described herein. For example, the peptide or fragment thereof can include amino acids 22-41 of pre-proADM (PAMP peptide), or amino acids 95-146 of pre-proADM (mature adrenomedullin, including the biologically active form also known as bio-ADM). The C-terminal fragment of proADM (amino acids 153-185 of pre-proADM) is called adrenotensin. A fragment of a proADM peptide or a fragment of MR-proADM can include, for example, at least about 5, 10, 20, 30, or more amino acids. Thus, a fragment of proADM can be selected from the group consisting of, for example, MR-proADM, PAMP, adrenotensin, and mature adrenomedullin, and preferably, the fragment herein is MR-proADM.

[0117] Determination of these various forms of ADM or proADM and fragments thereof also encompasses measuring and / or detecting specific subregions of these molecules, for example, by using antibodies or other affinity reagents directed to specific portions of the molecules, or by determining the presence and / or amount of the molecules by measuring portions of the protein using mass spectrometry.

[0118] Thus, the methods and kits of the invention may also include determining at least one further biomarker, marker, clinical score, and / or parameter in addition to ADM.

[0119] As used herein, a parameter is a characteristic, feature, or measurable factor that can help define a particular system. A parameter is an important element for assessment regarding health and physiology, such as disease / disorder / clinical condition risk, preferably organ dysfunction(s). Furthermore, a parameter is defined as a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological response to therapeutic intervention. Exemplary parameters can be selected from the group consisting of Acute Physiology and Longitudinal Health Evaluation II (APACHE II), Simplified Acute Physiology Score (SAPSII score), sequential organ failure assessment score (SOFA), quick sequential organ failure assessment score (qSOFA score), body mass index, weight, age, sex, IGS II, water intake, white blood cell count, sodium, potassium, body temperature, blood pressure, dopamine, bilirubin, respiratory rate, oxygen tension, World Federation of Neurological Surgeons (WFNS) assessment, and Glasgow Coma Scale (GCS).

[0120] As used herein, terms such as "marker", "surrogate", "prognostic marker", "factor", or "biomarker" or "biological marker" are used interchangeably and refer to a measurable and quantifiable biological marker (e.g., a specific protein or enzyme concentration or fragment thereof, a specific hormone concentration or fragment thereof, or the presence of a biological substance or fragment thereof) that serves as an indicator of a health- and physiology-related evaluation, such as a disease / disorder / clinical condition risk, preferably an adverse event. A marker or biomarker is defined as a characteristic that can be objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process, or a pharmacological response to a therapeutic intervention. Biomarkers can be measured in samples (blood, plasma, urine, or tissue tests).

[0121] The at least one additional marker and / or parameter of the subject is a level of lactate in the sample, a level of procalcitonin (PCT) in the sample, a Sequential Organ Failure Assessment Score (SOFA score) of the subject, a Simplified Acute Physiology Score (SAPSII) of the subject, an Acute Physiology and Longitudinal Health Evaluation II (APACHE II) score of the subject, and a soluble fms-like tyrosine kinase-1 (sFlt-1), histone H2A, histone H2B, histone H3, histone H4, calcitonin, endothelin-1 (ET-1), arginine vasopressin (AVP), atrial natriuretic peptide (ANP), neutrophil gelatinase-binding lipocalin (NGAL), troponin, brain natriuretic peptide (BNP), C-reactive protein (CRP), pancreatic stone protein (PSP), bone marrow cell-expressing protein (BMCP), ... Triggering receptor expressing 1 (TREM1), interleukin-6 (IL-6), interleukin-1, interleukin-24 (IL-24), interleukin-22 (IL-22), interleukin (IL-20), other ILs, presepsin (sCD14-ST), lipopolysaccharide-binding protein (LBP), alpha-1-antitrypsin, matrix metalloproteinase 2 (MMP2), metalloproteinase 8 (MMP8), matrix metalloproteinase MMP9, matrix metalloproteinase 7 (MMP7, placental growth factor (PlGF), chromogranin A, S100A protein, S100B protein and tumor necrosis factor α (TNFα), neopterin, alpha-1-antitrypsin, proarginine vasopressin (AVP, proAVP, or copeptin), procalcitonin, atrial natriuretic peptide (ANP, pro-ANP), endothelin-1, E-selectin, ICAM-1, V CAM-1, IP-10, CCL1 / TCA3, CCL11, CCL12 / MCP-5, CCL13 / MCP-4, CCL14, CCL15, CCL16, CCL17 / TARC, CCL18, CCL19, CCL2 / MCP-1, CC L20, CCL21, CCL22 / MDC, CCL23, CCL24, CCL25, CCL26, CCL27, CCL28, CCL3, CCL3L3, CCL4, CCL4L1 / LAG-1, CCL5, CCL6, CCL7, CCL8,CCL9, CX3CL1, CXCL1, CXCL10, CXCL11, CXCL12, CXCL13, CXCL14, CXCL15, CXCL16, CXCL17, CXCL2 / MIP-2, CXCL3, CXCL4, CXCL5, CXCL6, CXCL7 / Ppbp, CXCL9, IL8 / CXCL8, X CL1, XCL2, FAM19A1, FAM19A2, FAM19A3, FAM19A4, FAM19A5, CLCF1, CNTF, IL11, IL31, IL6, leptin, LIF, OSM, IFNA1, IFNA10, IFNA13, IFNA14, IFNA2, IFNA4, IFNA7, IFNB1, The level of IFNE, IFNG, IFNZ, IFNA8, IFNA5 / IFNaG, IFNω / IFNW1, BAFF, 4-1BBL, TNFSF8, CD40LG, CD70, CD95L / CD178, EDA-A1, TNFSF14, LTA / TNFB, LTB, TNFa, TNFSF10, TNFSF11, TNFSF12, TNFSF13, TNFSF15, TNFSF4, IL18, IL18BP, IL1A, IL1B, IL1F10, IL1F3 / IL1RA, IL1F5, IL1F6, IL1F7, IL1F8, IL1RL2, IL1F9, IL33, or a fragment thereof.

[0122] As used herein, "procalcitonin" or "PCT" refers to a peptide spanning amino acid residues 1-116, 2-116, 3-116, or fragments thereof of the procalcitonin peptide. PCT is the peptide precursor of the calcitonin hormone. Thus, the length of the procalcitonin fragment is at least 12 amino acids, preferably more than 50 amino acids, more preferably more than 110 amino acids. PCT may include post-translational modifications such as glycosylation, lipidation, or derivatization. Procalcitonin is the precursor of calcitonin and katacalcin. Thus, under normal conditions, PCT levels in circulation are very low (less than about 0.05 ng / ml).

[0123] The level of PCT in a subject's sample can be determined by immunoassay as described herein.As used herein, the level of ribonucleic acid or deoxyribonucleic acid coding for "procalcitonin" or "PCT" can also be determined.Methods for determining PCT are known to those skilled in the art, for example, by using products obtained from Thermo Fisher Scientific / B·R·A·H·M·S GmbH.

[0124] Lactic acid, or lactic acid, is an organic compound with the formula CH3CH(OH)COOH that occurs in bodily fluids, including blood. A blood test for lactate is performed to determine the state of acid-base homeostasis in the body. Lactate is a product of cellular metabolism that can accumulate when cells lack sufficient oxygen (hypoxia) and need to reduce the efficiency of their energy-generating means, or when conditions cause excessive production or reduced clearance of lactate. Lactic acidosis can result from insufficient amounts of oxygen to cells and tissues (hypoxia), for example, when one has a condition that can lead to a reduced amount of oxygen being delivered to cells and tissues, such as shock, septic shock, or congestive heart failure, and lactate testing can be used to help detect and assess the severity of hypoxia and lactic acidosis.

[0125] C-reactive protein (CRP) is a pentameric protein that can be found in body fluids such as plasma. CRP levels can be elevated in response to inflammation. Measuring and charting CRP values ​​can prove useful in determining disease progression or the effectiveness of treatment.

[0126] As used herein, the "Continuous Organ Failure Assessment score" or "SOFA score" is a score used to track the status of a patient during their stay in the intensive care unit (ICU). The SOFA score is a scoring system for determining the degree of organ function or failure rate of a person. The score is based on six different scores, one each for the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Both the average and highest SOFA scores are predictors of outcome. An increase in the SOFA score during the first 24-48 hours in the ICU predicts a mortality rate of at least 50% to up to 95%. A score below 9 gives a predicted mortality rate at 33%, while a score above 14 may approach or exceed 95%.

[0127] As used herein, the "quick SOFA score" (qSOFA score) is a scoring system that indicates a patient's risk of organ dysfunction or death. The score is based on three criteria: 1) altered mental status, 2) a drop in systolic blood pressure below 100 mm Hg, and 3) a respiratory rate above 22 breaths per minute. Patients with two or more of these conditions are at higher risk of having organ dysfunction or dying.

[0128] As used herein, "APACHE II" or "Acute Physiology and Chronic Health Evaluation II" is a scoring system for severity classification (Knaus et al., 1985). It can be applied within 24 hours of a patient's admission to the intensive care unit (ICU) and can be determined based on 12 different physiological parameters: AaDO2 or PaO2 (depending on FiO2), temperature (rectal), mean arterial pressure, arterial pH, heart rate, respiratory rate, sodium (serum), potassium (serum), creatinine, hematocrit, white blood cell count, and Glasgow Coma Scale.

[0129] As used herein, "SAPS II" or "Simplified Acute Physiology Score II" refers to a system for classifying the severity of a disease or disorder (see Le Gall JR et al., A new Simplified Acute Physiology Score (SAPS II) based on a European / North American multicenter study. JAMA. 1993;270(24):2957-63). The SAPS II score is composed of 12 physiological variables and 3 disease-related variables. A point score is calculated from 12 common physiological measurements, information on previous health conditions, and some information obtained at the time of admission to the ICU. The SAPS II score can be determined at any time, preferably on the second day. The "worst" measurement is defined as the scale that correlates with the highest score. The SAPS II score ranges from 0 to 163 points. The classification system includes the following parameters: age, heart rate, systolic blood pressure, temperature, Glasgow Coma Scale, mechanical ventilation or CPAP, PaO2, FiO2, urine output, blood urea nitrogen, sodium, potassium, bicarbonate, bilirubin, white blood cells, chronic diseases, and type of admission. There is an sigmoidal correlation between mortality and the total SAPS II score. The mortality rate of subjects is 10% with a SAPSII score of 29 points, mortality is 25% with a SAPSII score of 40 points, mortality is 50% with a SAPSII score of 52 points, mortality is 75% with a SAPSII score of 64 points, and mortality is 90% with a SAPSII score of 77 points (Le Gall loc.cit.).

[0130] As used herein, the term "sample" refers to a biological sample obtained or isolated from a patient or subject. As used herein, "sample" may refer to a sample of bodily fluid or tissue obtained for the purpose of analysis, diagnosis, prognosis, or evaluation of a subject of interest, such as a patient. Preferably, the sample herein is a sample of bodily fluid, such as blood, serum, plasma, cerebrospinal fluid, urine, saliva, sputum, pleural effusion, cell, cell extract, tissue sample, tissue biopsy, stool sample, etc. In particular, the sample is blood, plasma, serum, or urine.

[0131] The embodiment of the present invention refers to the isolation of a first sample and the isolation of a second sample. In the context of the method of the present invention, the terms "first sample" and "second sample" refer to the relative determination of the order of isolation of the samples used in the method of the present invention. When the terms first sample and second sample are used in identifying the method, these samples are not considered as an absolute determination of the number of samples taken. Thus, additional samples may be isolated from the patient before, during or after the isolation of the first and / or second sample, or between the first or second sample, and these additional samples may or may not be used in the method of the present invention. Thus, the first sample may be considered as any sample obtained previously. The second sample may be considered as any further or subsequent sample.

[0132] "Plasma" in the context of the present invention is the substantially cell-free supernatant of blood containing anticoagulants obtained after centrifugation. Examples of anticoagulants include calcium ion-binding compounds such as EDTA or citrate, and thrombin inhibitors such as heparate or hirudin. Cell-free plasma can be obtained by centrifuging anticoagulated blood (e.g., citrated, EDTA or heparinized blood) for example at 2000-3000 g for at least 15 minutes.

[0133] "Serum" in the context of the present invention is the liquid fraction of whole blood that is collected after the blood is allowed to clot. When the clotted blood (clot) is centrifuged, serum can be obtained as the supernatant.

[0134] As used herein, "urine" is the liquid product of the body secreted by the kidneys and excreted through the urethra through a process called urination (or micturition).

[0135] In an embodiment of the present invention, the trauma-related complication may be sepsis, severe sepsis, and / or septic shock. "Sepsis" in the context of the present invention refers to a systemic response to infection. Alternatively, sepsis may be seen as a combination of SIRS and a confirmed infectious process or infection. Sepsis may be characterized as a clinical syndrome defined by the presence of both infection and a systemic inflammatory response (Levy MM et al. 2001 SCCM / ESICM / ACCP / ATS / SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6). The term "sepsis" as used herein includes, but is not limited to, sepsis, severe sepsis, and septic shock.

[0136] The term "sepsis" as used herein includes, but is not limited to, sepsis, severe sepsis, and septic shock. Severe sepsis refers to sepsis associated with organ dysfunction, hypoperfusion abnormalities, or sepsis-induced hypotension. Hypoperfusion abnormalities include lactic acidosis, oliguria, and sudden changes in mental status. Sepsis-induced hypotension is defined by the presence of systolic blood pressure less than about 90 mm Hg or its reduction from baseline by about 40 mm Hg or more in the absence of other causes of hypotension (e.g., cardiogenic shock). Septic shock is defined as severe sepsis with sepsis-induced hypotension that persists despite adequate fluid resuscitation, together with the presence of hypoperfusion abnormalities or organ dysfunction (Bone et al., CHEST 101(6):1644-55, 1992).

[0137] Alternatively, the term sepsis can be defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. In clinical operationalism, organ dysfunction can be preferably represented by an increase of 2 or more points in the Sequential Organ Failure Assessment (SOFA) score and is associated with an in-hospital mortality rate of more than 10%. Septic shock can be defined as a subset of sepsis, in which particularly severe cardiovascular, cellular, and metabolic abnormalities are associated with a higher risk of death than sepsis alone. Patients with septic shock can be clinically identified by the need for vasopressors to maintain a mean arterial pressure of 65 mm Hg or higher and serum lactate levels of more than 2 mmol / L (>18 mg / dL) in the absence of hypovolemia.

[0138] The term "sepsis" as used herein relates to all possible stages in the development of sepsis. The term "sepsis" also includes severe sepsis or septic shock based on the definition of SEPSIS-2 (Bone et al., 2009). The term "sepsis" also includes subjects falling within the definition of SEPSIS-3 (Singer et al., 2016). The term "sepsis" as used herein relates to all possible stages in the development of sepsis.

[0139] As used herein, "infection" within the scope of the present invention means a pathological process caused by the invasion of normally sterile tissues or body fluids by a pathogenic or potentially pathogenic agent / pathogen, organism and / or microorganism, and preferably relates to bacterial, viral, fungal and / or parasitic infection(s). Thus, the infection may be a bacterial infection, a viral infection and / or a fungal infection. The infection may be a local or systemic infection. For the purposes of the present invention, a viral infection may be considered as an infection by a microorganism.

[0140] Additionally, infection-related complications may be "nosocomial" infections. Nosocomial infections, also called hospital-acquired infections (HAIs), are infections acquired in a hospital or other health care facility. To emphasize both hospital and non-hospital settings, they may alternatively be called health care-associated infections (HAIs or HCAIs). Such infections may be acquired in hospitals, nursing homes, rehabilitation facilities, outpatient clinics, or other clinical settings. Nosocomial infections may be transmitted to susceptible patients in the clinical setting by a variety of means. Medical staff may spread the infection through contaminated equipment, bed linen, or in addition to air droplets. Infection may be due to the external environment, another infected patient, potentially infected staff, or in some cases the source of infection cannot be determined. In some cases, microbes arise from the patient's own skin microbiota and become opportunistic infections after surgery or other procedures that remove the protective skin barrier. Although the patient may have contracted the infection from their own skin, the infection is considered nosocomial because it develops in a health care setting.

[0141] Furthermore, a subject suffering from an infectious disease may suffer from two or more sources of infection(s) at the same time. For example, a subject suffering from an infection may suffer from a bacterial infection and a viral infection, a viral infection and a fungal infection, a bacterial infection and a fungal infection, and a bacterial infection, a fungal infection, and a viral infection, or may suffer from a mixed infection that includes one or more of the infections listed herein, including a potential superinfection, such as one or more viral infections and / or one or more fungal infections as well as one or more bacterial infections.

[0142] As used herein, "infectious disease" includes all diseases or disorders associated with bacterial and / or viral and / or fungal infection.

[0143] According to the present invention, polytrauma patients may require very strict control over the monitoring of vital functions and / or organ protection and may be under medical care.

[0144] In the context of the present invention, the term "medical treatment" or "treatment" includes various treatments and therapeutic strategies, including, but not limited to, anti-inflammatory strategies, ADM antagonists such as therapeutic antibodies, administration of si-RNA or DNA, extracorporeal blood purification or apheresis, dialysis, removal of harmful substances via adsorbents to prevent cytokine storm, removal of inflammatory mediators, plasma apheresis, administration of vitamins such as vitamin C, surgery, emergency surgery, ventilation such as mechanical ventilation and non-mechanical ventilation to provide sufficient oxygen to the body, e.g., focal irrigation procedures, infusion of blood products, infusion of colloids, organ replacement such as renal or hepatic replacement, antibiotic treatment, invasive mechanical ventilation, non-invasive mechanical ventilation, vasopressor use, fluid therapy, apheresis, and measures for organ protection.

[0145] Further therapies of the invention include administration of cells or cell preparations such as stem cells, blood, or plasma, for example to reach normovolemia and to prevent or treat hypervolemia or hypovolemia, as well as stabilization of the patient's circulation and protection of the endothelial glycocalyx, for example via optimal fluid management strategies. Additionally, vasopressors, or inhibition of albumin or heparanase, for example via catecholamines, as well as unfractionated heparin or N-desulfated re-N-acetylated heparin, are useful therapies to support circulation and the endothelial layer.

[0146] Additionally, medical treatments of the present invention include, but are not limited to, stabilization of blood clots, anti-fibrinolytic therapy, iNOS inhibitors, anti-inflammatory agents such as hydrocortisone, sedatives and analgesics, and insulin.

[0147] Artificial and mechanical ventilation are effective approaches to improve proper gas exchange and ventilation and to save lives during severe hypoxemia. Artificial ventilation refers to supporting or stimulating the breathing of a subject. Artificial ventilation can be selected from the group consisting of mechanical ventilation, manual ventilation, extracorporeal membrane oxygenation (ECMO), and non-invasive ventilation (NIV). Mechanical ventilation refers to methods of mechanically supporting or replacing spontaneous breathing. It can involve a machine called a ventilator. Mechanical ventilation can be high frequency oscillatory ventilation or partial liquid ventilation.

[0148] Medical treatment also includes methods to avoid hypothermia, including the use of warmed intravenous fluids and hot air blankets.

[0149] Medical treatment also includes wound management, including bleeding control, bleeding control techniques with or without tourniquets, wound irrigation, application of local anesthetic, wound closure techniques which may use skin adhesive strips, tissue adhesives, sutures, staples and wound dressings.

[0150] "Fluid management" refers to the monitoring and control of a subject's fluid status and administration of fluids to stabilize circulation or organ vitality, for example by oral, enteral or intravenous fluid administration. This includes stabilizing fluid and electrolyte balance, or preventing or correcting hypervolemia or hypovolemia, and providing blood products.

[0151] Surgical emergency / emergency surgery is required when a subject is in a medical emergency and may require immediate surgical intervention to survive or maintain health.Subjects requiring emergency surgery may be selected from the group consisting of subjects suffering from acute trauma, active uncontrolled infection, organ transplantation, organ protection or stabilization surgery, or cancer.

[0152] Cleaning procedures are hygienic methods for preventing infection of subjects, especially nosocomial infections, and include disinfection of all organic and inorganic surfaces that may come into contact with patients, such as skin, objects in the hospital room, medical devices, diagnostic devices, or room air. Cleaning procedures include measures such as the use of protective clothing and units, such as mouth guards, gowns, gloves, or sanitary locks, and restrictions on patient visits. In addition, cleaning procedures include washing the patient himself and his clothes or the patient.

[0153] In a preferred embodiment, the term "medical treatment" or "treatment" includes antibiotic treatment, such as intravenous antibiotics, oral antibiotics or topical antibiotics.

[0154] In the case of polytrauma patients, it is very important to perform early diagnosis, as well as prognosis and risk assessment of the occurrence of trauma-related complications, in order to find the optimal therapy and patient management, since such patients are often unstable and require early therapeutic intervention in case of complications. Therapeutic approaches are very individual and need to differ from case to case. Therapeutic monitoring is necessary for best practice therapy and is influenced by the timing of treatment, the use of combination therapies, and the optimization of drug administration. Incorrect or omitted therapy or management will increase the mortality rate by the hour.

[0155] The medical treatment of the present invention may be an antibiotic treatment, and one or more "antibiotics" or "antibiotic agents" may be administered when an infection is diagnosed or when a prognosis is determined by the methods of the present invention. Antibiotics or antibiotic formulations according to the present invention also potentially include antifungal or antiviral compounds used to treat a diagnosed infection or sepsis. Dividing pathogens by classification, antibiotic formulations commonly applied to treat any given infection are as follows: Gram-positive coverage: Penicillins, (ampicillin, amoxicillin), penicillinase resistant, (dicloxacillin, oxacillin), cephalosporins (1st and 2nd generation), macrolides (erythromycin, clarithromycin, azithromycin), quinolones (gatifloxacin, moxifloxacin, levofloxacin), vancomycin, sulfonamides / trimethoprim, clindamycin, tetracyclines, chloramphenicol, linezolid, synercid.

[0156] Gram-negative coverage: Broad spectrum penicillins (ticarcillin, clavulanic acid, piperacillin, tazobactam), cephalosporins (2nd, 3rd, and 4th generation), aminoglycosides, macrolides, azithromycin, quinolones (ciprofloxacin), monobactams (azetreonam), sulfonamides / trimethoprim, carbapenems (imipenem), chloramphenicol.

[0157] Pseudomonas scope of application: ciprofloxacin, aminoglycosides, some third generation cephalosporins, fourth generation cephalosporins, broad spectrum penicillins, carbapenems.

[0158] Fungal Treatments: Allylamines, amphotericin B, fluconazole and other azoles, itraconazole, voriconazole, posaconazole, ravuconazole, echinocandins, flucytosine, sordarin, chitin synthase inhibitors, topoisomerase inhibitors, lipopeptides, pradimicin, liposomal nystatin, voriconazole, echinocandins, imidazoles, triazoles, thiazoles, polyenes.

[0159] Antiviral Treatment: Abacavir, Acyclovir (Aciclovir), Activated Caspase Oligomerizer, Adefovir, Amantadine, Amprenavir (Agenerase), Ampligen, Arbidol, Atazanavir, Atripla, Balavir, Cidofovir, Combivir, Dolutegravir, Darunavir, Delavirdine, Didanosine, Double-stranded RNA, Docosanol, Edoxudine, Efavirenz, Emtricitabine, Enfuvirtide, Entecavir, Ecoliever, Famciclovir, Fixed-dose combinations (antiretrovirals), Fomivirsen, Fosamprenavir, Foscarnet, Phosphonet, Fusion inhibitors, Ganciclovir, Ibacitabine, Imunovir, Idoxuridine, Imiquimod, Indinavir, Inosine, Integrase inhibitors, Interferon III, Interferon II, Interferon I, Interferon, Lamivudine, Lopinavir, Robiride, Maraviroc, Moroxydine, Methisazone, Morpholino, Nelfinavir, Nevirapine, Nexavir, Nitazoxanide, Nucleoside analogues, Novir, Oseltamivir (Tamiflu), Peginterferon alfa-2a, Penciclovir, Peramivir, Pleconaril, Podophyllotoxin, Protease inhibitors (pharmacology), Raltegravir, Reverse transcriptase inhibitors, Ribavirin, Ribozyme, Rifampicin, Rimantadine, Ritonavir, RNase H, protease inhibitors, pyramidine, saquinavir, sovosbuvir, stavudine, synergistic enhancer (antiretroviral), telaprevir, tenofovir, tenofovir disoproxil, tipranavir, trifluridine, trizivir, tromantadine, Truvada, valacyclovir (Valtrex), valganciclovir, vicriviroc, vidarabine, viramidine, zalcitabine, zanamivir (Relenza), zidovudine.

[0160] In addition, antibiotics include bacteriophages, synthetic antimicrobial peptides, or iron antagonists / chelators for the treatment of bacterial infections. Also, therapeutic antibodies or antagonists against pathogenic structures, such as anti-VAP antibodies, anti-resistant clonal vaccination, administration of immune cells such as in vitro stimulated or modified T effector cells, are antibiotics that represent treatment options for critically ill patients, such as septic patients. Further antibiotic preparations / treatments or therapeutic strategies against infections or for the prevention of new infections include the use of disinfectants, decontamination products, antivirals like liposomes, hygiene, wound care, surgery.

[0161] It is also possible to combine several of the aforementioned antibiotic agents or treatment strategies.

[0162] According to the present invention, ADM and optionally PCT and / or other markers or clinical scores are used as markers for diagnosis, prognosis, prediction, risk assessment and / or risk stratification of subsequent trauma-related complications in polytrauma patients.

[0163] A person skilled in the art can obtain or develop means for identifying, measuring, determining, and / or quantifying any one of the above ADM molecules, or fragments or variants thereof, as well as other markers of the present invention according to standard molecular biological practices.

[0164] The level of proADM or its fragments, as well as the level of other markers of the present invention, can be determined by any assay that reliably determines the concentration of the marker. In particular, mass spectrometry (MS) and / or immunoassays can be used as illustrated in the accompanying examples. As used herein, immunoassays are biochemical tests that measure the presence or concentration of macromolecules / polypeptides in solution through the use of antibodies or antibody binding fragments or immunoglobulins.

[0165] The method of determining ADM or other markers such as PCT used in the context of the present invention is contemplated in the present invention.As an example, the method selected from the group consisting of mass spectrometry (MS), luminescence immunoassay (LIA), radioimmunoassay (RIA), chemiluminescence and fluorescence immunoassay, enzyme immunoassay (EIA), enzyme-linked immunoassay (ELISA), luminescence-based bead array, magnetic bead-based array, protein microarray assay, rapid test format such as instant immunochromatography strip test, rare earth cryptate assay, and automated system / analyzer can be used.

[0166] The determination of ADM and optionally other markers based on antibody recognition is a preferred embodiment of the present invention. As used herein, the term "antibody" refers to immunoglobulin molecules and immunologically active parts of immunoglobulin (Ig) molecules, i.e. molecules that contain an antigen-binding site that specifically binds (immunoreacts with) an antigen. According to the present invention, antibodies may be monoclonal as well as polyclonal antibodies. In particular, antibodies that specifically bind at least proADM or a fragment thereof are used.

[0167] An antibody is considered specific if its affinity for a molecule of interest, such as ADM or a fragment thereof, is at least 50 times higher, preferably 100 times higher, and most preferably at least 1000 times higher than for other molecules contained in the sample containing the molecule of interest. How to develop and select an antibody with a given specificity is well known in the art. In the context of the present invention, monoclonal antibodies are preferred. The antibody or antibody-binding fragment specifically binds to a marker or a fragment thereof as defined herein. In particular, the antibody or antibody-binding fragment binds to the ADM of a peptide as defined herein. Thus, the peptide as defined herein may also be the epitope to which the antibody specifically binds. Furthermore, the methods and kits of the present invention use antibodies or antibody-binding fragments that specifically bind to ADM or proADM, in particular MR-proADM.

[0168] Furthermore, the methods and kits of the present invention use antibodies or antibody-binding fragments that specifically bind to proADM or fragments thereof, and optionally other markers of the present invention, such as PCT.Exemplary immunoassays may be luminescence immunoassays (LIA), radioimmunoassays (RIA), chemiluminescence and fluorescence immunoassays, enzyme immunoassays (EIA), enzyme-linked immunoassays (ELISA), luminescence-based bead arrays, magnetic bead-based arrays, protein microarray assays, rapid test formats, rare earth cryptate assays.In addition, assays suitable for point-of-care testing and rapid test formats, such as immunochromatographic strip tests, may be used.Automated immunoassays, such as KRYPTOR assays, are also contemplated.

[0169] Alternatively, instead of antibodies, other capture molecules or molecular scaffolds that specifically and / or selectively recognize ADM may be included within the scope of the present invention. As used herein, the term "capture molecule" or "molecular scaffold" includes molecules that can be used to bind target molecules or molecules of interest, i.e., analytes (e.g., ADM, proADM, MR-proADM, and PCT) from a sample. Thus, the capture molecule must be appropriately shaped both spatially and with respect to surface features such as surface charge, hydrophobicity, hydrophilicity, the presence or absence of Lewis donors and / or acceptors, to specifically bind to the target molecule or molecule of interest. Thereby, the binding may be mediated, for example, by ionic, van der Waals forces, pi-pi, sigma-pi, hydrophobic or hydrogen bond interactions, or a combination of two or more of the aforementioned interactions or covalent interactions between the capture molecule or molecular scaffold and the target molecule or molecule of interest. In the context of the present invention, the capture molecule or molecular scaffold may be selected, for example, from the group consisting of nucleic acid molecules, carbohydrate molecules, PNA molecules, proteins, peptides, and glycoproteins. Capture molecules or molecular scaffolds include, for example, aptamers, DAR pins (Designed Ankyrin Repeat Proteins), affimers, and the like.

[0170] In certain aspects of the invention, the method comprises: a) The sample i. a first antibody or antigen-binding fragment or derivative thereof specific for a first epitope of the proADM; and ii. contacting with a second antibody or antigen-binding fragment or derivative thereof specific for a second epitope of the proADM; b) detecting the binding of the two antibodies or antigen-binding fragments or derivatives thereof to the proADM.

[0171] Preferably, one antibody is labeled and the other antibody is bound to a solid phase or can be selectively bound to a solid phase. In a particularly preferred embodiment of the assay, one of the antibodies is labeled while the other antibody is either bound to a solid phase or can be selectively bound to a solid phase. The first and second antibodies can be present dispersed in a liquid reaction mixture, a first label component that is part of a labeling system based on fluorescence or chemiluminescence quenching or amplification binds to the first antibody and a second label component of the labeling system binds to the second antibody, thereby generating a measurable signal that allows the detection of the resulting sandwich complex in the measurement solution after binding of both antibodies to the proADM or fragments thereof to be detected. The labeling system can include rare earth cryptates or chelates in combination with fluorescent or chemiluminescent dyes, especially of the cyanine type.

[0172] In a preferred embodiment, the method is carried out as a heterogeneous sandwich immunoassay, in which one of the antibodies is immobilized on any selected solid phase, such as a coated test tube (e.g. polystyrene test tube; coated tube; CT) or a microtiter. The other antibody resembles a detectable label or has a group that allows selective binding to the label and serves to detect the sandwich structure formed. A temporary delay or subsequent immobilization with a suitable solid phase is also possible.

[0173] The method according to the invention can further be embodied as a homogeneous method, in which the sandwich complex formed by the antibody / antibodies to be detected and the marker, ADM or a fragment thereof, remains suspended in a liquid phase. In this case, when two antibodies are used, it is preferred that both antibodies are labeled with part of the detection system, which results in the generation of a signal or the induction of a signal when both antibodies are integrated into a single sandwich. Such a technique should be embodied in particular as a fluorescence enhancement or fluorescence quenching detection method. Particularly preferred embodiments relate to the use of detection reagents used in pairs, such as those described in US4882733, EP0180492, or EP0539477, and the prior art cited therein. In this way, measurements are possible in which only reaction products containing both labeled components directly in a single immune complex in the reaction mixture are detected. For example, such techniques are provided under the trade names TRACE® (Time Resolved Amplified Cryptate Emission), or KRYPTOR®, which implement the teachings of the above-cited applications. Thus, in a particularly preferred embodiment, a diagnostic device is used to carry out the method provided herein. For example, the level of proADM or a fragment thereof, and / or the level of any additional marker of the methods provided herein, such as PCT, is determined. In a particularly preferred embodiment, the diagnostic device is KRYPTOR®.

[0174] The level of the marker of the present invention, such as proADM or its fragment, PCT or its fragment, or other marker, can also be determined by a method based on mass spectrometry (MS). Such a method can include detecting the presence, amount or concentration of one or more modified or unmodified fragment peptides, such as ADM or PCT, in the biological sample or, for example, in a protein digest (e.g., a trypsin digest) from the biological sample, and optionally separating the sample using a chromatographic method, and subjecting the prepared and optionally separated sample to MS analysis. For example, selected reaction monitoring (SRM), multiple reaction monitoring (MRM) or parallel reaction monitoring (PRM) mass spectrometry can be used for MS analysis, particularly to determine the amount of proADM or its fragment.

[0175] As used herein, the term "mass spectrometry" or "MS" refers to analytical techniques for identifying compounds by their mass. To improve the mass resolution and mass determination capabilities of mass spectrometry, samples may be treated prior to MS analysis. Thus, the present invention relates to immunoenrichment techniques, methods for sample preparation and / or MS detection methods that can be combined with chromatographic methods, preferably liquid chromatography (LC), more preferably high performance liquid chromatography (HPLC) or ultra-high performance liquid chromatography (UHPLC). Sample preparation methods include techniques for dissolution, fractionation, digestion of samples into peptides, depletion, concentration, dialysis, desalting, alkylation, and / or peptide reduction, although these steps are optional. Selective detection of analyte ions can be performed using tandem mass spectrometry (MS / MS). Tandem mass spectrometry is characterized by a mass selection step (as used herein, the term "mass selection" refers to the isolation of ions with a specific m / z or a narrow range of m / z), followed by fragmentation of the selected ions and mass analysis of the resulting product (fragment) ions.

[0176] Those skilled in the art know how to quantify the levels of markers in a sample by mass spectrometry. For example, relative quantification "rSRM" or absolute quantification can be used as described above.

[0177] Furthermore, levels (including reference levels) can be determined by mass spectrometry-based methods, such as methods that determine relative quantification or methods that determine absolute quantification of a protein of interest or a fragment thereof.

[0178] Relative quantification "rSRM" can be achieved by: 1. Determine the increased or decreased presence of a target protein by comparing the SRM (selected reaction monitoring) signature peak area from a given target fragment peptide detected in a sample with the same SRM signature peak area of ​​the target fragment peptide in at least a second, third, fourth, or more biological samples.

[0179] 2. Determine the presence or absence of a target protein by comparing the SRM signature peak area from a given target peptide detected in a sample with the SRM signature peak area generated from fragment peptides from other proteins in other samples derived from different separate biological sources. The SRM signature peak area comparison between the two samples for peptide fragments is, for example, normalized to the amount of protein analyzed in each sample.

[0180] 3. To normalize changes in the levels of histone proteins to the levels of other proteins that do not change their expression levels under various cellular conditions, determine the increased or decreased presence of the target protein by comparing the SRM signature peak area for a given target peptide with the SRM signature peak areas from other fragment peptides derived from different proteins within the same biological sample.

[0181] 4. These assays can be applied to both unmodified fragment peptides and modified fragment peptides of target proteins, where modifications include phosphorylation and / or glycosylation, acetylation, methylation (mono-, di-, tri-), citrullination, and ubiquitination. The relative levels of modified peptides are determined in the same way as the relative amounts of unmodified peptides are determined.

[0182] Absolute quantification of a given peptide can be achieved by: 1. Compare the SRM / MRM signature peak area for a given fragment peptide from a target protein in an individual biological sample with the SRM / MRM signature peak area of ​​an internal fragment peptide standard spiked into a protein lysate from the biological sample. The internal standard can be a labeled synthetic version of the fragment peptide from the target protein being investigated or a labeled recombinant protein. This standard can be spiked into the sample in a known amount before (required for recombinant proteins) or after digestion, and the SRM / MRM signature peak area can be determined separately for both the internal fragment peptide standard and the native fragment peptide in the biological sample, followed by a comparison of both peak areas. This can be applied to unmodified and modified fragment peptides, where the modification is phosphorylation and / or glycosylation, acetylation, methylation (e.g. mono-, di-, or trimethylation), citrullination, ubiquitination, where the absolute level of the modified peptide can be determined in the same way as the absolute level of the unmodified peptide is determined.

[0183] 2. Peptides can also be quantified using external calibration curves. The normal curve approach uses a fixed amount of a heavy peptide as an internal standard, and various amounts of a light synthetic peptide spiked into the sample. A representative matrix similar to that of the test sample needs to be used to construct a standard curve to account for matrix effects. Besides, the inverse curve method avoids the problem of endogenous analytes in the matrix, a fixed amount of a light peptide is spiked on top of the endogenous analyte to create an internal standard, and various amounts of a heavy peptide are spiked to create a set of concentration standards. The test samples to be compared with either the normal curve or the inverse curve are spiked with the same amount of standard peptide as the internal standard spiked into the matrix used to create the calibration curve.

[0184] The present invention further relates to kits, the use of the kits, and methods in which such kits are used. The present invention relates to kits for carrying out the methods provided herein above and below. The definitions provided herein, such as those provided for the methods, also apply to the kits of the present invention. In particular, the present invention relates to kits for monitoring a therapy, including prognosis, risk assessment, or risk stratification of a subsequent adverse event in a patient's health, comprising: - detection reagents for determining the level of proADM or a fragment(s) thereof in a sample from a subject, and optionally for determining the level of PCT, lactate, and / or C-reactive protein or a fragment(s) thereof, and detection reagents for determining the level of ADM in said sample from said subject; - high and / or low severity levels of ADM, wherein a low severity level is less than 4 nmol / l, preferably less than 3 nmol / l, more preferably less than 2.7 nmol / l and a high severity level is more than 6.5 nmol / l, preferably more than 6.95 nmol / l, more preferably more than 10.9 nmol / l, and optionally reference data such as reference levels corresponding to PCT, lactate and / or C-reactive protein levels, said reference data being preferably stored on a computer readable medium and / or used in the form of a computer executable code configured for comparing the determined level of proADM or fragment(s) thereof, and optionally additionally the determined levels of PCT, lactate and / or C-reactive protein or fragment(s) thereof, with said reference data.

[0185] As used herein, "reference data" includes reference levels of ADM and optionally PCT, lactate, C-reactive protein, and / or other suitable markers disclosed herein, such as markers for rhabdomyolysis. The levels of ADM and optionally other markers, such as PCT, lactate, and / or C-reactive protein, in a subject's sample can be compared to the reference levels included in the reference data of the kit. The reference levels are described herein above and are also illustrated in the accompanying examples. The reference data may also include a reference sample to which the levels of ADM and optionally PCT, lactate, and / or C-reactive protein are compared. The reference data may also include instructions on how to use the kit of the present invention.

[0186] The kit may further include items useful for obtaining a sample, such as a blood sample, for example, the kit may include a container, where the container includes a device for attaching the container to a cannula or syringe, e.g., a syringe suitable for blood isolation and exhibiting an internal pressure less than atmospheric pressure, suitable for drawing a predetermined amount of sample into the container, and / or additionally includes a detergent, a chaotropic salt, a ribonuclease inhibitor, a chelating agent such as guanidinium isothiocyanate, guanidinium hydrochloride, sodium dodecyl sulfate, polyoxyethylene sorbitan monolaurate, RNAse inhibitor protein, and mixtures thereof, and a filter system comprising nitrocellulose, silica matrix, ferromagnetic spheres, cup collection spillover, trehalose, fructose, lactose, mannose, polyethylene glycol, glycerol, EDTA, TRIS, limonene, xylene, benzoyl, phenol, mineral oil, aniline, pyrrole, citrate, and mixtures thereof.

[0187] As used herein, a "detection reagent" or the like is a reagent suitable for determining a marker(s) described herein, e.g., ADM, PCT, lactate, and / or C-reactive protein. Such an exemplary detection reagent is, for example, a ligand, e.g., an antibody or a fragment thereof, that specifically binds to a peptide or epitope of a marker described herein. Such a ligand can be used in an immunoassay, as described above. Additional reagents used in an immunoassay to determine the level of a marker(s) can also be included in the kit and are considered detection reagents herein. Detection reagents can also relate to reagents used to detect a marker or fragments thereof by MS-based methods. Thus, such detection reagents can also be reagents used to prepare a sample for MS analysis, e.g., enzymes, chemicals, buffers, etc. Mass spectrometers can also be considered detection reagents. Detection reagents according to the present invention can also be, for example, calibration solution(s) that can be used to determine and compare the level of a marker(s).

[0188] The sensitivity and specificity of diagnostic and / or prognostic tests do not only depend on the analytical "quality" of the test, but they also depend on the definition of what constitutes an abnormal result. In practice, receiver operating characteristic curves (ROC curves) are typically calculated by plotting the value of a variable against its relative frequency in a "normal" population (i.e., apparently healthy individuals without infection), and a "disease" population, e.g., subjects with an infection. For any particular marker (such as ADM), the distributions of marker levels for subjects with and without disease / condition will likely overlap. Under such conditions, the test will not perfectly distinguish normal from disease with 100% accuracy, and the area of ​​overlap may indicate where the test cannot distinguish normal from disease. A threshold is selected below which the test is considered abnormal and above which the test is considered normal, or below or above which the test indicates a particular condition, e.g., infection. The area under the ROC curve is a measure of the probability that the perceived measurement will allow for correct identification of a condition. ROC curves can be used even when the test results do not necessarily give exact numbers. As long as the results can be ranked, ROC curves can be made. For example, the results of the test on "disease" samples can be ranked according to degree (e.g., 1=low, 2=normal, and 3=high). This ranking can be correlated with the results of "normal" populations, and ROC curves can be made. These methods are well known in the art, see, for example, Hanley et al. 1982.Radiology 143:29-36. Preferably, the threshold value is selected to provide a ROC curve area greater than about 0.5, more preferably greater than about 0.7, even more preferably greater than about 0.8, even more preferably greater than about 0.85, and most preferably greater than about 0.9. The term "about" in this context refers to + / - 5% of a given measurement value.

[0189] The horizontal axis of the ROC curve represents (1-specificity), which increases with the rate of false positives. The vertical axis of the curve represents sensitivity, which increases with the true positive rate. Thus, for a particular cutoff selected, the value of (1-specificity) can be determined, and the corresponding sensitivity can be obtained. The area under the ROC curve is a measure of the probability that the measured marker level will allow for correct identification of a disease or condition. Thus, the area under the ROC curve can be used to determine the validity of a test.

[0190] Thus, the present invention includes the administration of suitable antibiotics for treatment based on information obtained by the methods described herein.

[0191] As used herein, the terms "comprising" and "including" or grammatical variations thereof should be interpreted as specifying stated features, integers, steps, or components, but not excluding the addition of one or more additional features, integers, steps, components, or groups thereof. This term encompasses the terms "consisting of" and "consisting essentially of."

[0192] Thus, the terms "comprise" / "include" / "have" mean that any additional components (or similar features, integers, steps, etc.) may be present. The term "consisting of" means that no additional components (or similar features, integers, steps, etc.) are present.

[0193] The term "consisting essentially of" or grammatical variations thereof, as used herein, should be construed to identify the stated features, integers, steps, or components, but not to preclude the addition of one or more additional features, integers, steps, components, or groups thereof, but only if those additional features, integers, steps, components, or groups thereof do not materially alter the basic and novel characteristics of the composition, device, or method being claimed.

[0194] Thus, the term "consisting essentially of" means that certain additional components (or similar features, integers, steps, etc.) may be present, i.e., that do not substantially affect the essential characteristics of the composition, device, or method. In other words, the term "consisting essentially of" (which may be used interchangeably herein with the term "substantially comprising") allows for the presence of other components in the composition, device, or method in addition to the essential components (or similar features), provided that the essential characteristics of the device or method are not substantially affected by the presence of the other components.

[0195] The term "method" refers to methods, means, techniques, and procedures for accomplishing a given task, and includes, but is not limited to, those methods, means, techniques, and procedures known to those skilled in the chemical, biological, and biophysical arts or readily developed from known methods, means, techniques, and procedures by those skilled in the chemical, biological, and biophysical arts.

[0196] The invention is further described by reference to the following non-limiting examples. EXAMPLES

[0197] Example of the method: Study design and patients: The following is a secondary analysis of improved prognostic performance in severely injured patients by integrated clinical transcriptional biology: A translational approach study

[14] conducted among patients admitted to the Trauma Surgery Department (Level 1 trauma center) of the University Hospital of Zurich between December 2009 and March 2012. Patient inclusion criteria included patients aged 18 years or older, with an Injury Severity Scale (ISS) score of 17 or more, and time from injury to hospital admission less than 6 hours. Details of the original study design have been described previously

[14] .

[0198] Blood sample measurements and clinical data collection: Blood samples from trauma patients were collected within the first 6 hours after trauma (baseline) and then on days 1, 2, 3, 5, 7, 10, 14, and 24. Clinical outcomes, including hospital-acquired infections, development of sepsis, and non-infection-related complications, were recorded within the first 28 days after the initial trauma. Systemic inflammation was defined according to the criteria of the American College of Chest Physicians / Society of Critical care Medicine Consensus Conferenc [15, 16]. The systemic inflammation score (SI score)

[17] was used to evaluate the severity of trauma-induced systemic inflammation. The subsequent development of sepsis in trauma patients was defined as an increase of ≥2 points in the SI score between two consecutive time points in the presence of an infectious focus or positive blood cultures. Sequential Organ Failure Assessment (SOFA) scores were calculated at all time points.

[0199] Procalcitonin (PCT) and midregional proadrenomedullin (MR-proADM) concentrations were measured retrospectively with detection limits of 0.05 nmol / L and 0.02 ng / ml (Kryptor®, Thermo Fisher Scientific, Germany). CRP and lactate concentrations were measured locally.

[0200] Statistical analysis: Differences in patient demographic and clinical characteristics were evaluated according to the normality of distribution, with χ for categorical variables 2 Tests were evaluated using Student's t-test or Mann-Whitney U-test for continuous variables. Normally and non-normally distributed variables were expressed as mean (standard deviation) and median [1st-3rd quartile], respectively. Associations of each clinical score (SOFA and ISS) with biomarkers were evaluated at baseline and day 1. The total number of surgeries and their duration were recorded in each case, along with antibiotic administration requirements at baseline and over the first 7 days of hospitalization. The presence of nosocomial infection was identified and classified as surgical or nonsurgical.

[0201] We then created models of baseline and day 1 biomarker and clinical score dynamics to assess the likelihood of sepsis development or non-infection-related complications during the first 28 days after trauma. At both time points, we used pre-established cut-off values ​​for MR-proADM (<1.54 nmol / L) [SIDED], PCT (<0.5 ng / mL), lactate (<2.0 mmol / L) [8] and SOFA (<5 points). The resulting odds ratios (ORs) assessed the likelihood of adverse events among different patient subgroups.

[0202] Example 1: Patient characteristics Patient characteristics are summarized in Table 1. A total of 77 patients had samples available for biomarker measurement that could be retrospectively analyzed, of which 74.0% (N=57) were male, the mean age was 41.4 (17.3) years, and the 28-day mortality rate was 6.5% (N=5). The mean Glasgow Coma Scale (GCS) score on admission was 12.3 (4.0), with 16 (20.8%) patients having a GCS score <10. All patients were admitted to the ICU, with median ICU stay and overall hospital stay of 12 [4-21] and 25 [16-38] days, respectively.

[0203] Patients underwent a mean of 4.3 (2.7) surgeries in the first 28 days after the initial trauma, with emergency surgeries performed in 71 (92.2%) patients at baseline. An additional 20 surgeries were performed on day 1, of which 16 (80.0%) were reoperations and 4 (20.0%) were in patients who had not had surgery at baseline. Only 2 (2.6%) patients did not require any surgical intervention during their hospital stay. The mean duration of surgery was 116.2 (92.0) minutes.

[0204] Example 2: Development of sepsis and non-infection-related complications A total of 44 (57.9%) patients developed non-infection-related complications over the 28 days, with the development of rhabdomyolysis being the most common complication (N=15, 34.1%). Meanwhile, 48 (64.9%) patients developed hospital-acquired infections, with surgical and non-surgical infections accounting for 19 (38.0%) and 27 (54.0%) cases, respectively. Non-surgical ventilator-associated pneumonia was found in 12 (44.4%) patients. Of the 48 patients who developed hospital-acquired infections, 12 (24.0%) developed sepsis, with a mean time to diagnosis of 9.5 (4.7) days, of which 10 (83.3%) progressed to septic shock. Patient characteristics regarding the development of sepsis are shown in Table 1.

[0205] Antibiotics were administered to 44 (57.1%) patients at baseline, 45 (58.4%) at baseline or day 1, and 55 (71.4%) during the first 7 days of hospitalization. Of the 45 patients who received antibiotics at baseline or day 1, antibiotics were initiated in 11 (24.4%) patients who did not subsequently develop any infection, in contrast to 32 (71.1%) patients who developed hospital-acquired infections. A total of 11 (91.7%) patients who developed sepsis received antibiotics within the first 7 days of treatment.

[0206] Example 3: Correlation of biomarkers and clinical scores at baseline There were no significant correlations between biomarkers and SOFA scores at admission, but low but significant associations were found between lactate, SOFA, MR-proADM, and ISS scores.SOFA and lactate had the greatest correlations with ICU length of stay at baseline, but no significant correlations with either PCT or CRP.Interestingly, lactate also had the highest correlation with the overall length of patient hospital stay.

[0207] Example 4: Prediction of sepsis incidence at baseline and day 1 Only two parameters, MR-proADM and SOFA, were significantly associated with predicting sepsis onset both at baseline (AUROC [95% CI]: 0.71 [0.56-0.86], 0.73 [0.56-0.90]) and at day 1 (AUROC [95% CI]: 0.85 [0.76-0.94], 0.84 [0.70-0.98]), although both parameters showed improved performance at day 1 after trauma (Table 2).

[0208] Similarities were also observed in the occurrence of non-infection-related complications, with only two parameters, MR-proADM and lactate levels, showing a significant association both at baseline and on day 1. Conversely, CRP showed no significant association at either time point (Table 3).

[0209] Example 5: Exercise model to predict sepsis and trauma-related complications Biomarkers and clinical scores were then identified according to their baseline and day 1 predictive performance to include / exclude the development of sepsis within 28 days or to identify patient populations at high risk of developing non-infection-related complications within the same period.

[0210] Example 6: Sepsis over a 28-day period Lactate and MR-proADM were then investigated to predict the development of trauma-related complications over a 28-day period. In contrast to patients who developed sepsis, lactate levels <2 mmol / L from baseline to day 1 were able to identify a lower number of trauma-related complications (N=7, 28.0%) compared with persistently low MR-proADM (N=16, 40.0%). Conversely, increasing (14 patients, complication rate 87.5%) or persistently elevated (8 patients, complication rate 88.9%) MR-proADM concentrations allowed accurate identification of subgroups at risk for developing potential complications.

[0211] Discussion of the Examples In this retrospective analysis, we compared the performance of established and novel biomarkers and clinical scores in early inclusion or exclusion of sepsis after severe polytrauma.Maintaining continuously low MR-proADM or high SOFA levels to include or exclude the development of sepsis, respectively, may aid in the development of specific therapeutic strategies based on secondary complications resulting from infection. table

[0212] [Table 1]

[0213] [Table 2]

[0214] [Table 3]

[0215] [Table 4]

[0216] References 1.Mock CN,Jurkovich GJ,nii-Amon-Kotei D,Arreola-Risa C,Maier RV.Trauma mortality patterns in three nations at different economic levels:implications for global trauma system development.J Trauma.1998 May;44(5):804-12; discussion 12-4. 2. MacKenzie EJ. Epidemiology of injuries: current trends and future challenges. Epidemiol Rev.2000;22(1):112-9. 3.Wafaisade A,Lefering R,Bouillon B,Sakka SG,Thamm OC,Paffrath T,et al.Epidemiology and risk factors of sepsis after multiple trauma:an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery.Crit Care Med.2011 Apr;39(4):621-8. 4.Hirsiger S,Simmen HP,Werner CM,Wanner GA,Rittirsch D.Danger signals activating the immune response after trauma.Mediators Inflamm.2012;2012:315941. 5.Gentile LF,Cuenca AG,Efron PA,Ang D,Bihorac A,McKinley BA,et al.Persistent inflammation and immunosuppression:a common syndrome and new horizon for surgical intensive care.J Trauma Acute Care Surg.2012 Jun;72(6):1491-501. 6.Wanner GA,Keel M,Steckholzer U,Beier W,Stocker R,Ertel W.Relationship between procalcitonin plasma levels and severity of injury,sepsis,organ failure,and mortality in injured patients.Crit Care Med.2000 Apr;28(4):950-7. 7.Gebhard F,Huber-Lang M.Polytrauma--pathophysiology and management principles.Langenbecks Arch Surg.2008 Nov;393(6):825-31. 8.Singer M,Deutschman CS,Seymour CW,Shankar-Hari M,Annane D,Bauer M,et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA.2016 Feb 23;315(8):801-10. 9.Gille J,Ostermann H,Dragu A,Sablotzki A.MR-proADM:A New Biomarker for Early Diagnosis of Sepsis in Burned Patients.J Burn Care Res.2017 Sep / Oct;38(5):290-8. 10.Bustamante A,Garcia-Berrocoso T,Penalba A,Giralt D,Simats A,Muchada M,et al.Sepsis biomarkers reprofiling to predict stroke-associated infections.J Neuroimmunol.2017 Nov 15;312:19-23. 11.Andaluz-Ojeda D,Nguyen HB,Meunier-Beillard N,Cicuendez R,Quenot JP,Calvo D,et al.Superior accuracy of mid-regional proadrenomedullin for mortality prediction in sepsis with varying levels of illness severity.Ann Intensive Care.2017 Dec;7(1):15. 12.Charles PE,Peju E,Dantec A,Bruyere R,Meunier-Beillard N,Dargent A,et al.Mr-Proadm Elevation Upon Icu Admission Predicts the Outcome of Septic Patients and is Correlated with Upcoming Fluid Overload.Shock.2017 Oct;48(4):418-26. 13.Bernal-Morell E,Garcia-Villalba E,Vera MDC,Medina B,Martinez M,Callejo V,et al.Usefulness of midregional pro-adrenomedullin as a marker of organ damage and predictor of mortality in patients with sepsis.J Infect.2017 Dec 12. 14.Rittirsch D,Schoenborn V,Lindig S,Wanner E,Sprengel K,Gunkel S,et al.Improvement of prognostic performance in severely injured patients by integrated clinico-transcriptomics:a translational approach.Crit Care.2015 Nov 26;19:414. 15.Bone RC,Balk RA,Cerra FB,Dellinger RP,Fein AM,Knaus WA,et al.Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.The ACCP / SCCM Consensus Conference Committee.American College of Chest Physicians / Society of Critical Care Medicine.Chest.1992 Jun;101(6):1644-55. 16.Levy MM,Fink MP,Marshall JC,Abraham E,Angus D,Cook D,et al.2001 SCCM / ESICM / ACCP / ATS / SIS International Sepsis Definitions Conference.Crit Care Med.2003 Apr;31(4):1250-6. 17.Rangel-Frausto MS,Pittet D,Costigan M,Hwang T,Davis CS,Wenzel RP.The natural history of the systemic inflammatory response syndrome (SIRS).A prospective study.JAMA.1995 Jan 11;273(2):117-23.

Claims

1. 1. A method for diagnosis, prognosis, prediction, risk assessment and / or risk stratification of subsequent trauma-related complications in polytrauma patients, comprising: - determining the level of proADM or one or more fragments thereof in a first blood, serum or plasma sample of said patient, wherein the determined level of proADM or one or more fragments thereof correlates with the likelihood of a subsequent trauma-related complication; and - comparing the determined level of proADM or one or more fragments thereof with a reference value of 1.54 nmol / L, a level of proADM or one or more fragments thereof below the reference value corresponds to a low severity level, a low severity level in the first sample indicating no subsequent trauma-related complications within 28 days of the multiple trauma, - a level of proADM or one or more fragments thereof equal to or above the reference value corresponds to a high severity level, a high severity level in the first sample being indicative of subsequent trauma-related complications within 28 days of the multiple trauma; The method.

2. moreover, - determining the level of proADM or one or more fragments thereof in a second blood, serum or plasma sample from said patient, said second sample being isolated after said first sample, said first and second samples being isolated from said patient within 48 hours following multiple trauma; and - comparing the determined level of proADM or one or more fragments thereof with a reference value of 1.54 nmol / L, Including, - a level of proADM or one or more fragments thereof below the reference value corresponds to a low severity level, and a low severity level in the first and second samples indicates no subsequent trauma-related complications within 28 days of the multiple trauma; and The method of claim 1, wherein a level of proADM or one or more fragments thereof equal to or above the reference value corresponds to a high severity level, and wherein a high severity level in at least the second sample, or an increase in the severity level in the second sample compared to the first sample, is indicative of subsequent trauma-related complications within 28 days of the multiple trauma.

3. 3. The method of claim 1 or 2, wherein the polytrauma patient has an Injury Severity Score (ISS) of 17 or greater.

4. Trauma-related complications - infections, hospital-acquired infections, sepsis and / or septic shock; - complications not related to infection, such as rhabdomyolysis and / or organ failure; and / or -death, The method according to any one of claims 1 to 3, comprising:

5. The method of any one of claims 1 to 4, wherein determining the level of proADM or one or more fragments thereof comprises determining the level of MR-proADM in the sample.

6. moreover, - determining the level of at least one additional biomarker or one or more fragments thereof in a sample from said patient, said at least one additional biomarker being PCT or one or more fragments thereof and / or lactate, and / or - determining at least one clinical score, said at least one clinical score being SOFA, Including, The method according to any of claims 1 to 5, wherein the level of said at least one additional biomarker and / or said at least one clinical score and the level of proADM or one or more fragments thereof are indicative of subsequent trauma-related complications.

7. 7. The method of any of claims 2 to 6, wherein the first sample is isolated from the polytrauma patient within 24 hours after polytrauma and the second sample is isolated from the patient within 24 hours after isolation of the first sample.