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McCoy C, Keshvani N, Warsi M, Brown LS, Girod C, Chu ES, Hegde AA. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual 2023; 12:e002220. [PMID: 37730270 PMCID: PMC10510939 DOI: 10.1136/bmjoq-2022-002220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/09/2023] [Indexed: 09/22/2023] Open
Abstract
Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.
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Affiliation(s)
- Cody McCoy
- Division of Cardiology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Maryam Warsi
- Fred Hutchinson Cancer Research Center, Statistical Center for HIV/AIDS Research and Prevention, University of Washington School of Medicine, Seattle, Washington, USA
| | - L Steven Brown
- Department of Health Systems Research, Parkland Health, Dallas, Texas, USA
| | - Carlos Girod
- Division of Pulmonary & Critical Care, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
- Medicine Services, Parkland Health, Dallas, Texas, USA
| | - Eugene S Chu
- Medicine Services, Parkland Health, Dallas, Texas, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Anita A Hegde
- Medicine Services, Parkland Health, Dallas, Texas, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
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Jain MK, De Lemos JA, McGuire DK, Ayers C, Eitson JL, Sanchez CL, Kamel D, Meisner JA, Thomas EV, Hegde AA, Mocherla S, Strebe JK, Li X, Williams NS, Xing C, Ahmed MS, Wang P, Sadek HA, Schoggins JW. Atovaquone for treatment of COVID-19: A prospective randomized, double-blind, placebo-controlled clinical trial. Front Pharmacol 2022; 13:1020123. [PMID: 36249792 PMCID: PMC9561237 DOI: 10.3389/fphar.2022.1020123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background: An in silico screen was performed to identify FDA approved drugs that inhibit SARS-CoV-2 main protease (Mpro), followed by in vitro viral replication assays, and in vivo pharmacokinetic studies in mice. These studies identified atovaquone as a promising candidate for inhibiting viral replication. Methods: A 2-center, randomized, double-blind, placebo-controlled trial was performed among patients hospitalized with COVID-19 infection. Enrolled patients were randomized 2:1 to atovaquone 1500 mg BID versus matched placebo. Patients received standard of care treatment including remdesivir, dexamethasone, or convalescent plasma as deemed necessary by the treating team. Saliva was collected at baseline and twice per day for up to 10 days for RNA extraction for SARS-CoV-2 viral load measurement by quantitative reverse-transcriptase PCR. The primary outcome was the between group difference in log-transformed viral load (copies/mL) using a generalized linear mixed-effect models of repeated measures from all samples. Results: Of the 61 patients enrolled; 41 received atovaquone and 19 received placebo. Overall, the population was predominately male (63%) and Hispanic (70%), with a mean age of 51 years, enrolled a mean of 5 days from symptom onset. The log10 viral load was 5.25 copies/mL vs. 4.79 copies/mL at baseline in the atovaquone vs. placebo group. Change in viral load did not differ over time between the atovaquone plus standard of care arm versus the placebo plus standard of care arm. Pharmacokinetic (PK) studies of atovaquone plasma concentration demonstrated a wide variation in atovaquone levels, with an inverse correlation between BMI and atovaquone levels, (Rho −0.45, p = 0.02). In post hoc analysis, an inverse correlation was observed between atovaquone levels and viral load (Rho −0.54, p = 0.005). Conclusion: In this prospective, randomized, placebo-controlled trial, atovaquone did not demonstrate evidence of enhanced SARS-CoV-2 viral clearance compared with placebo. However, based on the observed inverse correlation between atovaquone levels and viral load, additional PK-guided studies may be warranted to examine the antiviral effect of atovaquone in COVID-19 patients.
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Affiliation(s)
- Mamta K. Jain
- Department of Internal Medicine/Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
- *Correspondence: Mamta K. Jain, ; Hesham A. Sadek, ; John W. Schoggins,
| | - James A. De Lemos
- Parkland Health and Hospital System, Dallas, TX, United States
- Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Darren K. McGuire
- Parkland Health and Hospital System, Dallas, TX, United States
- Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Colby. Ayers
- Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Jennifer L. Eitson
- Department of Microbiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Claudia L. Sanchez
- Department of Internal Medicine/Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Dena Kamel
- Department of Internal Medicine/Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Jessica A. Meisner
- Department of Internal Medicine/Infectious Diseases, University of Pennsylvania, Philadelphia, PA, United States
| | - Emilia V. Thomas
- Department of Internal Medicine/Hospital Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Anita A. Hegde
- Parkland Health and Hospital System, Dallas, TX, United States
- Department of Internal Medicine/Hospital Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Satish Mocherla
- Department of Internal Medicine/Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Parkland Health and Hospital System, Dallas, TX, United States
| | | | - Xilong Li
- Department of Population and Data Science, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Noelle S. Williams
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Chao Xing
- McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mahmoud S. Ahmed
- Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ping Wang
- Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Hesham A. Sadek
- Department of Internal Medicine/Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Departments Biophysics, and Molecular Biology, and Center for Regenerative Science and Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
- *Correspondence: Mamta K. Jain, ; Hesham A. Sadek, ; John W. Schoggins,
| | - John W. Schoggins
- Department of Microbiology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- *Correspondence: Mamta K. Jain, ; Hesham A. Sadek, ; John W. Schoggins,
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Hendren NS, de Lemos JA, Ayers C, Das SR, Rao A, Carter S, Rosenblatt A, Walchok J, Omar W, Khera R, Hegde AA, Drazner MH, Neeland IJ, Grodin JL. Association of Body Mass Index and Age With Morbidity and Mortality in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Disease Registry. Circulation 2020; 143:135-144. [PMID: 33200947 DOI: 10.1161/circulationaha.120.051936] [Citation(s) in RCA: 191] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Obesity may contribute to adverse outcomes in coronavirus disease 2019 (COVID-19). However, studies of large, broadly generalizable patient populations are lacking, and the effect of body mass index (BMI) on COVID-19 outcomes- particularly in younger adults-remains uncertain. METHODS We analyzed data from patients hospitalized with COVID-19 at 88 US hospitals enrolled in the American Heart Association's COVID-19 Cardiovascular Disease Registry with data collection through July 22, 2020. BMI was stratified by World Health Organization obesity class, with normal weight prespecified as the reference group. RESULTS Obesity, and, in particular, class III obesity, was overrepresented in the registry in comparison with the US population, with the largest differences among adults ≤50 years. Among 7606 patients, in-hospital death or mechanical ventilation occurred in 2109 (27.7%), in-hospital death in 1302 (17.1%), and mechanical ventilation in 1602 (21.1%). After multivariable adjustment, classes I to III obesity were associated with higher risks of in-hospital death or mechanical ventilation (odds ratio, 1.28 [95% CI, 1.09-1.51], 1.57 [1.29-1.91], 1.80 [1.47-2.20], respectively), and class III obesity was associated with a higher risk of in-hospital death (hazard ratio, 1.26 [95% CI, 1.00-1.58]). Overweight and class I to III obese individuals were at higher risk for mechanical ventilation (odds ratio, 1.28 [95% CI, 1.09-1.51], 1.54 [1.29-1.84], 1.88 [1.52-2.32], and 2.08 [1.68-2.58], respectively). Significant BMI by age interactions were seen for all primary end points (P-interaction<0.05 for each), such that the association of BMI with death or mechanical ventilation was strongest in adults ≤50 years, intermediate in adults 51 to 70 years, and weakest in adults >70 years. Severe obesity (BMI ≥40 kg/m2) was associated with an increased risk of in-hospital death only in those ≤50 years (hazard ratio, 1.36 [1.01-1.84]). In adjusted analyses, higher BMI was associated with dialysis initiation and with venous thromboembolism but not with major adverse cardiac events. CONCLUSIONS Obese patients are more likely to be hospitalized with COVID-19, and are at higher risk of in-hospital death or mechanical ventilation, in particular, if young (age ≤50 years). Obese patients are also at higher risk for venous thromboembolism and dialysis. These observations support clear public health messaging and rigorous adherence to COVID-19 prevention strategies in all obese individuals regardless of age.
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Affiliation(s)
- Nicholas S Hendren
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | - James A de Lemos
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | - Colby Ayers
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
| | - Sandeep R Das
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | - Anjali Rao
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | - Spencer Carter
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | - Anna Rosenblatt
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | | | - Wally Omar
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA (W.O.)
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.K.)
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (R.K.)
| | - Anita A Hegde
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
| | - Mark H Drazner
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
| | - Ian J Neeland
- University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, OH (I.J.N.)
| | - Justin L Grodin
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.S.H., J.A.d.L., C.A., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., M.H.D., J.L.G.)
- Parkland Health and Hospital System, Dallas, TX (N.S.H., J.A.d.L., S.R.D., A. Rao, S.C., A. Rosenblatt, A.A.H., J.L.G.)
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