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Borthwick M, Granholm A, Marker S, Krag M, Lange T, Wise MP, Bendel S, Keus F, Guttormsen AB, Schefold JC, Wetterslev J, Perner A, Møller MH. Associations between enteral nutrition and outcomes in the SUP-ICU trial: Results of exploratory post hoc analyses. Acta Anaesthesiol Scand 2024. [PMID: 38867404 DOI: 10.1111/aas.14471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Enteral nutrition may affect risks of gastrointestinal bleeding, pneumonia and mortality in critically ill patients and may also modify the effects of pharmacological stress ulcer prophylaxis. We undertook post hoc analyses of the stress ulcer prophylaxis in the intensive care unit trial to assess for any associations and interactions between enteral nutrition and pantoprazole. METHODS Extended Cox models with time-varying co-variates and competing events were used to assess potential associations, adjusted for baseline severity of illness. Potential interactions between daily enteral nutrition and allocation to pantoprazole on outcomes were similarly assessed. RESULTS Enteral nutrition was associated with lower risk of clinically important gastrointestinal bleeding (cause-specific hazard ratio [HR]: 0.29, 95% confidence interval: [CI] 0.19-0.44, p < .001), higher risk of pneumonia (HR: 1.44, 95% CI: 1.14-1.82, p = .003), and lower risk of all-cause mortality (HR: 0.22, 95% CI: 0.18-0.27, p < .001). Enteral nutrition with allocation to pantoprazole was associated with a lower risk of mortality (HR: 0.27, 95% CI: 0.21-0.35, p < .001), similar to enteral nutrition with allocation to placebo (HR: 0.17, 95% CI: 0.13-0.23, p < .001). Allocation to pantoprazole with no enteral nutrition had little effect on mortality (HR: 0.83, 95% CI: 0.63-1.09, p = .179), whilst allocation to pantoprazole and receipt of enteral nutrition was mostly compatible with increased all-cause mortality (HR: 1.27, 95% CI: 0.99-1.64, p = .061). The test of interaction between enteral nutrition and pantoprazole treatment allocation for all-cause mortality was statistically significant (p = .024). CONCLUSIONS Enteral nutrition was associated with an increased risk of pneumonia and a reduced risk of gastrointestinal bleeding. The interaction between pantoprazole and enteral nutrition suggesting an increased risk of mortality requires further study.
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Affiliation(s)
- Mark Borthwick
- Departments of Pharmacy and Critical Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Søren Marker
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Mette Krag
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Stepani Bendel
- Department of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anne Berit Guttormsen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, University of Bergen, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Jørn Wetterslev
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Private office, Tuborg Sundpark, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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McGraw C, Briscoe A, Reynolds C, Carrick M, Palacio CH, Waswick W, Miller A, Trujillo L, Bar-Or D. Outcomes of patients with traumatic brain injury after stress ulcer prophylaxis: a retrospective multicenter study. Trauma Surg Acute Care Open 2024; 9:e001285. [PMID: 38410756 PMCID: PMC10895230 DOI: 10.1136/tsaco-2023-001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/08/2024] [Indexed: 02/28/2024] Open
Abstract
Background Stress ulcers in patients with traumatic brain injury (TBI) and spinal cord injury (SCI) present significant morbidity and mortality risks. Despite the low reported stress ulcer rates, stress ulcer prophylaxis (SUP) is widely administered in neurocritical care. It was hypothesized that universal SUP administration may not be associated with reduced rates of complications across all neurocritical care patients. Methods This retrospective study encompassed neurocritical care patients aged ≥18 with moderate or severe TBI or SCI, admitted to the intensive care unit (ICU) between October 2020 and September 2021, across six level I trauma centers. Exclusions included patients with an ICU stay <2 days, prior SUP medication use, and pre-existing SUP diagnoses. The primary exposure was SUP, with the primary outcome being clinically significant gastrointestinal bleeds (CSGIBs). Secondary outcomes included pneumonia and in-hospital mortality. Patients were stratified by admission Glasgow Coma Scale (GCS) groups. Results Among 407 patients, 83% received SUP, primarily H2 receptor antagonists (88%) and proton pump inhibitors (12%). Patients on SUP were significantly younger, had lower admission GCS scores, higher Injury Severity Scores, longer ICU stays, and higher rates of mechanical ventilation than non-SUP patients. Overall, CSGIBs were rare (1%) and not significantly different between the SUP and non-SUP groups (p=0.06). However, CSGIBs exclusively occurred in patients with GCS scores of 3-8, and SUP was associated with a significantly lower rate of CSGIBs in this subgroup (p=0.03). SUP was also linked to significantly higher pneumonia rates in both GCS 3-8 and GCS 9-12 patients. Conclusions This study highlights the low incidence of CSGIBs in neurocritical trauma patients and suggests potential benefits of SUP, particularly for those with severe neurological impairment. Nevertheless, the increased risk of pneumonia associated with SUP in these patients warrants caution. Further research is crucial to refine SUP guidelines for neurocritical care patients and inform optimal strategies. Level of evidence Level III, retrospective.
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Affiliation(s)
- Constance McGraw
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
| | - Abigale Briscoe
- Trauma Services, St Anthony Hospital & Medical Campus, Lakewood, Colorado, USA
| | | | | | - Carlos H Palacio
- Trauma Services, South Texas Health System, McAllen Medical Center, McAllen, Texas, USA
| | - William Waswick
- Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - April Miller
- Trauma Services, Medical City Plano, Plano, Texas, USA
| | - Laura Trujillo
- Trauma Services, Penrose Hospital, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
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Hamilton LA, Darby SH, Rowe AS. A Retrospective Cohort Analysis of the Use of Enteral Nutrition Plus Pharmacologic Prophylaxis or Enteral Nutrition Alone. Hosp Pharm 2021; 56:729-736. [PMID: 34732931 DOI: 10.1177/0018578720954159] [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: 11/16/2022]
Abstract
Background: Due to the risk of development of stress ulcers in intensive care unit (ICU) patients, pharmacologic prophylaxis is often utilized. However, some literature describes the use of enteral nutrition instead as stress ulcer prophylaxis. Methods: The purpose of this study is to determine if enteral nutrition is similar to pharmacologic stress ulcer prophylaxis (SUP) with enteral nutrition for reduction of gastrointestinal (GI) bleeding, perforation, or ulceration in ICU patients. This was a retrospective, single-center cohort study that took place at an academic medical center. Adult ICU patients receiving enteral nutrition who had a risk factor for stress-related mucosal damage were included. The primary outcome was the incidence of GI bleeding, perforation, or ulcer formation. Results: Overall, 167 patients were included in the study, 147 in the pharmacologic prophylaxis plus EN group (PPEN) and 20 in the enteral therapy only (EN) group. Of 167 patients included, 22 patients (21 in the PPEN group and 1 in the EN group) developed a primary outcome of GI bleeding, perforation, or ulceration (14.3% vs 5%, P = .4781). Patients in the PPEN group had a higher incidence of pneumonia (42.2% vs 15%, P = .0194), but no difference was seen between groups when patients with pneumonia present on admission were excluded (20.6% vs 10.5%, P = .5254). Conclusion: In this small cohort of patients, enteral nutrition alone is as effective as pharmacologic therapy in addition to enteral nutrition for the reduction of stress-related GI bleeding, perforation, and ulceration.
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Affiliation(s)
- Leslie A Hamilton
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, USA
| | - Sarah H Darby
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, USA
| | - Anthony Shaun Rowe
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, USA
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Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients. J Healthc Qual 2021; 42:e39-e49. [PMID: 31157697 DOI: 10.1097/jhq.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Proton pump inhibitors (PPIs) are a risk factor for hospital-acquired Clostridium difficile infection (CDI). Much PPI use is inappropriate, and interventions to reduce PPI use, such as for stress ulcer prophylaxis in all critically ill patients, are essential to reduce CDI rates. This mixed-methods study in a combined medical-surgical intensive care unit at a tertiary academic medical center used a human factors engineering approach to understand barriers and facilitators to optimizing PPI prescribing in these patients. We performed chart review of patients for whom PPIs were prescribed to evaluate prescribing practices. Semistructured provider interviews were conducted to determine barriers and facilitators to reducing unnecessary PPI use. Emergent themes from provider interviews were classified according to the Systems Engineering Initiative for Patient Safety model. In our intensive care unit, 25% of PPI days were not clinically indicated. Barriers to optimizing PPI prescribing included inadequate provider education, lack of institutional guidelines for stress ulcer prophylaxis, and strong institutional culture favoring PPI use. Potential facilitators included increased pharmacy oversight, provider education, and embedded decision support in the electronic medical record. Interventions addressing barriers noted by front line providers are needed to reduce unnecessary PPI use, and future studies should assess the impact of such interventions on CDI rates.
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GÜNDOĞAN K, KARAKOÇ E, TEKE T, ZERMAN A, ESMAOĞLU A, TEMEL Ş, GÜVEN M, SUNGUR M. Effects of oral/enteral nutrition alone versus plus pantoprazole on gastrointestinal bleeding in critically ill patients with low risk factor: a multicenter, randomized controlled trial. Turk J Med Sci 2020; 50:776-783. [PMID: 32151119 PMCID: PMC7379460 DOI: 10.3906/sag-1911-42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/05/2020] [Indexed: 01/14/2023] Open
Abstract
Background/aim Critically ill patients are at risk of developing gastrointestinal (GI) bleeding due to stress causing mucosal damage. Aim of the study was to determine the effect of oral/enteral nutrition with or without concomitant pantoprazole on upper GI bleeding in low risk critically ill patients. Materials and methods This was a prospective, randomized, open-label, multicenter study conducted with intensive care unit (ICU) patients receiving oral/enteral nutritional support. Patients were randomly assigned into two groups including intervention group (received oral/EN plus pantoprazole) and control group (received only oral/EN). Results A total of 300 patients (intervention group: 152, control group: 148) participated in the study. Overall, 226 (75%) patients were fed by orally and 74 (25%) patients fed by enteral tube feeding. Median duration of nutritional support 4 (range: 2–33) days. Overt upper GI bleeding was noted only in one patient (0.65%) who was in the intervention group. The overall length of ICU stay of 4 (2–105) days, while ICU stay was significantly longer in the intervention group than in the control group (P = 0.006). Conclusions Our findings seems to indicate that in patients who are at low risk for GI bleeding and under oral/enteral nutritional support, the use of PPIs may not reduce the risk of bleeding, however these results are imprecise because of low event (GI bleeding) rate and limited power.
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Affiliation(s)
- Kürşat GÜNDOĞAN
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Emre KARAKOÇ
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Çukurova University, AdanaTurkey
| | - Turgut TEKE
- Division of Intensive Care, Department of Pulmonary Disease, Faculty of Medicine, Necmettin Erbakan University, KonyaTurkey
| | - Avşar ZERMAN
- Intensive Care Unit, Department of Internal Medicine, Ministry of Health Adana Numune Training and Educational Hospital, AdanaTurkey
| | - Aliye ESMAOĞLU
- Division of Intensive Care, Department of Anesthesiology and Reanimation, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Şahin TEMEL
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Muhammet GÜVEN
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
| | - Murat SUNGUR
- Division of Intensive Care, Department of Internal Medicine, Faculty of Medicine, Erciyes University, KayseriTurkey
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Abstract
PURPOSE OF REVIEW Stress ulcer prophylaxis in critically-ill patients has been a subject of extensive research, with multiple clinical trials attempting to study the best method of stress ulcer prophylaxis with the least adverse effects. Until recently, pharmacologic prophylaxis has prevailed as the primary choice for the prevention of stress ulcers but recent clinical studies have attempted to evaluate the role of enteral nutrition in stress ulcer prophylaxis. RECENT FINDINGS The incidence of stress ulcers that result in clinically important gastrointestinal bleeding (CIGIB) has drastically decreased over the last two decades. Furthermore, in the current era CIGB in the ICU does not seem to be associated with an increased mortality. Multiple recent clinical studies aimed to evaluate the role of proton pump inhibitors (PPIs) in patients who tolerate enteral nutrition in the ICU. SUMMARY The results of multiple recent clinical studies call for re-evaluation of the routine use of PPIs in critically ill patients who tolerates enteral nutrition in the ICU. Despite the promising preliminary results, definitive recommendations need larger clinical trials that are powered to evaluate any added benefits of using PPI in critically ill patients who tolerate enteral nutrition given the low incidence of CIGB in the current era.
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Gupta D, Bhalotra AR, Singh R. Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients. Indian J Crit Care Med 2020; 24:160-167. [PMID: 32435093 PMCID: PMC7225769 DOI: 10.5005/jp-journals-10071-23368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background This audit was aimed at studying current practices regarding the use of stress ulcer prophylaxis (SUP) in the Indian critical care setup, with the background aim of raising awareness regarding the use and indications of SUP in critically ill patients. Materials and methods After registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 26 questions pertaining to SUP was distributed through electronic media among clinicians working in the intensive care units (ICUs) across India. Responses obtained were statistically analyzed. Results The questionnaire was sent to 550 clinicians. Only 197 responded, of whom 91.4% were anesthesiologists, 5.6% were physicians, and 3% were intensivists. The audit revealed that 33% respondents were unaware of the existing SUP guidelines and around 32% did not have protocols for SUP in their ICU. Sixty-nine percent of respondents felt that all ICU patients must receive SUP and 44.7% opined that it should be started on ICU arrival. Almost 94% knew that early enteral feeding is protective against stress ulceration. Only 24.9% responders agreed that there must be clear indications for SUP, and most of them were unaware of all the potential side effects. Once initiated, 43.7% respondents would stop prophylaxis when no indication was left, whereas 69 respondents would stop on ICU discharge. Conclusion There is a lack of awareness regarding initiation, choice of agent, adverse effects as well as termination of SUP in ICU and guidelines for the same. Institutional protocols should be in place and steps need to be taken to prevent unwarranted use. How to cite this article Gupta D, Bhalotra AR, Singh R. Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(3):160–167.
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Affiliation(s)
- Divya Gupta
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Anju R Bhalotra
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Rahil Singh
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
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Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature. Curr Nutr Rep 2018; 7:116-120. [PMID: 29974343 DOI: 10.1007/s13668-018-0232-3] [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: 10/28/2022]
Abstract
PURPOSE OF REVIEW This review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention. RECENT FINDINGS Recent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery. Stress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.
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Buendgens L, Tacke F. Do we still need pharmacological stress ulcer prophylaxis at the ICU? J Thorac Dis 2017; 9:4201-4204. [PMID: 29268471 DOI: 10.21037/jtd.2017.09.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Lukas Buendgens
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
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El-Kersh K, Jalil B, McClave SA, Cavallazzi R, Guardiola J, Guilkey K, Persaud AK, Furmanek SP, Guinn BE, Wiemken TL, Alhariri BC, Kellie SP, Saad M. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study. J Crit Care 2017; 43:108-113. [PMID: 28865339 DOI: 10.1016/j.jcrc.2017.08.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/07/2017] [Accepted: 08/22/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress-related gastrointestinal (GI) bleeding in mechanically ventilated patients. MATERIALS AND METHODS Prospective, double blind, randomized, placebo-controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress-ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups. RESULTS 124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24-hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p=0.99). CONCLUSION We found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid-suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation.
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Affiliation(s)
- Karim El-Kersh
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States.
| | - Bilal Jalil
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Stephen A McClave
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, KY, United States
| | - Rodrigo Cavallazzi
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Juan Guardiola
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Karen Guilkey
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Annuradha K Persaud
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Stephen P Furmanek
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Brian E Guinn
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Timothy L Wiemken
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Bashar Chihada Alhariri
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Scott P Kellie
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Mohamed Saad
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
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