1
|
Chang AJ, Mallat AF, Edwards MJ, Gabra JN, Cucci MD. Evaluation of pre-hospital cannabis exposure and hospital opioid utilization in a trauma population: A retrospective cohort. Injury 2024; 55:111305. [PMID: 38216357 DOI: 10.1016/j.injury.2023.111305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 12/07/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE Cannabis utilization has increased over time for recreational and medical purposes due to its legalization or decriminalization. The effects of cannabis use on opioid utilization are not well understood. The primary objective was to evaluate the total opioid utilization, measured in morphine milligram equivalents (MME), in hospitalized trauma patients that tested positive for tetrahydrocannabinol (THC) on a urine drug screen (UDS). METHODS This was a retrospective, cohort study in a level 1 trauma center between 10/17/17 and 12/31/19. Adult trauma patients (aged 15 years and older) who had a UDS completed within 48 h of hospital arrival were eligible for inclusion. Patients were excluded for a hospitalization >14 days, death within 24 h, severe alcohol withdrawal, prescribed cannabinoids, high daily opioid use prior-to-arrival, or transitioned to hospice or palliative care. Group assignments were determined based on the presence or absence of THC on the UDS. RESULTS The analysis included 750 patients with 160 (21 %) THC positive patients. The population were primarily male (64.6 %), median age of 56 years [IQR 35-72], with blunt (93 %) injuries from motor vehicle crash or falls (79 %). The THC group was more likely to have other substances present, including amphetamines, benzodiazepines, opiates, and cocaine. The THC group had a higher median injury severity score (10 [IQR 5-17] vs. 9 [5-14], p = 0.0056), and maximum abbreviated injury score (3 [IQR 2-3] vs. 2 [IQR 2-3], p = 0.0009). The THC group had a total higher median opioid utilization during the hospitalization (155 [IQR 68-367] vs. 62 [IQR 13-175] MME; p < 0.0001), which included higher opioid use in the emergency department, floor, and intensive care unit. There were no significant differences in secondary outcomes except the THC group was more likely to receive an opioid prescription at discharge and more likely to require mechanical ventilation. Based on multivariable regression analyses, other variables were associated with increased opioid utilization. CONCLUSION Pre-existing THC exposure may be associated with an increased hospital opioid utilization in a trauma population. However, other variables may also play a role in opioid utilization.
Collapse
Affiliation(s)
- Alexander J Chang
- Cleveland Clinic Akron General, Department of Surgery, 1 Akron General Ave, Akron, OH, 44303, USA
| | - Ali F Mallat
- Executive Director, Acute Care Surgery, Cleveland Clinic Akron General, Acute Care Surgery, Digestive Diseases and Surgery Institute, 1 Akron General Ave., Akron, OH, 44307, USA
| | - Marc J Edwards
- Cleveland Clinic Akron General, Department of Research, 1 Akron General Ave., Akron, OH, 44307, USA
| | - Joseph N Gabra
- Cleveland Clinic Akron General, Department of Research, 1 Akron General Ave., Akron, OH, 44307, USA
| | - Michaelia D Cucci
- Cleveland Clinic Akron General, Department of Pharmacy, 1 Akron General Ave., Akron, OH, 44307, USA.
| |
Collapse
|
2
|
Anticoagulation in hospitalized patients with COVID-19. Blood 2022; 140:809-814. [PMID: 35653590 PMCID: PMC9361053 DOI: 10.1182/blood.2021014527] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) includes a thromboinflammatory syndrome that may manifest with microvascular and macrovascular thrombosis. Patients with COVID-19 have a higher incidence of venous thromboembolism than other hospitalized patients. Three randomized control trials suggesting benefit of therapeutic heparin in hospitalized noncritically ill patients with COVID-19 have led to conditional guideline recommendations for this treatment. By contrast, prophylactic-dose heparin is recommended for critically ill patients. Unprecedented collaboration and rapidly funded research have improved care of hospitalized patients with COVID-19.
Collapse
|
3
|
Identification of Nine mRNA Signatures for Sepsis Using Random Forest. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5650024. [PMID: 35345523 PMCID: PMC8957445 DOI: 10.1155/2022/5650024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 11/17/2022]
Abstract
Sepsis has high fatality rates. Early diagnosis could increase its curating rates. There were no reliable molecular biomarkers to distinguish between infected and uninfected patients currently, which limit the treatment of sepsis. To this end, we analyzed gene expression datasets from the GEO database to identify its mRNA signature. First, two gene expression datasets (GSE154918 and GSE131761) were downloaded to identify the differentially expressed genes (DEGs) using Limma package. Totally 384 common DEGs were found in three contrast groups. We found that as the condition worsens, more genes were under disorder condition. Then, random forest model was performed with expression matrix of all genes as feature and disease state as label. After which 279 genes were left. We further analyzed the functions of 279 important DEGs, and their potential biological roles mainly focused on neutrophil threshing, neutrophil activation involved in immune response, neutrophil-mediated immunity, RAGE receptor binding, long-chain fatty acid binding, specific granule, tertiary granule, and secretory granule lumen. Finally, the top nine mRNAs (MCEMP1, PSTPIP2, CD177, GCA, NDUFAF1, CLIC1, UFD1, SEPT9, and UBE2A) associated with sepsis were considered as signatures for distinguishing between sepsis and healthy controls. Based on 5-fold cross-validation and leave-one-out cross-validation, the nine mRNA signature showed very high AUC.
Collapse
|
4
|
Yin S, Xu Y, Wang Z, Wei Z, Xu T, Zhao W, Zhao C. Molecularly-imprinted hydrogel beads via self-sacrificing micro-reactors as safe and selective bilirubin adsorbents. J Mater Chem B 2021; 10:2534-2543. [PMID: 34786576 DOI: 10.1039/d1tb01895g] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For patients who are suffering from liver dysfunction or metabolic obstruction, excessive bilirubin (BIL) in their bodies may cause jaundice with irreversible cerebral injury. Traditional exchange transfusion and photodynamic therapy pose a risk of serious adverse reactions or limited curative effects. Therefore, as a generally used treatment, hemoperfusion (HP) purifies patients' blood with solid adsorbents. However, the development of clinical BIL absorbents is greatly impeded by low selectivity and unsatisfactory blood compatibility. Herein, inspired by oviparity, we propose BIL-imprinted poly(acrylic acid-co-sodium p-styrenesulfonate)-reduced graphene oxide (PAA-SS-rGO@BIL) hydrogel beads as BIL adsorbents via self-sacrificing micro-reactors. In the micro-reactors, cross-linked polymerization is achieved and a solidified gel is formed. The received hydrogel beads show outstanding selective adsorption capabilities toward BIL due to the recognition sites, and π-π and hydrophobic interactions. Such hydrogel beads possess superior blood compatibility owing to their bioinspired heparin-mimicking gel structure. Simulated BIL selective adsorption experiments in vitro demonstrate that the BIL concentrations in the plasma of a patient with severe jaundice can be restored to a moderate level within 3 hours. Therefore, hydrogel beads offer new options for clinical BIL adsorption.
Collapse
Affiliation(s)
- Shiqi Yin
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Yinghui Xu
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Zhoujun Wang
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Zhiwei Wei
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Tao Xu
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China. .,College of Chemical Engineering, Sichuan University, Chengdu, 610065, China
| |
Collapse
|
5
|
Cucci MD, Cunningham BS, Patel JS, Shimer AT, Mofleh DI, Mullen CL. Impact of Early Reinitiation of Neuropsychiatric Medications on Agitation and Delirium in the Intensive Care Unit: A Retrospective Study. Ann Pharmacother 2020; 55:15-24. [PMID: 32567359 DOI: 10.1177/1060028020935589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Approximately 17% of intensive care unit (ICU) patients are prescribed at least 1 home neuropsychiatric medication (NPM). When abruptly discontinued, withdrawal symptoms may occur manifesting as agitation or delirium in the ICU setting. OBJECTIVE To evaluate the impact of early reinitiation of NPMs. METHODS This was a retrospective, observational cohort of adult ICU patients in a tertiary care hospital. Patients were included if admitted to the ICU and prescribed a NPM prior to arrival. Study groups were based on the timing of reinitiation of at least 50% of NPMs: ≤72 hours (early group) versus >72 hours (late group). RESULTS The primary outcome was the proportion of patients with at least 1 agitation or delirium episode in the first 72 hours. Agitation and delirium were defined as at least 1 RASS assessment between +2 to +4 and a positive CAM-ICU assessment, respectively. A total of 300 patients were included, with 187 (62%) and 113 (38%) in the early and late groups, respectively. There was no difference in agitation or delirium (late 54 [48%] vs early 62 [33%]; adjusted odds ratio [aOR] = 1.5; 95% CI = 0.8-2.8; P = 0.193). Independent risk factors found to be associated with the primary outcome were restraints (aOR = 12.9; 95% CI = 6.9-24.0; P < 0.001) and benzodiazepines (BZDs; aOR = 2.0; 95% CI = 1.0-3.7; P = 0.038). CONCLUSIONS After adjustment for baseline differences, there was no difference in agitation or delirium. Independent risk factors were restraint use and newly initiated BZDs.
Collapse
|
6
|
Baghdadi JD, Brook RH, Uslan DZ, Needleman J, Bell DS, Cunningham WE, Wong MD. Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis. JAMA Intern Med 2020; 180:707-716. [PMID: 32250412 PMCID: PMC7136852 DOI: 10.1001/jamainternmed.2020.0183] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis. OBJECTIVE To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020. EXPOSURES Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment). MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days. RESULTS Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset). CONCLUSIONS AND RELEVANCE SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.
Collapse
Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland, Baltimore
| | - Robert H Brook
- RAND Corporation, Santa Monica, California.,David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | | | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, UCLA
| | | | - William E Cunningham
- Department of Health Policy and Management, Fielding School of Public Health, UCLA.,Division of General Internal Medicine, UCLA
| | | |
Collapse
|
7
|
Yang Y, Yin S, He C, Wu X, Yin J, Zhang J, Ma L, Zhao W, Cheng C, Zhao C. Construction of Kevlar nanofiber/graphene oxide composite beads as safe, self-anticoagulant, and highly efficient hemoperfusion adsorbents. J Mater Chem B 2020; 8:1960-1970. [PMID: 32067017 DOI: 10.1039/c9tb02789k] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recently emerged hemoperfusion absorbents, e.g. ion-exchange resin, activated carbon, and other porous materials, provide numerous novel possibilities to cure chronic liver failure (CLF) and renal failure (CRF). However, the limited adsorption performance and unsatisfactory blood compatibility significantly impede the development of the absorbents. Hence, designing safe and self-anticoagulant hemoperfusion absorbents with robust toxin clearance remains a considerable challenge. Here, brand new Kevlar-based composite gel beads for hemoperfusion are prepared by interface assembly based on π-π interaction. First, Kevlar nanofiber-graphene oxide (K-GO) beads are produced by liquid-liquid phase separation. Then, sodium p-styrenesulfonate (SS) is adsorbed onto the K-GO interface by π-π interaction and initiated to achieve the composite gel (K-GO/PSS) beads with an interfacial crosslinked structure. Such composite gel beads possess superior mechanical strength and self-anticoagulation capability, owing to the dual-network structure and heparin-mimicking gel structure, respectively. Furthermore, the K-GO/PSS beads show robust adsorption capacities for different kinds of toxins due to their strong charge and π-π interactions. A simulated hemoperfusion experiment in vitro demonstrates that the concentrations of the toxins in the blood can be restored to normal values within 30 minutes. In general, we envision that such composite gel beads will provide new strategies for future clinical CLF and CRF treatments.
Collapse
Affiliation(s)
- Ye Yang
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Shiqi Yin
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Chao He
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Xizheng Wu
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Jiarui Yin
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Jue Zhang
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Lang Ma
- Laboratory of Ultrasound Imaging Drug, Department of Ultrasound, West China School of Medicine/West China Hospital, Sichuan University, Chengdu 610041, China
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Chong Cheng
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu 610065, China.
| |
Collapse
|
8
|
Contemporary strategies to improve clinical trial design for critical care research: insights from the First Critical Care Clinical Trialists Workshop. Intensive Care Med 2020; 46:930-942. [PMID: 32072303 PMCID: PMC7224097 DOI: 10.1007/s00134-020-05934-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/11/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Conducting research in critically-ill patient populations is challenging, and most randomized trials of critically-ill patients have not achieved pre-specified statistical thresholds to conclude that the intervention being investigated was beneficial. METHODS In 2019, a diverse group of patient representatives, regulators from the USA and European Union, federal grant managers, industry representatives, clinical trialists, epidemiologists, and clinicians convened the First Critical Care Clinical Trialists (3CT) Workshop to discuss challenges and opportunities in conducting and assessing critical care trials. Herein, we present the advantages and disadvantages of available methodologies for clinical trial design, conduct, and analysis, and a series of recommendations to potentially improve future trials in critical care. CONCLUSION The 3CT Workshop participants identified opportunities to improve critical care trials using strategies to optimize sample size calculations, account for patient and disease heterogeneity, increase the efficiency of trial conduct, maximize the use of trial data, and to refine and standardize the collection of patient-centered and patient-informed outcome measures beyond mortality.
Collapse
|