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Patel BK, Ye F, Liyanage WLNC, Buchanan CC, Gilbert DA, Kolis JW, Sanjeewa LD. Large magnetic anisotropy of a decorated spin-chain system K 2Co 3(MoO 4) 3(OH) 2. Dalton Trans 2024; 53:6592-6600. [PMID: 38375683 DOI: 10.1039/d4dt00203b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
The magnetic structure of K2Co3(MoO4)3(OH)2 is studied in detail. The material has a half-sawtooth one-dimensional (1-D) structure containing two unique Co2+ ions, one in the chain backbone and one on the apex of the sawtooth creating a series of isosceles triangles along the b-axis. These triangles can be a source of magnetic frustration. The ability to grow large single crystals enables detailed magnetic measurements with the crystals oriented in a magnetic field along the respective axes. It has a Curie-Weiss temperature θCW of 5.3(2) K with an effective magnetic moment of 4.8(3)μB/Co. The material is highly anisotropic with a sharp antiferromagnetic ordering transition at 7 K with a metamagnetic transition at 2 kOe. Neutron diffraction was used to determine the magnetic structure and revealed a magnetic structure with canted spins along the backbone of the chain while spins along the sawtooth caps maintained a colinear orientation, arranging antiferromagnetically relative to the backbone spins. The parallel chains arrange antiferromagnetically relative to each other along the c-axis and ferromagnetically along the a-axis.
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Affiliation(s)
- Bhakti K Patel
- Department of Chemistry and Center for Optical Materials Science and Engineering Technologies (COMSET), Clemson University, Clemson, SC 29634-0973, USA
| | - Feng Ye
- Neutron Scattering Division, Oak Ridge National Laboratory, Oak Ridge, TN 37831, USA
| | - W L N C Liyanage
- Department of Physics and Astronomy, University of Tennessee, Knoxville, Tennessee 37996, USA
| | - C Charlotte Buchanan
- Materials Science and Engineering, University of Tennessee, Knoxville, Tennessee 37996, USA
| | - Dustin A Gilbert
- Department of Physics and Astronomy, University of Tennessee, Knoxville, Tennessee 37996, USA
- Materials Science and Engineering, University of Tennessee, Knoxville, Tennessee 37996, USA
| | - Joseph W Kolis
- Department of Chemistry and Center for Optical Materials Science and Engineering Technologies (COMSET), Clemson University, Clemson, SC 29634-0973, USA
| | - Liurukara D Sanjeewa
- University of Missouri Research Reactor (MURR), University of Missouri, Columbia, MO 65211, USA.
- Department of Chemistry, University of Missouri, Columbia, MO 65211, USA
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Szafran JC, Patel BK. Invasive Mechanical Ventilation. Crit Care Clin 2024; 40:255-273. [PMID: 38432695 DOI: 10.1016/j.ccc.2024.01.003] [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] [Indexed: 03/05/2024]
Abstract
Invasive mechanical ventilation allows clinicians to support gas exchange and work of breathing in patients with respiratory failure. However, there is also potential for iatrogenesis. By understanding the benefits and limitations of different modes of ventilation and goals for gas exchange, clinicians can choose a strategy that provides appropriate support while minimizing harm. The ventilator can also provide crucial diagnostic information in the form of respiratory mechanics. These, and the mechanical ventilation strategy, should be regularly reassessed.
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Affiliation(s)
- Jennifer C Szafran
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Zhao JO, Patel BK, Krishack P, Stutz MR, Pearson SD, Lin J, Lecompte-Osorio PA, Dugan KC, Kim S, Gras N, Pohlman A, Kress JP, Hall JB, Sperling AI, Adegunsoye A, Verhoef PA, Wolfe KS. Identification of Clinically Significant Cytokine Signature Clusters in Patients With Septic Shock. Crit Care Med 2023; 51:e253-e263. [PMID: 37678209 PMCID: PMC10840934 DOI: 10.1097/ccm.0000000000006032] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To identify cytokine signature clusters in patients with septic shock. DESIGN Prospective observational cohort study. SETTING Single academic center in the United States. PATIENTS Adult (≥ 18 yr old) patients admitted to the medical ICU with septic shock requiring vasoactive medication support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred fourteen patients with septic shock completed cytokine measurement at time of enrollment (t 1 ) and 24 hours later (t 2 ). Unsupervised random forest analysis of the change in cytokines over time, defined as delta (t 2 -t 1 ), identified three clusters with distinct cytokine profiles. Patients in cluster 1 had the lowest initial levels of circulating cytokines that decreased over time. Patients in cluster 2 and cluster 3 had higher initial levels that decreased over time in cluster 2 and increased in cluster 3. Patients in clusters 2 and 3 had higher mortality compared with cluster 1 (clusters 1-3: 11% vs 31%; odds ratio [OR], 3.56 [1.10-14.23] vs 54% OR, 9.23 [2.89-37.22]). Cluster 3 was independently associated with in-hospital mortality (hazard ratio, 5.24; p = 0.005) in multivariable analysis. There were no significant differences in initial clinical severity scoring or steroid use between the clusters. Analysis of either t 1 or t 2 cytokine measurements alone or in combination did not reveal clusters with clear clinical significance. CONCLUSIONS Longitudinal measurement of cytokine profiles at initiation of vasoactive medications and 24 hours later revealed three distinct cytokine signature clusters that correlated with clinical outcomes.
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Affiliation(s)
- Jack O Zhao
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Bhakti K Patel
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Paulette Krishack
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Matthew R Stutz
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Steven D Pearson
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Julie Lin
- Pulmonary Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | | | | | - Seoyoen Kim
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Nicole Gras
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Anne Pohlman
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - John P Kress
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Jesse B Hall
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Anne I Sperling
- Pulmonary & Critical Care, University of Virginia, Charlottesville, VA
| | - Ayodeji Adegunsoye
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Philip A Verhoef
- Critical Care Medicine, Hawaii Permanente Medical Group, Honolulu, HI
| | - Krysta S Wolfe
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
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Adegunsoye A, Baccile R, Best TJ, Zaksas V, Zhang H, Karnik R, Patel BK, Solomonides AE, Parker WF, Solway J. Pharmacotherapy and pulmonary fibrosis risk after SARS-CoV-2 infection-response to Guangting Zeng and Yuchi Zhou. Lancet Reg Health Am 2023; 26:100611. [PMID: 37829195 PMCID: PMC10565760 DOI: 10.1016/j.lana.2023.100611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Ayodeji Adegunsoye
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, IL, USA
| | - Rachel Baccile
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Thomas J. Best
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Victoria Zaksas
- Center for Translational Data Science, The University of Chicago, Chicago, IL, USA
- Clever Research Lab, Springfield, IL, USA
| | - Hui Zhang
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Rasika Karnik
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Bhakti K. Patel
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Anthony E. Solomonides
- Outcomes Research Network, Research Institute, NorthShore University HealthSystem, Evanston, IL, USA
- The Institute for Translational Medicine, University of Chicago, Chicago, IL, USA
| | - William F. Parker
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Julian Solway
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
- The Institute for Translational Medicine, University of Chicago, Chicago, IL, USA
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5
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Adegunsoye A, Baccile R, Best TJ, Zaksas V, Zhang H, Karnik R, Patel BK, Solomonides AE, Parker WF, Solway J. Pharmacotherapy and pulmonary fibrosis risk after SARS-CoV-2 infection: a prospective nationwide cohort study in the United States. Lancet Reg Health Am 2023; 25:100566. [PMID: 37564420 PMCID: PMC10410516 DOI: 10.1016/j.lana.2023.100566] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023]
Abstract
Background Pulmonary fibrosis is characterized by lung parenchymal destruction and can increase morbidity and mortality. Pulmonary fibrosis commonly occurs following hospitalization for SARS-CoV-2 infection. As there are medications that modify pulmonary fibrosis risk, we investigated whether distinct pharmacotherapies (amiodarone, cancer chemotherapy, corticosteroids, and rituximab) are associated with differences in post-COVID-19 pulmonary fibrosis incidence. Methods We used the National COVID-19 Cohort Collaboration (N3C) Data Enclave, which aggregates and harmonizes COVID-19 data across the United States, to assess pulmonary fibrosis incidence documented at least 60 days after COVID-19 diagnosis among adults hospitalized between January 1st, 2020 and July 6th, 2022 without pre-existing pulmonary fibrosis. We used propensity scores to match pre-COVID-19 drug-exposed and unexposed cohorts (1:1) based on covariates with known influence on pulmonary fibrosis incidence, and estimated the association of drug exposure with risk for post-COVID-19 pulmonary fibrosis. Sensitivity analyses considered pulmonary fibrosis incidence documented at least 30- or 90-days post-hospitalization and pulmonary fibrosis incidence in the COVID-19-negative N3C population. Findings Among 5,923,394 patients with COVID-19, we analyzed 452,951 hospitalized adults, among whom pulmonary fibrosis incidence was 1.1 per 100-person-years. 277,984 hospitalized adults with COVID-19 were included in our primary analysis, among whom all drug exposed cohorts were well-matched to unexposed cohorts (standardized mean differences <0.1). The post-COVID-19 pulmonary fibrosis incidence rate ratio (IRR) was 2.5 (95% CI 1.2-5.1, P = 0.01) for rituximab, 1.6 (95% CI 1.3-2.0, P < 0.0001) for chemotherapy, and 1.2 (95% CI 1.0-1.3, P = 0.02) for corticosteroids. Amiodarone exposure had no significant association with post-COVID-19 pulmonary fibrosis (IRR = 0.8, 95% CI 0.6-1.1, P = 0.24). In sensitivity analyses, pre-COVID-19 corticosteroid use was not consistently associated with post-COVID-19 pulmonary fibrosis. In the COVID-19 negative hospitalized population (n = 1,240,461), pulmonary fibrosis incidence was lower overall (0.6 per 100-person-years) and for patients exposed to all four drugs. Interpretation Recent rituximab or cancer chemotherapy before COVID-19 infection in hospitalized patients is associated with increased risk for post-COVID-19 pulmonary fibrosis. Funding The analyses described in this publication were conducted with data or tools accessed through the NCATS N3C Data Enclave https://covid.cd2h.org and N3C Attribution & Publication Policy v1.2-2020-08-25b supported by NIHK23HL146942, NIHK08HL150291, NIHK23HL148387, NIHUL1TR002389, NCATSU24 TR002306, and a SECURED grant from the Walder Foundation/Center for Healthcare Delivery Science and Innovation, University of Chicago. WFP received a grant from the Greenwall Foundation. This research was possible because of the patients whose information is included within the data and the organizations (https://ncats.nih.gov/n3c/resources/data-contribution/data-transfer-agreement-signatories) and scientists who have contributed to the on-going development of this community resource (https://doi.org/10.1093/jamia/ocaa196).
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Affiliation(s)
- Ayodeji Adegunsoye
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, IL, USA
| | - Rachel Baccile
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Thomas J. Best
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Victoria Zaksas
- Center for Translational Data Science, The University of Chicago, Chicago, IL, USA
- Clever Research Lab, Springfield, IL, USA
| | - Hui Zhang
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Rasika Karnik
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Bhakti K. Patel
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Anthony E. Solomonides
- Outcomes Research Network, Research Institute, NorthShore University HealthSystem, Evanston, IL, USA
- The Institute for Translational Medicine, University of Chicago, Chicago, IL, USA
| | - William F. Parker
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Julian Solway
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
- The Institute for Translational Medicine, University of Chicago, Chicago, IL, USA
| | - N3C Consortium
- Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology & Pharmacogenomics, The University of Chicago, Chicago, IL, USA
- Center for Health and the Social Sciences, The University of Chicago, Chicago, IL, USA
- Center for Translational Data Science, The University of Chicago, Chicago, IL, USA
- Clever Research Lab, Springfield, IL, USA
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Outcomes Research Network, Research Institute, NorthShore University HealthSystem, Evanston, IL, USA
- The Institute for Translational Medicine, University of Chicago, Chicago, IL, USA
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6
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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7
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Arabi YM, Patel BK, Antonelli M. Helmet trials: resolving the puzzle. Intensive Care Med 2023; 49:458-461. [PMID: 36856774 PMCID: PMC9976661 DOI: 10.1007/s00134-023-07004-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/10/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Yaseen M. Arabi
- Intensive Care Department, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Bhakti K. Patel
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL USA
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy ,Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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8
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Abstract
Intubation during Hypoxemic Respiratory FailureThere is little evidence to guide the common and high-stakes decision to initiate invasive ventilation in hypoxemic respiratory failure. In this Tomorrow's Trial, Yarnell and Patel propose a randomized trial of different physiological thresholds for the initiation of invasive ventilation.
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9
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Ajmani GS, Patel BK. To Intubate or Not Intubate, That Is the Question. Am J Respir Crit Care Med 2023; 207:233-235. [PMID: 36170646 PMCID: PMC9896640 DOI: 10.1164/rccm.202209-1823ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Gaurav S. Ajmani
- Section of Pulmonary & Critical CareUniversity of ChicagoChicago, Illinois
| | - Bhakti K. Patel
- Section of Pulmonary & Critical CareUniversity of ChicagoChicago, Illinois
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10
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Buell KG, Patel BK. Helmet noninvasive ventilation in acute hypoxic respiratory failure. Curr Opin Crit Care 2023; 29:8-13. [PMID: 36580369 PMCID: PMC9830589 DOI: 10.1097/mcc.0000000000001008] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Invasive mechanical ventilation is a lifesaving intervention for patients with severe acute hypoxic respiratory failure (AHRF), but it is associated with neuromuscular, cognitive, and infectious complications. Noninvasive ventilation (NIV) may provide sufficient respiratory support without these complications. The helmet interface for NIV could address concerns raised for the use of NIV as first-line therapy in AHRF. This review will summarize and appraise the current evidence for helmet NIV in AHRF. RECENT FINDINGS There are only six randomized controlled trials comparing helmet NIV to standard nasal cannula, facemask NIV, or high-flow nasal oxygen in patients with AHRF. Lower rates of endotracheal intubations and fewer days of mechanical ventilation were reported, with inconsistent findings on patient survival. Facemask NIV may worsen preexisting lung injury, delay intubations, and be inferior at delivering lung protective ventilation strategies compared with mechanical ventilation. The helmet interface could circumvent some of these concerns through the delivery of higher positive end expiratory pressure and more uniform distribution of negative pleural pressure. SUMMARY There is limited evidence to support or refute the use of helmet NIV in AHRF. Further studies investigating the interface of helmet in NIV as a separate clinical entity are needed.
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Affiliation(s)
- Kevin G. Buell
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - Bhakti K. Patel
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
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11
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Patel BK, Wolfe KS, Patel SB, Dugan KC, Esbrook CL, Pawlik AJ, Stulberg M, Kemple C, Teele M, Zeleny E, Hedeker D, Pohlman AS, Arora VM, Hall JB, Kress JP. Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial. Lancet Respir Med 2023:S2213-2600(22)00489-1. [PMID: 36693400 DOI: 10.1016/s2213-2600(22)00489-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Patients who have received mechanical ventilation can have prolonged cognitive impairment for which there is no known treatment. We aimed to establish whether early mobilisation could reduce the rates of cognitive impairment and other aspects of disability 1 year after critical illness. METHODS In this single-centre, parallel, randomised controlled trial, patients admitted to the adult medical-surgical intensive-care unit (ICU), at the University of Chicago (IL, USA), were recruited. Inclusion criteria were adult patients (aged ≥18 years) who were functionally independent and mechanically ventilated at baseline and within the first 96 h of mechanical ventilation, and expected to continue for at least 24 h. Patients were randomly assigned (1:1) via computer-generated permuted balanced block randomisation to early physical and occupational therapy (early mobilisation) or usual care. An investigator designated each assignment in consecutively numbered, sealed, opaque envelopes; they had no further involvement in the trial. Only the assessors were masked to group assignment. The primary outcome was cognitive impairment 1 year after hospital discharge, measured with a Montreal Cognitive Assessment. Patients were assessed for cognitive impairment, neuromuscular weakness, institution-free days, functional independence, and quality of life at hospital discharge and 1 year. Analysis was by intention to treat. This trial was registered with ClinicalTrials.gov, number NCT01777035, and is now completed. FINDINGS Between Aug 11, 2011, and Oct 24, 2019, 1222 patients were screened, 200 were enrolled (usual care n=100, intervention n=100), and one patient withdrew from the study in each group; thus 99 patients in each group were included in the intention-to-treat analysis (113 [57%] men and 85 [43%] women). 65 (88%) of 74 in the usual care group and 62 (89%) of 70 in the intervention group underwent testing for cognitive impairment at 1 year. The rate of cognitive impairment at 1 year with early mobilisation was 24% (24 of 99 patients) compared with 43% (43 of 99) with usual care (absolute difference -19·2%, 95% CI -32·1 to -6·3%; p=0·0043). Cognitive impairment was lower at hospital discharge in the intervention group (53 [54%] 99 patients vs 68 [69%] 99 patients; -15·2%, -28·6 to -1·7; p=0·029). At 1 year, the intervention group had fewer ICU-acquired weaknesses (none [0%] of 99 patients vs 14 [14%] of 99 patients; -14·1%; -21·0 to -7·3; p=0·0001) and higher physical component scores on quality-of-life testing than did the usual care group (median 52·4 [IQR 45·3-56·8] vs median 41·1 [31·8-49·4]; p<0·0001). There was no difference in the rates of functional independence (64 [65%] of 99 patients vs 61 [62%] of 99 patients; 3%, -10·4 to 16·5%; p=0·66) or mental component scores (median 55·9 [50·2-58·9] vs median 55·2 [49·5-59·7]; p=0·98) between the intervention and usual care groups at 1 year. Seven adverse events (haemodynamic changes [n=3], arterial catheter removal [n=1], rectal tube dislodgement [n=1], and respiratory distress [n=2]) were reported in six (6%) of 99 patients in the intervention group and in none of the patients in the usual care group (p=0·029). INTERPRETATION Early mobilisation might be the first known intervention to improve long-term cognitive impairment in ICU survivors after mechanical ventilation. These findings clearly emphasise the importance of avoiding delays in initiating mobilisation. However, the increased adverse events in the intervention group warrants further investigation to replicate these findings. FUNDING None.
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Affiliation(s)
- Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Krysta S Wolfe
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Shruti B Patel
- Loyola University Chicago Stritch School of Medicine, Department of Medicine, Division of Pulmonary/Critical Care, Maywood, IL, USA
| | - Karen C Dugan
- Section of Pulmonary/Critical Care, Northwest Permanente, Hillsboro, OR, USA
| | - Cheryl L Esbrook
- Department of Therapy Services, University of Chicago, Chicago, IL, USA
| | - Amy J Pawlik
- Vitality Women's Physical Therapy and Wellness, Elmhurst, IL, USA
| | - Megan Stulberg
- Department of Therapy Services, University of Chicago, Chicago, IL, USA
| | - Crystal Kemple
- Department of Therapy Services, University of Chicago, Chicago, IL, USA
| | - Megan Teele
- Department of Therapy Services, University of Chicago, Chicago, IL, USA
| | - Erin Zeleny
- Department of Therapy Services, University of Chicago, Chicago, IL, USA
| | - Donald Hedeker
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Anne S Pohlman
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Vineet M Arora
- Section of General Internal Medicine, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Jesse B Hall
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - John P Kress
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA.
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12
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Stutz MR, Dylla NP, Pearson SD, Lecompte-Osorio P, Nayak R, Khalid M, Adler E, Boissiere J, Lin H, Leiter W, Little J, Rose A, Moran D, Mullowney MW, Wolfe KS, Lehmann C, Odenwald M, De La Cruz M, Giurcanu M, Pohlman AS, Hall JB, Chaubard JL, Sundararajan A, Sidebottom A, Kress JP, Pamer EG, Patel BK. Immunomodulatory fecal metabolites are associated with mortality in COVID-19 patients with respiratory failure. Nat Commun 2022; 13:6615. [PMID: 36329015 PMCID: PMC9633022 DOI: 10.1038/s41467-022-34260-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Respiratory failure and mortality from COVID-19 result from virus- and inflammation-induced lung tissue damage. The intestinal microbiome and associated metabolites are implicated in immune responses to respiratory viral infections, however their impact on progression of severe COVID-19 remains unclear. We prospectively enrolled 71 patients with COVID-19 associated critical illness, collected fecal specimens within 3 days of medical intensive care unit admission, defined microbiome compositions by shotgun metagenomic sequencing, and quantified microbiota-derived metabolites (NCT #04552834). Of the 71 patients, 39 survived and 32 died. Mortality was associated with increased representation of Proteobacteria in the fecal microbiota and decreased concentrations of fecal secondary bile acids and desaminotyrosine (DAT). A microbiome metabolic profile (MMP) that accounts for fecal secondary bile acids and desaminotyrosine concentrations was independently associated with progression of respiratory failure leading to mechanical ventilation. Our findings demonstrate that fecal microbiota composition and microbiota-derived metabolite concentrations can predict the trajectory of respiratory function and death in patients with severe SARS-Cov-2 infection and suggest that the gut-lung axis plays an important role in the recovery from COVID-19.
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Affiliation(s)
- Matthew R. Stutz
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Nicholas P. Dylla
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Steven D. Pearson
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Paola Lecompte-Osorio
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Ravi Nayak
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Maryam Khalid
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Emerald Adler
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Jaye Boissiere
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Huaiying Lin
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - William Leiter
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Jessica Little
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Amber Rose
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - David Moran
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Michael W. Mullowney
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Krysta S. Wolfe
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Christopher Lehmann
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Infectious Diseases & Global Health, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Matthew Odenwald
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Mark De La Cruz
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Cardiology, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Mihai Giurcanu
- grid.170205.10000 0004 1936 7822Biological Sciences Division, Biostatistics Laboratory & Research Computing Group, University of Chicago, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Anne S. Pohlman
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Jesse B. Hall
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Jean-Luc Chaubard
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Anitha Sundararajan
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - Ashley Sidebottom
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA
| | - John P. Kress
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Eric G. Pamer
- grid.170205.10000 0004 1936 7822Duchossois Family Institute, University of Chicago, 900 E. 57th St, Chicago, IL 60637 USA ,grid.170205.10000 0004 1936 7822Department of Medicine, Section of Infectious Diseases & Global Health, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
| | - Bhakti K. Patel
- grid.170205.10000 0004 1936 7822Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, 5841 South Maryland Ave, Chicago, IL 60637 USA
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13
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Schweickert WD, Patel BK, Kress JP. Timing of early mobilization to optimize outcomes in mechanically ventilated ICU patients. Intensive Care Med 2022; 48:1305-1307. [PMID: 35925320 PMCID: PMC10139766 DOI: 10.1007/s00134-022-06819-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023]
Affiliation(s)
- William D Schweickert
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
| | - John P Kress
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA.
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14
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Pearson SD, Lin J, Stutz MR, Lecompte-Osorio P, Pohlman AS, Wolfe KS, Hall JB, Kress JP, Patel BK. Immediate Effect of Mechanical Ventilation Mode and Sedative Infusion on Measured Diaphragm Thickness. Ann Am Thorac Soc 2022; 19:1543-1550. [PMID: 35404772 PMCID: PMC9447392 DOI: 10.1513/annalsats.202111-1280oc] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/11/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: In patients who are mechanically ventilated, diaphragm thinning on ultrasound is thought to correlate with diaphragm atrophy and has been associated with prolonged intubation. Factors other than atrophy, however, may cause changes in diaphragm thickness, which may confound studies examining changes in diaphragm thickness over time. Objectives: To determine if changes in the mode of mechanical ventilation or an interruption of sedatives have immediate effects on diaphragm thickness measurements in adult patients in the intensive care unit who are mechanically ventilated. Methods: Adult patients receiving invasive mechanical ventilation for less than 48 hours were included. Diaphragm thickness was measured at end-expiration and peak inspiration using ultrasound while patients were receiving both volume assist-control and pressure-support modes in a randomized crossover fashion. In patients receiving sedatives, additional measurements were taken after an interruption of sedatives. Measurements were compared between modes and on assist-control before and after an interruption of sedatives. Results: Of 85 patients enrolled, 66 had measurements on assist-control and spontaneous modes, and 40 had measurements before and after an interruption of sedatives. End-expiratory diaphragm thickness increased by a median of 0.08 mm after an interruption of sedatives (95% confidence interval [CI], 0.002 mm to 0.164 mm; P = 0.017), corresponding to a median increase of 6.5%. No difference was seen when comparing measurements taken on volume assist-control and pressure support (median difference, 0 mm; 95% CI, -0.07 mm to 0.08 mm; P = 0.98). Conclusions: End-expiratory diaphragm thickness increased by 6.5% after an interruption of sedatives. The effect of sedatives on measured diaphragm thickness should be considered in future studies examining changes in diaphragm thickness over time. Clinical trial registered with Clinicaltrials.gov (NCT04319939).
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Affiliation(s)
- Steven D. Pearson
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Julie Lin
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Matthew R. Stutz
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Anne S. Pohlman
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Krysta S. Wolfe
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jesse B. Hall
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - John P. Kress
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Bhakti K. Patel
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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15
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Goligher EC, Telias I, Sahetya SK, Baedorf-Kassis E, Patel BK, Yehya N, Silversides JA, Ferguson ND, Brochard LJ, Lawler PR, Zarychanski R, Slutsky AS. Physiology Is Vital to Precision Medicine in Acute Respiratory Distress Syndrome and Sepsis. Am J Respir Crit Care Med 2022; 206:14-16. [PMID: 35442864 PMCID: PMC9954327 DOI: 10.1164/rccm.202202-0230ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ewan C. Goligher
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Department of Medicine University Health NetworkToronto, Ontario, Canada,Toronto General Hospital Research InstituteToronto, Ontario, Canada
| | - Irene Telias
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Department of Medicine University Health NetworkToronto, Ontario, Canada,Li Ka Shing Knowledge Institute Unity HealthToronto, Ontario, Canada
| | | | - Elias Baedorf-Kassis
- Division of Pulmonary and Critical CareHarvard Medical SchoolBoston, Massachusetts
| | - Bhakti K. Patel
- Department of MedicineUniversity of ChicagoChicago, Illinois
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care MedicineChildren’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Jonathan A Silversides
- Wellcome-Wolfson Institute for Experimental MedicineQueen’s University BelfastBelfast, United Kingdom,Department of Critical CareBelfast Health and Social Care TrustBelfast, United Kingdom
| | - Niall D. Ferguson
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Department of Medicine University Health NetworkToronto, Ontario, Canada,Toronto General Hospital Research InstituteToronto, Ontario, Canada
| | - Laurent J. Brochard
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Li Ka Shing Knowledge Institute Unity HealthToronto, Ontario, Canada
| | - Patrick R. Lawler
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Toronto General Hospital Research InstituteToronto, Ontario, Canada,Peter Munk Cardiac CentreUniversity Health NetworkToronto, Ontario, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and HematologyCancerCare ManitobaWinnipeg, Manitoba, Canada
| | - Arthur S. Slutsky
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Li Ka Shing Knowledge Institute Unity HealthToronto, Ontario, Canada
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16
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Pearson SD, Koyner JL, Patel BK. Management of Respiratory Failure: Ventilator Management 101 and Noninvasive Ventilation. Clin J Am Soc Nephrol 2022; 17:572-580. [PMID: 35273008 PMCID: PMC8993478 DOI: 10.2215/cjn.13091021] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mechanical ventilation is a lifesaving therapy for critically ill patients with respiratory failure, but like all treatments, it has the potential to cause harm if not administered appropriately. This review aims to give an overview of the basic principles of invasive and noninvasive mechanical ventilation. Topics covered include modes of mechanical ventilation, respiratory mechanics and ventilator waveform interpretation, strategies for initial ventilator settings, indications and contraindications for noninvasive ventilation, and the effect of the ventilator on kidney function.
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Affiliation(s)
- Steven D Pearson
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Jay L Koyner
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, Illinois
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
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17
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Stutz MR, Leonhard AG, Ward CM, Pearson SD, Osorio PL, Herbst PR, Wolfe KS, Pohlman AS, Hall JB, Kress JP, Patel BK. Early Rehabilitation Feasibility in a COVID-19 ICU. Chest 2021; 160:2146-2148. [PMID: 34116067 PMCID: PMC8185320 DOI: 10.1016/j.chest.2021.05.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/15/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Matthew R Stutz
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Aristotle G Leonhard
- Department of Medicine, Internal Medicine Residency Program, University of Chicago, Chicago, IL
| | - Colleen M Ward
- Department of Physical Therapy, University of Chicago, Chicago, IL
| | - Steven D Pearson
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Paola Lecompte Osorio
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Peter R Herbst
- Department of Physical Therapy, University of Chicago, Chicago, IL
| | - Krysta S Wolfe
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Anne S Pohlman
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Jesse B Hall
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - John P Kress
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
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18
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Lecompte-Osorio P, Pearson SD, Pieroni CH, Stutz MR, Pohlman AS, Lin J, Hall JB, Htwe YM, Belvitch PG, Dudek SM, Wolfe K, Patel BK, Kress JP. Bedside estimates of dead space using end-tidal CO 2 are independently associated with mortality in ARDS. Crit Care 2021; 25:333. [PMID: 34526077 PMCID: PMC8442447 DOI: 10.1186/s13054-021-03751-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023]
Abstract
Purpose In acute respiratory distress syndrome (ARDS), dead space fraction has been independently associated with mortality. We hypothesized that early measurement of the difference between arterial and end-tidal CO2 (arterial-ET difference), a surrogate for dead space fraction, would predict mortality in mechanically ventilated patients with ARDS. Methods We performed two separate exploratory analyses. We first used publicly available databases from the ALTA, EDEN, and OMEGA ARDS Network trials (N = 124) as a derivation cohort to test our hypothesis. We then performed a separate retrospective analysis of patients with ARDS using University of Chicago patients (N = 302) as a validation cohort. Results The ARDS Network derivation cohort demonstrated arterial-ET difference, vasopressor requirement, age, and APACHE III to be associated with mortality by univariable analysis. By multivariable analysis, only the arterial-ET difference remained significant (P = 0.047). In a separate analysis, the modified Enghoff equation ((PaCO2–PETCO2)/PaCO2) was used in place of the arterial-ET difference and did not alter the results. The University of Chicago cohort found arterial-ET difference, age, ventilator mode, vasopressor requirement, and APACHE II to be associated with mortality in a univariate analysis. By multivariable analysis, the arterial-ET difference continued to be predictive of mortality (P = 0.031). In the validation cohort, substitution of the arterial-ET difference for the modified Enghoff equation showed similar results. Conclusion Arterial to end-tidal CO2 (ETCO2) difference is an independent predictor of mortality in patients with ARDS.
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Affiliation(s)
- Paola Lecompte-Osorio
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | - Steven D Pearson
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | | | - Matthew R Stutz
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | - Anne S Pohlman
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | - Julie Lin
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jesse B Hall
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | - Yu M Htwe
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois Chicago, Chicago, USA
| | - Patrick G Belvitch
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois Chicago, Chicago, USA
| | - Steven M Dudek
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois Chicago, Chicago, USA
| | - Krysta Wolfe
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | - Bhakti K Patel
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA
| | - John P Kress
- Section of Pulmonology and Critical Care, University of Chicago, 5841 South Maryland Ave. MC 6026, Chicago, IL, 60637, USA.
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19
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Jarou ZJ, Beiser DG, Sharp WW, Chacko R, Goode D, Rubin DS, Kurian D, Dalton A, Estime SR, O’Connor M, Patel BK, Kress JP, Spiegel TF. Emergency Department-initiated High-flow Nasal Cannula for COVID-19 Respiratory Distress. West J Emerg Med 2021; 22:979-987. [PMID: 35354003 PMCID: PMC8328178 DOI: 10.5811/westjem.2021.3.50116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 04/07/2021] [Accepted: 03/30/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Patients with coronavirus disease 2019 (COVID-19) can develop rapidly progressive respiratory failure. Ventilation strategies during the COVID-19 pandemic seek to minimize patient mortality. In this study we examine associations between the availability of emergency department (ED)-initiated high-flow nasal cannula (HFNC) for patients presenting with COVID-19 respiratory distress and outcomes, including rates of endotracheal intubation (ETT), mortality, and hospital length of stay. METHODS We performed a retrospective, non-concurrent cohort study of patients with COVID-19 respiratory distress presenting to the ED who required HFNC or ETT in the ED or within 24 hours following ED departure. Comparisons were made between patients presenting before and after the introduction of an ED-HFNC protocol. RESULTS Use of HFNC was associated with a reduced rate of ETT in the ED (46.4% vs 26.3%, P <0.001) and decreased the cumulative proportion of patients who required ETT within 24 hours of ED departure (85.7% vs 32.6%, P <0.001) or during their entire hospitalization (89.3% vs 48.4%, P <0.001). Using HFNC was also associated with a trend toward increased survival to hospital discharge; however, this was not statistically significant (50.0% vs 68.4%, P = 0.115). There was no impact on intensive care unit or hospital length of stay. Demographics, comorbidities, and illness severity were similar in both cohorts. CONCLUSIONS The institution of an ED-HFNC protocol for patients with COVID-19 respiratory distress was associated with reductions in the rate of ETT. Early initiation of HFNC is a promising strategy for avoiding ETT and improving outcomes in patients with COVID-19.
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Affiliation(s)
- Zachary J. Jarou
- University of Chicago, Section of Emergency Medicine, Department of Medicine, Chicago, Illinois
| | - David G. Beiser
- University of Chicago, Section of Emergency Medicine, Department of Medicine, Chicago, Illinois
| | - Willard W. Sharp
- University of Chicago, Section of Emergency Medicine, Department of Medicine, Chicago, Illinois
| | - Ravi Chacko
- University of Chicago, Section of Emergency Medicine, Department of Medicine, Chicago, Illinois
| | - Deirdre Goode
- University of Chicago, Section of Emergency Medicine, Department of Medicine, Chicago, Illinois
| | - Daniel S. Rubin
- University of Chicago, Department of Anesthesia and Critical Care, Chicago, Illinois
| | - Dinesh Kurian
- University of Chicago, Department of Anesthesia and Critical Care, Chicago, Illinois
| | - Allison Dalton
- University of Chicago, Department of Anesthesia and Critical Care, Chicago, Illinois
| | - Stephen R. Estime
- University of Chicago, Department of Anesthesia and Critical Care, Chicago, Illinois
| | - Michael O’Connor
- University of Chicago, Department of Anesthesia and Critical Care, Chicago, Illinois
| | - Bhakti K. Patel
- University of Chicago, Section of Pulmonary and Critical Care Medicine, Department of Medicine, Chicago, Illinois
| | - John P. Kress
- University of Chicago, Section of Pulmonary and Critical Care Medicine, Department of Medicine, Chicago, Illinois
| | - Thomas F. Spiegel
- University of Chicago, Section of Emergency Medicine, Department of Medicine, Chicago, Illinois
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20
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Grieco DL, Maggiore SM, Roca O, Spinelli E, Patel BK, Thille AW, Barbas CSV, de Acilu MG, Cutuli SL, Bongiovanni F, Amato M, Frat JP, Mauri T, Kress JP, Mancebo J, Antonelli M. Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensive Care Med 2021; 47:851-866. [PMID: 34232336 PMCID: PMC8261815 DOI: 10.1007/s00134-021-06459-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/09/2021] [Indexed: 12/21/2022]
Abstract
The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO2 > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO2 ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy.
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy.,University Department of Innovative Technologies in Medicine and Dentistry, Gabriele D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Arnaud W Thille
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Carmen Sílvia V Barbas
- Division of Pulmonary and Critical Care, University of São Paulo, São Paulo, Brazil.,Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Marina Garcia de Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - John P Kress
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
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21
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Bhavani SV, Wolfe KS, Hrusch CL, Greenberg JA, Krishack PA, Lin J, Lecompte-Osorio P, Carey KA, Kress JP, Coopersmith CM, Sperling AI, Verhoef PA, Churpek MM, Patel BK. Temperature Trajectory Subphenotypes Correlate With Immune Responses in Patients With Sepsis. Crit Care Med 2021; 48:1645-1653. [PMID: 32947475 DOI: 10.1097/ccm.0000000000004610] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We recently found that distinct body temperature trajectories of infected patients correlated with survival. Understanding the relationship between the temperature trajectories and the host immune response to infection could allow us to immunophenotype patients at the bedside using temperature. The objective was to identify whether temperature trajectories have consistent associations with specific cytokine responses in two distinct cohorts of infected patients. DESIGN Prospective observational study. SETTING Large academic medical center between 2013 and 2019. SUBJECTS Two cohorts of infected patients: 1) patients in the ICU with septic shock and 2) hospitalized patients with Staphylococcus aureus bacteremia. INTERVENTIONS Clinical data (including body temperature) and plasma cytokine concentrations were measured. Patients were classified into four temperature trajectory subphenotypes using their temperature measurements in the first 72 hours from the onset of infection. Log-transformed cytokine levels were standardized to the mean and compared with the subphenotypes in both cohorts. MEASUREMENTS AND MAIN RESULTS The cohorts consisted of 120 patients with septic shock (cohort 1) and 88 patients with S. aureus bacteremia (cohort 2). Patients from both cohorts were classified into one of four previously validated temperature subphenotypes: "hyperthermic, slow resolvers" (n = 19 cohort 1; n = 13 cohort 2), "hyperthermic, fast resolvers" (n = 18 C1; n = 24 C2), "normothermic" (n = 54 C1; n = 31 C2), and "hypothermic" (n = 29 C1; n = 20 C2). Both "hyperthermic, slow resolvers" and "hyperthermic, fast resolvers" had high levels of G-CSF, CCL2, and interleukin-10 compared with the "hypothermic" group when controlling for cohort and timing of cytokine measurement (p < 0.05). In contrast to the "hyperthermic, slow resolvers," the "hyperthermic, fast resolvers" showed significant decreases in the levels of several cytokines over a 24-hour period, including interleukin-1RA, interleukin-6, interleukin-8, G-CSF, and M-CSF (p < 0.001). CONCLUSIONS Temperature trajectory subphenotypes are associated with consistent cytokine profiles in two distinct cohorts of infected patients. These subphenotypes could play a role in the bedside identification of cytokine profiles in patients with sepsis.
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Affiliation(s)
| | - Krysta S Wolfe
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Cara L Hrusch
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | | | | | - Julie Lin
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | | | - Kyle A Carey
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - John P Kress
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | | | - Anne I Sperling
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | | | - Matthew M Churpek
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Bhakti K Patel
- Department of Medicine, University of Chicago Medical Center, Chicago, IL
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22
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Strohbehn GW, Heiss BL, Rouhani SJ, Trujillo JA, Yu J, Kacew AJ, Higgs EF, Bloodworth JC, Cabanov A, Wright RC, Koziol AK, Weiss A, Danahey K, Karrison TG, Edens CC, Bauer Ventura I, Pettit NN, Patel BK, Pisano J, Strek ME, Gajewski TF, Ratain MJ, Reid PD. COVIDOSE: A Phase II Clinical Trial of Low-Dose Tocilizumab in the Treatment of Noncritical COVID-19 Pneumonia. Clin Pharmacol Ther 2021; 109:688-696. [PMID: 33210302 PMCID: PMC7753375 DOI: 10.1002/cpt.2117] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/03/2020] [Indexed: 12/22/2022]
Abstract
Interleukin-6 (IL-6)-mediated hyperinflammation may contribute to the mortality of coronavirus disease 2019 (COVID-19). The IL-6 receptor-blocking monoclonal antibody tocilizumab has been repurposed for COVID-19, but prospective trials and dose-finding studies in COVID-19 have not yet fully reported. We conducted a single-arm phase II trial of low-dose tocilizumab in nonintubated hospitalized adult patients with COVID-19, radiographic pulmonary infiltrate, fever, and C-reactive protein (CRP) ≥ 40 mg/L. We hypothesized that doses significantly lower than the emerging standards of 400 mg or 8 mg/kg would resolve clinical and laboratory indicators of hyperinflammation. A dose range from 40 to 200 mg was evaluated, with allowance for one repeat dose at 24 to 48 hours. The primary objective was to assess the relationship of dose to fever resolution and CRP response. Thirty-two patients received low-dose tocilizumab, with the majority experiencing fever resolution (75%) and CRP decline consistent with IL-6 pathway abrogation (86%) in the 24-48 hours following drug administration. There was no evidence of a relationship between dose and fever resolution or CRP decline over the dose range of 40-200 mg. Within the 28-day follow-up, 5 (16%) patients died. For patients who recovered, median time to clinical recovery was 3 days (interquartile range, 2-5). Clinically presumed and/or cultured bacterial superinfections were reported in 5 (16%) patients. Low-dose tocilizumab was associated with rapid improvement in clinical and laboratory measures of hyperinflammation in hospitalized patients with COVID-19. Results of this trial provide rationale for a randomized, controlled trial of low-dose tocilizumab in COVID-19.
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MESH Headings
- Aged
- Anti-Inflammatory Agents/administration & dosage
- Anti-Inflammatory Agents/adverse effects
- Anti-Inflammatory Agents/pharmacology
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- C-Reactive Protein/analysis
- COVID-19/blood
- COVID-19/physiopathology
- Dose-Response Relationship, Drug
- Drug Monitoring/methods
- Female
- Fever/diagnosis
- Fever/drug therapy
- Humans
- Male
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/drug therapy
- Pneumonia, Viral/etiology
- Receptors, Interleukin-6/antagonists & inhibitors
- SARS-CoV-2/isolation & purification
- Severity of Illness Index
- Time Factors
- Treatment Outcome
- COVID-19 Drug Treatment
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Affiliation(s)
- Garth W. Strohbehn
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Brian L. Heiss
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Sherin J. Rouhani
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Jonathan A. Trujillo
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Jovian Yu
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Alec J. Kacew
- Pritzker School of MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Emily F. Higgs
- Committee on ImmunologyThe University of ChicagoChicagoIllinoisUSA
| | - Jeffrey C. Bloodworth
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | | | - Rachel C. Wright
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Adriana K. Koziol
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Alexandra Weiss
- Department of MedicineSection of Pulmonary and Critical Care MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Keith Danahey
- Center for Personalized TherapeuticsThe University of ChicagoChicagoIllinoisUSA
- Center for Research InformaticsThe University of ChicagoChicagoIllinoisUSA
| | | | - Cuoghi C. Edens
- Department of MedicineSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
- Department of PediatricsSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
| | - Iazsmin Bauer Ventura
- Department of MedicineSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
| | | | - Bhakti K. Patel
- Department of MedicineSection of Pulmonary and Critical Care MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Jennifer Pisano
- Department of MedicineSection of Infectious Diseases and Global HealthThe University of ChicagoChicagoIllinoisUSA
| | - Mary E. Strek
- Department of MedicineSection of Pulmonary and Critical Care MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Thomas F. Gajewski
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Mark J. Ratain
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
- Center for Personalized TherapeuticsThe University of ChicagoChicagoIllinoisUSA
| | - Pankti D. Reid
- Department of MedicineSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
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23
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Affiliation(s)
| | - Bhakti K Patel
- University of Chicago, Chicago, Illinois (S.D.P., B.K.P.)
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24
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Affiliation(s)
- Steven D Pearson
- Section of Pulmonary & Critical Care, University of Chicago, Chicago, Illinois
| | - Bhakti K Patel
- Section of Pulmonary & Critical Care, University of Chicago, Chicago, Illinois
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25
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Goligher EC, Dres M, Patel BK, Sahetya SK, Beitler JR, Telias I, Yoshida T, Vaporidi K, Grieco DL, Schepens T, Grasselli G, Spadaro S, Dianti J, Amato M, Bellani G, Demoule A, Fan E, Ferguson ND, Georgopoulos D, Guérin C, Khemani RG, Laghi F, Mercat A, Mojoli F, Ottenheijm CAC, Jaber S, Heunks L, Mancebo J, Mauri T, Pesenti A, Brochard L. Lung- and Diaphragm-Protective Ventilation. Am J Respir Crit Care Med 2020; 202:950-961. [PMID: 32516052 DOI: 10.1164/rccm.202003-0655cp] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Martin Dres
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, ICU, St. Anne's Archbishop Hospital, University of Ferrara, Ferrara, Italy
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Intensive Care Unit, Department of Medicine, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Amato
- Laboratório de Pneumologia, Laboratório de Investicação Médica 9, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alexandre Demoule
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hopital Edouard Herriot Lyon, Faculté de Médecine Lyon-Est, Université de Lyon, Institut National de la Santé et de la Recherche Médicale 955 Créteil, Lyon, France
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Stritch School of Medicine, Loyola University, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier d'Angers, Angers, France
| | - Francesco Mojoli
- Department of Anesthesia and Intensive Care, Scientific Hospitalization and Care Institute, San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | | | - Samir Jaber
- Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, Montpellier University Hospital Center, University of Montpellier, Joint Research Unit 9214, National Institute of Health and Medical Research U1046, National Scientific Research Center, Montpellier, France; and
| | - Leo Heunks
- Department of Intensive Care, Vrije University Location, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jordi Mancebo
- Servei de Medicina Intensiva Hospital de Sant Pau, Barcelona, Spain
| | - Tommaso Mauri
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Antonio Pesenti
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Goligher EC, Jonkman AH, Dianti J, Vaporidi K, Beitler JR, Patel BK, Yoshida T, Jaber S, Dres M, Mauri T, Bellani G, Demoule A, Brochard L, Heunks L. Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 2020; 46:2314-2326. [PMID: 33140181 PMCID: PMC7605467 DOI: 10.1007/s00134-020-06288-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Annemijn H Jonkman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Samir Jaber
- Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, PhyMedExp, Université de Montpellier, Montpellier, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Tommaso Mauri
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Leo Heunks
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
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Affiliation(s)
- Bhakti K Patel
- Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - John P Kress
- Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jesse B Hall
- Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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28
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Affiliation(s)
- Jason T Poston
- Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Bhakti K Patel
- Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Andrew M Davis
- General Internal Medicine, University of Chicago, Chicago, Illinois
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Mokhlesi B, Masa JF, Brozek JL, Gurubhagavatula I, Murphy PB, Piper AJ, Tulaimat A, Afshar M, Balachandran JS, Dweik RA, Grunstein RR, Hart N, Kaw R, Lorenzi-Filho G, Pamidi S, Patel BK, Patil SP, Pépin JL, Soghier I, Tamae Kakazu M, Teodorescu M. Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 200:e6-e24. [PMID: 31368798 PMCID: PMC6680300 DOI: 10.1164/rccm.201905-1071st] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). Methods: A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. Recommendations: After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: 1) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, 2) stable ambulatory patients with OHS receive positive airway pressure (PAP), 3) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, 4) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2–3 mo), and 5) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Conclusions: Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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Abstract
Mechanical ventilation practices in patients with acute respiratory distress syndrome (ARDS) have progressed with a growing understanding of the disease pathophysiology. Paramount to the care of affected patients is the delivery of lung-protective mechanical ventilation which prioritizes tidal volume and plateau pressure limitation. Lung protection can probably be further enhanced by scaling target tidal volumes to the specific respiratory mechanics of individual patients. The best procedure for selecting optimal positive end-expiratory pressure (PEEP) in ARDS remains uncertain; several relevant issues must be considered when selecting PEEP, particularly lung recruitability. Noninvasive ventilation must be used with caution in ARDS as excessively high respiratory drive can further exacerbate lung injury; newer modes of delivery offer promising approaches in hypoxemic respiratory failure. Airway pressure release ventilation offers an alternative approach to maximize lung recruitment and oxygenation, but clinical trials have not demonstrated a survival benefit of this mode over conventional ventilation strategies. Rescue therapy with high-frequency oscillatory ventilation is an important option in refractory hypoxemia. Despite a disappointing lack of benefit (and possible harm) in patients with moderate or severe ARDS, possibly due to lung hyperdistention and right ventricular dysfunction, high-frequency oscillation may improve outcome in patients with very severe hypoxemia.
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Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, New York
| | - Thomas Piraino
- Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,Department of Respiratory Therapy, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
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31
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Affiliation(s)
- Karen C Dugan
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jesse B Hall
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
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Wolfe KS, Patel BK, MacKenzie EL, Giovanni SP, Pohlman AS, Churpek MM, Hall JB, Kress JP. Impact of Vasoactive Medications on ICU-Acquired Weakness in Mechanically Ventilated Patients. Chest 2018; 154:781-787. [PMID: 30217640 DOI: 10.1016/j.chest.2018.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/01/2018] [Accepted: 07/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vasoactive medications are commonly used in the treatment of critically ill patients, but their impact on the development of ICU-acquired weakness is not well described. The objective of this study is to evaluate the relationship between vasoactive medication use and the outcome of ICU-acquired weakness. METHODS This is a secondary analysis of mechanically ventilated patients (N = 172) enrolled in a randomized clinical trial of early occupational and physical therapy vs conventional therapy, which evaluated the end point of ICU-acquired weakness on hospital discharge. Patients underwent bedside muscle strength testing by a therapist blinded to study allocation to evaluate for ICU-acquired weakness. The effects of vasoactive medication use on the incidence of ICU-acquired weakness in this population were assessed. RESULTS On logistic regression analysis, the use of vasoactive medications increased the odds of developing ICU-acquired weakness (odds ratio [OR], 3.2; P = .01) independent of all other established risk factors for weakness. Duration of vasoactive medication use (in days) (OR, 1.35; P = .004) and cumulative norepinephrine dose (μg/kg/d) (OR, 1.01; P = .02) (but not vasopressin or phenylephrine) were also independently associated with the outcome of ICU-acquired weakness. CONCLUSIONS In mechanically ventilated patients enrolled in a randomized clinical trial of early mobilization, the use of vasoactive medications was independently associated with the development of ICU-acquired weakness. Prospective trials to further evaluate this relationship are merited. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01777035; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Krysta S Wolfe
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL.
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | | | - Shewit P Giovanni
- Section of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA
| | - Anne S Pohlman
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - Matthew M Churpek
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - Jesse B Hall
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - John P Kress
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
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Patel JG, Patel BJ, Patel SS, Raval SH, Parmar RS, Joshi DV, Chauhan HC, Chandel BS, Patel BK. Metagenomic of clinically diseased and healthy broiler affected with respiratory disease complex. Data Brief 2018; 19:82-85. [PMID: 29892620 PMCID: PMC5993000 DOI: 10.1016/j.dib.2018.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/03/2018] [Indexed: 10/25/2022] Open
Abstract
In recent past, the respiratory infection has emerged as a great challenge to the poultry farmers. Various pathogens including Avian pneumovirus (APV), Avian influenza virus (AIV), Infectious bronchitis virus (IBV) and Newcastle disease virus (NDV), Avibacterium paragallinarum, Ornithobacterium rhinotracheale (ORT), Mycoplasma synoviae (MS), Mycoplasma gallisepticum (MG) and Avian pathogenic Escherichia coli (APEC) are involved in the respiratory disease complex in birds [1], [2] (Bradbury, 1984; Roussan et al., 2008). Hence, respiratory disease complex is the most serious disease affecting to poultry and causes heavy economic losses in the poultry industry worldwide [3] (Murthy et al., 2008). In recent years, metagenomics is powerful analyzing tool for detection of pathogens directly from clinical samples without any prior knowledge of the organism in a given sample [4], [5] (Schuster, 2008; Pereira et al., 2010). High throughput Next-Generation-Sequencing technology was used for sequencing the isolated genomic DNA. These data provides an insight about taxonomic and functional status of microorganisms responsible for causing respiratory infection in broiler. The data of these metagenome are available in the BioSample Submission Portal as Bioproject PRJNA339659 and SRA accession number SRR5997823, SRR5992854, SRR6037376, SRR6024702, SRR6012248 and SRR6008913.
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Affiliation(s)
- J G Patel
- Department of Veterinary Pathology, College of Veterinary Science and Anima Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - B J Patel
- Department of Veterinary Pathology, College of Veterinary Science and Anima Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - S S Patel
- Department of Veterinary Microbiology, College of Veterinary Science and Animal, Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - S H Raval
- Department of Veterinary Pathology, College of Veterinary Science and Anima Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - R S Parmar
- Department of Veterinary Pathology, College of Veterinary Science and Anima Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - D V Joshi
- Department of Veterinary Pathology, College of Veterinary Science and Anima Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - H C Chauhan
- Department of Veterinary Microbiology, College of Veterinary Science and Animal, Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - B S Chandel
- Department of Animal Biotechnology, College of Veterinary Science and Animal, Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
| | - B K Patel
- Department of Animal Biotechnology, College of Veterinary Science and Animal, Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar, Gujarat, India
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Hilal T, Covington M, Pockaj B, Northfelt D, Wu T, Zwart C, Li J, Patel BK. Abstract P4-02-03: Pre-neoadjuavnt therapy MRI phenotype can predict response to neoadjuvant endocrine therapy. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p4-02-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
OBJECTIVE: Neoadjuvant endocrine therapy (NET) is increasingly used for the treatment of low and intermediate grade, hormone receptor positive, HER2 negative breast cancer. Several MRI phenotypes that may predict response to neoadjuvant chemotherapy (NAC) have been identified, but little data exists for phenotypes associated with response to NET. This study analyzed imaging phenotypes for all patients treated with NET with the aim to identify specific features that can be predictive of response to therapy.
MATERIALS AND METHODS: The study was retrospective and included 21 patients with clinical stage I, II, and III breast cancer. The tumors were grade 1 or 2, estrogen receptor (ER) positive in >20% of cells, and HER2 non-amplified. MRI examinations were performed in all women before NET. MRI interpretation included mass shape, non-mass enhancement (NME) pattern, background parenchymal enhancement, and MRI phenotype (I well-defined unicentric mass; II well defined multilobulated mass; III area enhancement with nodularity; IV area enhancement without nodularity; V septal spreading). Type of neoadjuvant endocrine therapy included: tamoxifien alone, an aromatase inhibitor (AI) alone, AI + ovarian suppression, and AI + a non-chemotherapeutic agent. Patients received NET for a total duration ranging between 3 - 6 months, with one patient receiving therapy for 18 months. Clinically meaningful response was defined as stable or decreased tumor size by clinical exam and confirmed at resection by comparing final pathologic T stage with clinical T stage.
RESULTS: Twenty-one patients were identified. Median age was 62 (range 36-84) years. Most were post-menopausal 17 (81%). Pre-neoadjuvant meadian tumor size on MRI was 3.9 (range 1.0-7.5) cm and comprised T1 3 (14.3%), T2 8 (38.1%), T3/4 10 (47.6%). Pre-treatment N stage was N0 14 (66.7%), N1 7 (33.3%) and pre-NET stage was I in 3 (14.3%), II in 8 (38.1%), and III in 10 (47.6%) patients. The majority 17 (81%) had some tumor reduction, and 4 (19%) had no response. No one achieved a complete response. Of the 17 responders, 7 (41%) had a good response defined as >25% decrease in tumor size. Median tumor size after NET was 3.1 (range 0.6-11) cm and the distribution of T stage was T1 7 (33.3%), T2 9 (42.9%), and T3/4 5 (23.8%). Eleven of 12 (92%) patients with well-defined phenotypes had a response as compared to 6 of 9 (67%) patients with non-well defined phenotypes. Phenotype was not predictive of a good response to therapy, 4 were in the well-defined phenotype and 3 were in the non-well defined phenotype groups. All 4 non-responders had moderate or marked background enhancement as compared to 5 of 17 responders (p = 0.02).
CONCLUSION: A well-defined pre treatment MRI phenotype was significantly predictive of a positive response to NET, while a non well-defined MRI phenotype and higher degree of background enhancement was significantly predictive of negative response to NET. This warrants further prospective evaluation, especially in association with Ki-67 levels. If validated, pre treatment MRI phenotype can be applied in the clinical decision to either initiate NET or referral for upfront surgical resection.
Citation Format: Hilal T, Covington M, Pockaj B, Northfelt D, Wu T, Zwart C, Li J, Patel BK. Pre-neoadjuavnt therapy MRI phenotype can predict response to neoadjuvant endocrine therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-02-03.
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Hilal T, Covington M, Sugi M, Zhang N, Pockaj B, Northfelt D, Ocal IT, Patel BK. Abstract PD2-11: Contrast-enhanced spectral mammography is comparable to MRI in the assessment of residual breast cancer following neoadjuvant systemic therapy. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-pd2-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
OBJECTIVE: Currently, no study has assessed the performance of contrast-enhanced spectral mammography (CESM) in evaluating tumor response in breast cancer patients undergoing neoadjuvant systemic therapy (NST). This study aims to evaluate whether the accuracy of CESM is comparable to MRI in detection of residual breast cancer following NST.
MATERIALS AND METHODS: Retrospective review of CESM cases at our institution between September 2014 and June 2016 identified patients who had both CESM and MRI pre- and post-NST with pathologic assessment after surgical management. Size of residual malignancy (if any) on post-neoadjuvant CESM and MRI was compared to surgical pathology (reference standard). Pathologic complete response (pCR) was documented and compared to Residual Cancer Burden (RCB) score for confirmation. Bland-Altman plots were used to visualize the differences between CESM/MRI and pathologic tumor size.
RESULTS: Forty female patients met inclusion criteria. Mean age was 52.3 years (range 35-73). Type of NST included: 34 (85%) chemotherapy and 6 (15%) endocrine therapy. Histological analysis showed invasive ductal carcinoma in 38 (95%), the remaining cases consisted of one invasive lobular carcinoma, and one mixed invasive carcinoma. Mean tumor size after NST was 10.3 mm (range 0-75 mm) for CESM and 9.7 mm (range 0-60 mm) for MRI compared to 15.7 mm (range 0-100 mm) on final surgical pathology. Equivalence tests demonstrated that the mean tumor size measured by CESM or by MRI is equivalent to the mean tumor size measured by pathology within -1 and 1 cm range (p=0.0132 for CESM and p=0.0194 for MRI).
Difference in Measurement Post-NST Compared to Pathology Path Tumor Size (mm)CESM Tumor Size (mm)MRI Tumor Size (mm)Mean (SD)15.7 (24.5)10.3 (18.9)9.7 (16.3)Difference Compared with Path (SD); P value -5.4 (12.6); 0.0132-6.0 (11.7); 0.0194
A complete radiologic response was seen in 25 CESM and 22 MRI cases which was confirmed by pathology in 17 and 14, respectively. Alternatively, CESM and MRI demonstrated residual disease in 15 patients and 18 patients respectively and this was confirmed on pathology in 15 and 15, respectively.
Accuracy of CESM vs. MRIModalityResidual Disease by Pathology (N=23)Complete Response by Pathology (N=17)SensitivitySpecificityPPVNPVResidual Disease by CESM (N=15)150Complete Response by CESM (N=25)81765.2%100%100%68%Residual Disease by MRI (N=18)153Complete Response by MRI (N=22)81465.2%82.4%83.3%63.6%
All patients who achieved a pCR had an RCB score of 0 indicating no residual cancer in lymph nodes. Among patients with residual disease, their mean RCB score was 2.6 (range 0.8-4.18).
CONCLUSION: In this study, CESM was comparable to MRI in assessing residual malignancy after completion of NST, thereby offering a potentially faster and less expensive alternative to MRI for monitoring treatment response in the neoadjuvant setting.
Citation Format: Hilal T, Covington M, Sugi M, Zhang N, Pockaj B, Northfelt D, Ocal IT, Patel BK. Contrast-enhanced spectral mammography is comparable to MRI in the assessment of residual breast cancer following neoadjuvant systemic therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-11.
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Patel BK, Wolfe KS, Hall JB, Kress JP. A Word of Caution Regarding Patient Self-inflicted Lung Injury and Prophylactic Intubation. Am J Respir Crit Care Med 2017; 196:936. [PMID: 28460177 DOI: 10.1164/rccm.201702-0410le] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Daly B, Hantel A, Wroblewski K, Balachandran JS, Chow S, DeBoer R, Fleming GF, Hahn OM, Kline J, Liu H, Patel BK, Verma A, Witt LJ, Fukui M, Kumar A, Howell MD, Polite BN. No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations. J Oncol Pract 2017; 12:e901-e911. [PMID: 27601514 DOI: 10.1200/jop.2016.012823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. METHODS This was a retrospective case series of patients cared for in an academic medical center's ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient's electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. RESULTS Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). CONCLUSION Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.
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Affiliation(s)
- Bobby Daly
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Andrew Hantel
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | | | | | - Selina Chow
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Rebecca DeBoer
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Gini F Fleming
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Olwen M Hahn
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Justin Kline
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Hongtao Liu
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Bhakti K Patel
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Anshu Verma
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Leah J Witt
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Mayumi Fukui
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Aditi Kumar
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Michael D Howell
- University of Chicago Medicine; and University of Chicago, Chicago, IL
| | - Blase N Polite
- University of Chicago Medicine; and University of Chicago, Chicago, IL
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Affiliation(s)
- Bhakti K Patel
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Jesse B Hall
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - John P Kress
- Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
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Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2016; 315:2435-41. [PMID: 27179847 PMCID: PMC4967560 DOI: 10.1001/jama.2016.6338] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients. OBJECTIVE To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS. DESIGN, SETTING, AND PARTICIPANTS Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015. INTERVENTIONS Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator-free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality. RESULTS Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, -43.3%; 95% CI, -62.4% to -24.3%; P < .001). The number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5, P < .001). At 90 days, 15 patients (34.1%) in the helmet group died compared with 22 patients (56.4%) in the face mask group (absolute difference, -22.3%; 95% CI, -43.3 to -1.4; P = .02). Adverse events included 3 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers). CONCLUSIONS AND RELEVANCE Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01680783.
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Affiliation(s)
- Bhakti K Patel
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - Krysta S Wolfe
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - Anne S Pohlman
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - Jesse B Hall
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
| | - John P Kress
- University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois
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Chauhan HC, Patel BK, Bhagat AG, Patel MV, Patel SI, Raval SH, Panchasara HH, Shrimali MD, Patel AC, Chandel BS. Comparison of molecular and microscopic technique for detection of Theileria annulata from the field cases of cattle. Vet World 2015; 8:1370-4. [PMID: 27047045 PMCID: PMC4774753 DOI: 10.14202/vetworld.2015.1370-1374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/08/2015] [Accepted: 10/19/2015] [Indexed: 11/16/2022] Open
Abstract
AIM Tropical theileriosis is fatal hemoprotozoal disease of dairy animals caused by Theileria annulata. The aim of the present study was to detect the T. annulata and comparison of results of molecular and microscopic techniques. MATERIALS AND METHODS A total of 52 blood samples were collected from the cattle suspected for theileriosis across the Banaskantha district. All the samples were screened for theileriosis using Giemsa's staining technique and polymerase chain reaction (PCR). RESULTS Total of 17 (32.69%) and 24 (46.15%) samples were found positive for theileriosis by microscopic examination and PCR test, respectively. It revealed that the study area is endemic for theileriosis, and the microscopic technique has 70.83% sensitivity and 100% specificity with respect to PCR technique. CONCLUSION It may be concluded from the present study that the PCR is comparatively sensitive technique than microscopic examination and may be recommended to use in the field for screening of theileriosis in the study area, where a high prevalence of diseases have been reported due to intensive dairy farming.
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Affiliation(s)
- H C Chauhan
- Division of Animal Biotechnology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - B K Patel
- Division of Animal Biotechnology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - A G Bhagat
- Division of Veterinary Microbiology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - M V Patel
- Division of Veterinary Microbiology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - S I Patel
- Division of Veterinary Microbiology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - S H Raval
- Division of Veterinary Pathology, College of Veterinary Science & Animal House, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - H H Panchasara
- Teaching Veterinary Clinical Complex (College Clinics), College of Veterinary Science & Animal House, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - M D Shrimali
- Division of Animal Biotechnology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - A C Patel
- Division of Veterinary Microbiology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
| | - B S Chandel
- Division of Animal Biotechnology, College of Veterinary Science & Animal Husbandry, Sardarkrushinagar Dantiwada Agricultural University, Sardarkrushinagar - 385 506, Gujarat, India
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Affiliation(s)
- Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - John P Kress
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
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Patel BK, Pohlman AS, Hall JB, Kress JP. Impact of early mobilization on glycemic control and ICU-acquired weakness in critically ill patients who are mechanically ventilated. Chest 2015; 146:583-589. [PMID: 25180722 DOI: 10.1378/chest.13-2046] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND ICU-acquired weakness (ICU-AW) has immediate and long-term consequences for critically ill patients. Strategies for the prevention of weakness include modification of known risk factors, such as hyperglycemia and immobility. Intensive insulin therapy (IIT) has been proposed to prevent critical illness polyneuropathy. However, the effect of insulin and early mobilization on clinically apparent weakness is not well known. METHODS This is a secondary analysis of all patients with mechanical ventilation (N = 104) previously enrolled in a randomized controlled trial of early occupational and physical therapy vs conventional therapy, which evaluated the end point of functional independence. Every patient had IIT and blinded muscle strength testing on hospital discharge to determine the incidence of clinically apparent weakness. The effects of insulin dose and early mobilization on the incidence of ICU-AW were assessed. RESULTS On logistic regression analyses, early mobilization and increasing insulin dose prevented the incidence of ICU-AW (OR, 0.18, P = .001; OR, 0.001, P = .011; respectively) independent of known risk factors for weakness. Early mobilization also significantly reduced insulin requirements to achieve similar glycemic goals as compared with control patients (0.07 units/kg/d vs 0.2 units/kg/d, P < .001). CONCLUSIONS The duel effect of early mobilization in reducing clinically relevant ICU-AW and promoting euglycemia suggests its potential usefulness as an alternative to IIT.
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Affiliation(s)
- Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - Anne S Pohlman
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - Jesse B Hall
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - John P Kress
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
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Luo N, Chapman CG, Patel BK, Woodruff JN, Arora VM. Expectations of iPad use in an internal medicine residency program: is it worth the "hype"? J Med Internet Res 2013; 15:e88. [PMID: 23656727 PMCID: PMC3650925 DOI: 10.2196/jmir.2524] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/19/2013] [Accepted: 03/26/2013] [Indexed: 11/13/2022] Open
Abstract
Background While early reports highlight the benefits of tablet computing in hospitals, introducing any new technology can result in inflated expectations. Objective The aim of the study is to compare anticipated expectations of Apple iPad use and perceptions after deployment among residents. Methods 115 internal medicine residents received Apple iPads in October 2010. Residents completed matched surveys on anticipated usage and perceptions after distribution 1 month prior and 4 months after deployment. Results In total, 99% (114/115) of residents responded. Prior to deployment, most residents believed that the iPad would improve patient care and efficiency on the wards; however, fewer residents “strongly agreed” after deployment (34% vs 15% for patient care, P<.001; 41% vs 24% for efficiency, P=.005). Residents with higher expectations were more likely to report using the iPad for placing orders post call and during admission (71% vs 44% post call, P=.01, and 16% vs 0% admission, P=.04). Previous Apple iOS product owners were also more likely to use the iPad in key areas. Overall, 84% of residents thought the iPad was a good investment for the residency program, and over half of residents (58%) reported that patients commented on the iPad in a positive way. Conclusions While the use of tablets such as the iPad by residents is generally well received, high initial expectations highlight the danger of implementing new technologies. Education on the realistic expectations of iPad benefits may be warranted.
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Affiliation(s)
- Nancy Luo
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Patel BK, Vij R, Patel SB. A microRNA processing defect in rapidly progressing idiopathic pulmonary fibrosis; enteral omega-3 fatty acid, γ-linoleic acid, and antioxidant supplementation in ALI; and management of asthma in pregnancy guided by exhaled nitric oxide. Am J Respir Crit Care Med 2012; 186:458-9. [PMID: 22942345 DOI: 10.1164/rccm.201202-0328rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland, MC 6026, Chicago, IL 60637, USA
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Abstract
Pregnancy is a special physiological condition where drug treatment presents a special concern because the physiology of pregnancy affects the pharmacokinetics of medications used and certain medications can reach the fetus and cause harm. Total avoidance of pharmacological treatment in pregnancy is not possible and may be dangerous because some women enter pregnancy with medical conditions that require ongoing and episodic treatment (e.g. asthma, epilepsy, hypertension). Also during pregnancy new medical problems can develop and old ones can be exacerbated (e.g. migraine, headache) requiring pharmacological therapy. The fact that certain drugs given during pregnancy may prove harmful to the unborn child is one of the classical problems in medical treatment. In 1960's pregnant ladies who ingested thalidomide gave birth to children with phocomalia. Various other examples of teratogenic effects of drugs are known. It has been documented that congenital abnormalities caused by human teratogenic drugs account for less than 1% of total congenital abnormalities. Hence in 1979, Food and Drug Administration developed a system that determines the teratogenic risk of drugs by considering the quality of data from animal and human studies. FDA classifies various drugs used in pregnancy into five categories, categories A, B, C, D and X. Category A is considered the safest category and category X is absolutely contraindicated in pregnancy. This provides therapeutic guidance for the clinician. This article focuses on various aspects relating to drug use during pregnancy.
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Affiliation(s)
- Punam Sachdeva
- Department of Pharmacology, A. R. College of Pharmacy, Vallabh Vidyanagar-388 120, India
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von Maltzan XF, Slováková A, Patel BK, Drake AF, Hutt AJ. Enantiomeric resolution of sulindac by chiral-phase chromatography: Determination of enantiomeric composition in human urine. J Pharm Pharmacol 2011. [DOI: 10.1111/j.2042-7158.1998.tb02315.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- X F von Maltzan
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - A Slováková
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - B K Patel
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - A F Drake
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - A J Hutt
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
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Patel BK, Tan SC, Jackson SHD, Swift CG, Hutt AJ. Enantiomeric disposition of ibuprofen in young and elderly volunteers. J Pharm Pharmacol 2011. [DOI: 10.1111/j.2042-7158.1998.tb02441.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- B K Patel
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - S C Tan
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - S H D Jackson
- Clinical Age Research Unit, King’s College London, Denmark Hill, London SE5 9RS
| | - C G Swift
- Clinical Age Research Unit, King’s College London, Denmark Hill, London SE5 9RS
| | - A J Hutt
- Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
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Abstract
1. The stereoselective metabolism and pharmacokinetics of the enantiomers of flurbiprofen were investigated following the oral administration of the racemic drug (100 mg) to four young and four elderly healthy volunteers (two males and two females per group). 2. The stereochemical composition of the drug and the 4'-hydroxy- metabolite in serum and the drug, 4'-hydroxy- and 3'-hydroxy-4'-methoxy- metabolites, both free and conjugated, in urine were determined by a direct chromatographic method of enantiomeric analysis. 3. Modest enantioselectivity in clearance (CL S/R: young, 0.86; elderly, 0.88) was largely responsible for the apparent elimination half-life of (S)-flurbiprofen being significantly greater (p<0.01) than that of the R-enantiomer in both age groups (young, S: 5.2 +/- 0.7 versus R: 4.5 +/- 0.6 h; elderly, S: 9.6 +/- 1.2 versus R: 7.1 +/- 1.0 h). The serum concentrations of 4'-hydroxyflurbiprofen were five- to 20-fold lower than those of the corresponding drug enantiomers, stereoselective disposition being evident in the significantly greater (p<0.05) apparent half-lives of the S- compared with the R-enantiomer in both groups (young, S: 10.6 +/- 2.4 versus R: 6.7 +/- 1.1 h; elderly, S: 13.7 +/- 1.7 versus R: 10.2 +/- 1.2 h). 4. Some 60 and 72% of the dose was excreted in 24-h urine in elderly and young volunteers, respectively, a significantly greater (p<0.05) proportion of which was of the R-configuration in both age groups (S/R: young, 0.87; elderly, 0.81). The major urinary excretion products were flurbiprofen and 4'-hydroxyflurbiprofen, and their acyl-conjugates in both groups. 5. Age-associated differences in the pharmacokinetics of flurbiprofen occurred in a non-stereoselective manner and were primarily as a consequence of a significant approximately 40% decrease (p<0.01) in clearance of both enantiomers in the elderly due to reduced metabolic activity. Consequently, the elderly had greater exposure to both enantiomers, as reflected by the AUCs(0-inf) being significantly higher (p<0.05), by 60%, in this age group compared with the young. 6. The findings suggest that age-related alterations in the disposition of flurbiprofen could have significant implications for the use of the drug in the elderly.
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Affiliation(s)
- B K Patel
- Department of Pharmacy, King's College London, UK
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Andrews KT, Patel BK, Clarke FM. FgoI, a Type II restriction endonuclease from the thermoanaerobe Fervidobacterium gondwanense AB39(T). Anaerobe 2007; 4:227-32. [PMID: 16887647 DOI: 10.1006/anae.1998.0167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/1998] [Accepted: 09/16/1998] [Indexed: 11/22/2022]
Abstract
Restriction endonuclease activity was detected in 11 out of 13 Fervidobacterium isolates, including F. islandicum H21(T), F. gondwanense AB39(T), and nine other Fervidobacterium-like strains isolated from the Great Artesian Basin of Australia. The restriction endonuclease from F. gondwanense AB39(T) was partially purified and designated FgoI. FgoI recognized a 4 nucleotide sequence 5'-CTAG-3' and cleaved between nucleotides C and T to produce a 2 base 5' overhang (5'-C/TAG-3'). As predicted from the enzyme recognition and cleavage specificity, FgoI was found to cleave delta DNA 13 times, phiX174 three times, pBR322 five times, pUC18 four times, and pSK six times. FgoI exhibited a broad temperature optimum range (between 60 to 70 degrees C) and was active at pH 6.5 to 8.5, but not at pH 9.0. Manganese could replace magnesium as a cofactor for activity, but not cobalt chloride, calcium chloride, cupric chloride, or zinc chloride. The restriction endonuclease was completely inactivated by phenol/chloroform extraction and was heat inactivated at 80 degrees C for 60 min or at 100 degrees C for 15 min. FgoI has been identified as a heat stable isoschizomer of the Type II restriction endonucleases, MaeI and BfaI.
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Affiliation(s)
- K T Andrews
- School of Biomolecular and Biomedical Sciences, Faculty of Science, Griffith University, Nathan, Brisbane, Australia, 4111
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