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Bajwa EK, Cislak D, Palcza J, Feng HP, Messina EJ, Reynders T, Denef JF, Corcea V, Lai E, Stoch SA. Effects of an inhaled soluble guanylate cyclase (sGC) stimulator MK-5475 in pulmonary arterial hypertension (PAH). Respir Med 2023; 206:107065. [PMID: 36521262 DOI: 10.1016/j.rmed.2022.107065] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/09/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Novel therapeutics for pulmonary arterial hypertension (PAH) with improved safety/tolerability profiles are needed to address continued high rates of morbidity/mortality. METHODS This Phase 1 study evaluated efficacy/safety of inhaled single-dose MK-5475, an investigational, small-molecule stimulator of soluble guanylate cyclase designed for inhaled delivery via a dry-powder inhaler device, in participants with PAH (Clinicaltrials.gov: NCT03744637). Eligible participants were 18-70 years of age; body mass index ≤35 kg/m2; diagnosis of PAH (Group 1 pulmonary hypertension). In Part 1, participants received double-blind MK-5475 or placebo for safety assessment (primary outcome). In Part 2, 4 panels participated in ≤3 open-label periods. Part 2/Period 1 assessed safety/tolerability. Part 2/Periods 2 and 3, respectively, involved functional respiratory imaging for measuring pulmonary blood volume (secondary outcome) and right heart catheterization for measuring pulmonary vascular resistance (primary outcome). RESULTS MK-5475 was generally well tolerated without systemic side effects on blood pressure or heart rate up to 24 h post dose. With respect to the primary pharmacodynamic outcome, mean reductions in pulmonary vascular resistance ranged from 21% to 30% across 120 μg and 360 μg doses. CONCLUSIONS Treatment with inhaled single-dose MK-5475 showed rapid and sustained reductions in pulmonary vascular resistance and increases in pulmonary blood volume. MK-5475 was generally well tolerated versus placebo without vasodilatory systemic side effects. The promising pulmonary selectivity and favorable safety/tolerability profile of MK-5475 seen in this study of adult participants with PAH lays the foundation for further clinical development.
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Affiliation(s)
| | | | | | | | | | - Tom Reynders
- Translational Medicine, MSD Belgium, Brussels, Belgium
| | | | - Vasile Corcea
- PMSI Republican Clinical Hospital "T. Mosneaga", ARENSIA EM Unit, Chisinau, Republic of Moldova
| | - Eseng Lai
- MRL, Merck & Co., Inc., Rahway, NJ, USA
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2
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Weiss TJ, Rosen Ramey D, Yang L, Liu X, Patel MJ, Rajpathak S, Bajwa EK, Lautsch D. Medication use by US patients with pulmonary hypertension associated with chronic obstructive pulmonary disease: a retrospective study of administrative data. BMC Pulm Med 2022; 22:383. [PMID: 36258171 PMCID: PMC9578250 DOI: 10.1186/s12890-022-02167-9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a serious complication of chronic obstructive pulmonary disease (COPD). While clinical guidelines recommend specific drug therapies for pulmonary arterial hypertension (PAH), these drug therapies are not recommended for PH due to lung disease. METHODS This was a retrospective cohort study using the Optum® Clinformatics® Data Mart from January 2009-September 2019. An algorithm was designed to identify adults with ≥ 2 ICD-9-CM or ICD-10-CM diagnosis codes for PH and with ≥ 2 diagnosis codes for COPD. Sensitivity analyses were conducted among subgroups of patients with evidence of a right heart catheterization (RHC) or pulmonary function test (PFT). Patient characteristics, medications used, and durations of use of PAH and COPD medications were analyzed. RESULTS A total of 25,975 patients met the study inclusion criteria. Their mean age was 73.5 (SD 10.0) years and 63.8% were female. Medications targeting PAH were prescribed to 643 (2.5%) patients, most frequently a phosphodiesterase-5 inhibitor (2.1%) or an endothelin receptor antagonist (0.75%). Medications for COPD were prescribed to 17,765 (68.4%) patients, most frequently an inhaled corticosteroid (57.4%) or short-acting beta agonist (50.4%). The median durations of use ranged from 4.9 to 12.8 months for PAH medications, and from 0.4 to 5.9 months for COPD medications. Of the subgroup of patients with RHC (N = 2325), 257 (11.1%) were prescribed a PAH medication and 1670 (71.8%) used a COPD medication. Of the subgroup with a PFT (N = 2995), 58 (1.9%) were prescribed a PAH medication and 2100 (70.1%) a COPD medication. CONCLUSIONS Patients with PH associated with COPD were identified in a US administrative claims database. Very few of these patients received any of the medications recommended for PAH, and only about two thirds received medications for COPD.
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Anderko RR, Gómez H, Canna SW, Shakoory B, Angus DC, Yealy DM, Huang DT, Kellum JA, Carcillo JA, Angus DC, Barnato AE, Eaton TL, Gimbel E, Huang DT, Keener C, Kellum JA, Landis K, Pike F, Stapleton DK, Weissfeld LA, Willochell M, Wofford KA, Yealy DM, Kulstad E, Watts H, Venkat A, Hou PC, Massaro A, Parmar S, Limkakeng AT, Brewer K, Delbridge TR, Mainhart A, Chawla LS, Miner JR, Allen TL, Grissom CK, Swadron S, Conrad SA, Carlson R, LoVecchio F, Bajwa EK, Filbin MR, Parry BA, Ellender TJ, Sama AE, Fine J, Nafeei S, Terndrup T, Wojnar M, Pearl RG, Wilber ST, Sinert R, Orban DJ, Wilson JW, Ufberg JW, Albertson T, Panacek EA, Parekh S, Gunn SR, Rittenberger JS, Wadas RJ, yEdwards AR, Kelly M, Wang HE, Holmes TM, McCurdy MT, Weinert C, Harris ES, Self WH, Phillips CA, Migues RM. Sepsis with liver dysfunction and coagulopathy predicts an inflammatory pattern of macrophage activation. Intensive Care Med Exp 2022; 10:6. [PMID: 35190900 PMCID: PMC8861227 DOI: 10.1186/s40635-022-00433-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Background Interleukin-1 receptor antagonists can reduce mortality in septic shock patients with hepatobiliary dysfunction and disseminated intravascular coagulation (HBD + DIC), an organ failure pattern with inflammatory features consistent with macrophage activation. Identification of clinical phenotypes in sepsis may allow for improved care. We aim to describe the occurrence of HBD + DIC in a contemporary cohort of patients with sepsis and determine the association of this phenotype with known macrophage activation syndrome (MAS) biomarkers and mortality. We performed a retrospective nested case–control study in adult septic shock patients with concurrent HBD + DIC and an equal number of age-matched controls, with comparative analyses of all-cause mortality and circulating biomarkers between the groups. Multiple logistic regression explored the effect of HBD + DIC on mortality and the discriminatory power of the measured biomarkers for HBD + DIC and mortality. Results Six percent of septic shock patients (n = 82/1341) had HBD + DIC, which was an independent risk factor for 90-day mortality (OR = 3.1, 95% CI 1.4–7.5, p = 0.008). Relative to sepsis controls, the HBD + DIC cohort had increased levels of 21 of the 26 biomarkers related to macrophage activation (p < 0.05). This panel was predictive of both HBD + DIC (sensitivity = 82%, specificity = 84%) and mortality (sensitivity = 92%, specificity = 90%). Conclusion The HBD + DIC phenotype identified patients with high mortality and a molecular signature resembling that of MAS. These observations suggest trials of MAS-directed therapies are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00433-y.
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Alladina J, Levy SD, Cho JL, Brait KL, Rao SR, Camacho A, Hibbert KA, Harris RS, Medoff BD, Januzzi JL, Thompson BT, Bajwa EK. Plasma Soluble Suppression of Tumorigenicity-2 Associates with Ventilator Liberation in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2021; 203:1257-1265. [PMID: 33400890 DOI: 10.1164/rccm.202005-1951oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/22/2022] Open
Abstract
Rationale: Standard physiologic assessments of extubation readiness in patients with acute hypoxemic respiratory failure (AHRF) may not reflect lung injury resolution and could adversely affect clinical decision-making and patient outcomes. Objectives: We hypothesized that elevations in inflammatory plasma biomarkers sST2 (soluble suppression of tumorigenicity-2) and IL-6 indicate ongoing lung injury in AHRF and better inform patient outcomes compared with standard clinical assessments. Methods: We measured daily plasma biomarkers and physiologic variables in 200 patients with AHRF for up to 9 days after intubation. We tested the associations of baseline values with the primary outcome of unassisted breathing at Day 29. We analyzed the ability of serial biomarker measurements to inform successful ventilator liberation. Measurements and Main Results: Baseline sST2 concentrations were higher in patients dead or mechanically ventilated versus breathing unassisted at Day 29 (491.7 ng/ml [interquartile range (IQR), 294.5-670.1 ng/ml] vs. 314.4 ng/ml [IQR, 127.5-550.1 ng/ml]; P = 0.0003). Higher sST2 concentrations over time were associated with a decreased probability of ventilator liberation (hazard ratio, 0.80 per log-unit increase; 95% confidence interval [CI], 0.75-0.83; P = 0.03). Patients with higher sST2 concentrations on the day of liberation were more likely to fail liberation compared with patients who remained successfully liberated (320.9 ng/ml [IQR, 181.1- 495.6 ng/ml] vs. 161.6 ng/ml [IQR, 95.8-292.5 ng/ml]; P = 0.002). Elevated sST2 concentrations on the day of liberation decreased the odds of successful liberation when adjusted for standard physiologic parameters (odds ratio, 0.325; 95% CI, 0.119-0.885; P = 0.03). IL-6 concentrations did not associate with outcomes. Conclusions: Using sST2 concentrations to guide ventilator management may more accurately reflect underlying lung injury and outperform traditional measures of readiness for ventilator liberation.
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Affiliation(s)
| | - Sean D Levy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Josalyn L Cho
- Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Sowmya R Rao
- Boston University School of Public Health, Boston, Massachusetts; and
| | - Alexander Camacho
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - R Scott Harris
- Division of Pulmonary and Critical Care Medicine and.,Vertex Pharmaceuticals, Boston, Massachusetts
| | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ednan K Bajwa
- Division of Pulmonary and Critical Care Medicine and
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5
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Quraishi SA, Bhan I, Matthay MA, Thompson BT, Camargo CA, Bajwa EK. Vitamin D Status and Clinical Outcomes in Acute Respiratory Distress Syndrome: A Secondary Analysis From the Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury (ALVEOLI) Trial. J Intensive Care Med 2021; 37:793-802. [PMID: 34165010 DOI: 10.1177/08850666211028139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a highly morbid condition that has limited therapeutic options. Optimal vitamin D status has been linked to immunological effects that may benefit critically ill patients. Therefore, we investigated whether admission 25-hydroxyvitamin D levels (25OHD) are associated with clinical outcomes in ARDS patients. METHODS We performed a secondary analysis of data from a randomized, controlled trial comparing oxygenation strategies in 549 patients with ARDS (NCT00000579). Baseline 25OHD was measured in stored plasma samples. We investigated the relationship between vitamin D status and ventilator-free days (VFD) as well as 90-day survival, using linear regression and Cox proportional hazard models, respectively. Analyses were adjusted for age, race, and Acute Physiology and Chronic Health Evaluation III score. RESULTS Baseline 25OHD was measured in 476 patients. 90% of these individuals had 25OHD <20 ng/ml and 40% had 25OHD <10 ng/ml. Patients with 25OHD <20 ng/ml were likely to be ventilated for 3 days longer than patients with levels ≥20 ng/ml (ß 3.41; 95%CI 0.42-6.39: P = 0.02). Patients with 25OHD <10 ng/ml were likely to be ventilated for 9 days longer (ß 9.27; 95%CI 7.24-11.02: P < 0.001) and to have a 34% higher risk of 90-day mortality (HR 1.34; 95% CI 1.06-1.71: P = 0.02) compared to patients with levels >10 ng/ml. CONCLUSIONS In patients with ARDS, vitamin D status is associated with duration of mechanical ventilation and 90-day mortality. Randomized, controlled trials are warranted to determine whether vitamin D supplementation improves clinical outcomes in ARDS patients.
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Affiliation(s)
- Sadeq A Quraishi
- Department of Anesthesiology and Perioperative Medicine, 1867Tufts Medical Center, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Ishir Bhan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,10774Alnylam Pharmaceuticals Inc, Cambridge, MA, USA
| | - Michael A Matthay
- Department of Medicine, 8785University of California San Francisco, CA, USA
| | - Boyd T Thompson
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Carlos A Camargo
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Merck & Co., Inc., Kenilworth, NJ, USA
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Kaner RJ, Bajwa EK, El-Amine M, Gorina E, Gupta R, Lazarus HM, Luckhardt TR, Mouded M, Posada K, Richeldi L, Stauffer J, Tutuncu A, Martinez FJ. Design of Idiopathic Pulmonary Fibrosis Clinical Trials in the Era of Approved Therapies. Am J Respir Crit Care Med 2020; 200:133-139. [PMID: 30985215 DOI: 10.1164/rccm.201903-0592pp] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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
Affiliation(s)
- Robert J Kaner
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and.,2 Department of Genetic Medicine, Weill Cornell Medicine, New York, New York
| | | | | | - Eduard Gorina
- 5 Pliant Therapeutics, Inc., South San Francisco, California
| | - Renu Gupta
- 6 Promedior, Inc., Lexington, Massachusetts
| | - Howard M Lazarus
- 7 Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut
| | - Tracy R Luckhardt
- 8 Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Kaity Posada
- 10 Acceleron Pharma, Inc., Cambridge, Massachusetts
| | - Luca Richeldi
- 11 Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - John Stauffer
- 12 Genentech, Inc., South San Francisco, California; and
| | | | - Fernando J Martinez
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
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7
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Elmer J, Yamane D, Hou PC, Wilcox SR, Bajwa EK, Hess DR, Camargo CA, Greenberg SM, Rosand J, Pallin DJ, Goldstein JN, Takhar SS. Cost and Utility of Microbiological Cultures Early After Intensive Care Unit Admission for Intracerebral Hemorrhage. Neurocrit Care 2017; 26:58-63. [PMID: 27605253 DOI: 10.1007/s12028-016-0285-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 01/25/2023]
Abstract
BACKGROUND Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH). METHODS We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure. RESULTS Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure. CONCLUSIONS The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.
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Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
| | - David Yamane
- Department of Anesthesiology and Critical Care Medicine, George Washington University Hospital, Washington, DC, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Surgical Intensive Care Unit, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan R Wilcox
- Divisions of Emergency Medicine and Pulmonary, Critical Care and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Dean R Hess
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sukhjit S Takhar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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8
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Zhu Z, Liang L, Zhang R, Wei Y, Su L, Tejera P, Guo Y, Wang Z, Lu Q, Baccarelli AA, Zhu X, Bajwa EK, Taylor Thompson B, Shi GP, Christiani DC. Whole blood microRNA markers are associated with acute respiratory distress syndrome. Intensive Care Med Exp 2017; 5:38. [PMID: 28856588 PMCID: PMC5577350 DOI: 10.1186/s40635-017-0155-0] [Citation(s) in RCA: 40] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 08/21/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND MicroRNAs (miRNAs) can play important roles in inflammation and infection, which are common manifestations of acute respiratory distress syndrome (ARDS). We assessed if whole blood miRNAs were potential diagnostic biomarkers for human ARDS. METHODS This nested case-control study (N = 530) examined a cohort of ARDS patients and critically ill at-risk controls. Whole blood miRNA profiles and logistic regression analyses identified miRNAs correlated with ARDS. Stratification analysis also assessed selected miRNA markers for their role in sepsis and pneumonia associated with ARDS. Receiver operating characteristic (ROC) analysis evaluated miRNA diagnostic performance, along with Lung Injury Prediction Score (LIPS). RESULTS Statistical analyses were performed on 294 miRNAs, selected from 754 miRNAs after quality control screening. Logistic regression identified 22 miRNAs from a 156-patient discovery cohort as potential risk or protective markers of ARDS. Three miRNAs-miR-181a, miR-92a, and miR-424-from the discovery cohort remained significantly associated with ARDS in a 373-patient independent validation cohort (FDR q < 0.05) and meta-analysis (p < 0.001). ROC analyses demonstrated a LIPS baseline area-under-the-curve (AUC) value of ARDS of 0.708 (95% CI 0.651-0.766). Addition of miR-181a, miR-92a, and miR-424 to LIPS increased baseline AUC to 0.723 (95% CI 0.667-0.778), with a relative integrated discrimination improvement of 2.40 (p = 0.005) and a category-free net reclassification index of 27.21% (p = 0.01). CONCLUSIONS miR-181a and miR-92a are risk biomarkers for ARDS, whereas miR-424 is a protective biomarker. Addition of these miRNAs to LIPS can improve the risk estimate for ARDS.
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Affiliation(s)
- Zhaozhong Zhu
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Liming Liang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ruyang Zhang
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA.,Department of Environmental Health, Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yongyue Wei
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA.,Department of Environmental Health, Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Li Su
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Paula Tejera
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Yichen Guo
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Zhaoxi Wang
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Quan Lu
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Andrea A Baccarelli
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA
| | - Xi Zhu
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Ednan K Bajwa
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B Taylor Thompson
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Guo-Ping Shi
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David C Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, USA. .,Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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9
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Wei Y, Tejera P, Wang Z, Zhang R, Chen F, Su L, Lin X, Bajwa EK, Thompson BT, Christiani DC. A Missense Genetic Variant in LRRC16A/CARMIL1 Improves Acute Respiratory Distress Syndrome Survival by Attenuating Platelet Count Decline. Am J Respir Crit Care Med 2017; 195:1353-1361. [PMID: 27768389 DOI: 10.1164/rccm.201605-0946oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 12/22/2022] Open
Abstract
RATIONALE Platelets are believed to contribute to acute respiratory distress syndrome (ARDS) pathogenesis through inflammatory coagulation pathways. We recently reported that leucine-rich repeat-containing 16A (LRRC16A) modulates baseline platelet counts to mediate ARDS risk. OBJECTIVES To examine the role of LRRC16A in ARDS survival and its mediating effect through platelets. METHODS A total of 414 cases with ARDS from intensive care units (ICUs) were recruited who had exome-wide genotyping data, detailed platelet counts, and follow-up data during ICU hospitalization. Association of LRRC16A single-nucleotide polymorphisms (SNPs) and ARDS prognosis, and the mediating effect of SNPs through platelet counts were analyzed. LRRC16A mRNA expression levels for 39 cases with ARDS were also evaluated. MEASUREMENTS AND MAIN RESULTS Missense SNP rs9358856G>A within LRRC16A was associated with favorable survival within 28 days (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.38-0.87; P = 0.0084) and 60 days (P = 0.0021) after ICU admission. Patients with ARDS who carried the variant genotype versus the wild-type genotype showed an attenuated platelet count decline (∆PLT) within 28 days (difference of ∆PLT, -27.8; P = 0.025) after ICU admission. Patients with ∆PLT were associated with favorable ARDS outcomes. Mediation analysis indicated that the SNP prognostic effect was mediated through ∆PLT within 28 days (28-day survival: HRIndirect, 0.937; 95% CI, 0.918-0.957; P = 0.0009, 11.53% effects mediated; 60-day survival: HRIndirect, 0.919; 95% CI, 0.901-0.936; P = 0.0001, 14.35% effects mediated). Functional exploration suggested that this SNP reduced LRRC16A expression at ICU admission, which was associated with a lesser ∆PLT during ICU hospitalization. CONCLUSIONS LRRC16A appears to mediate ∆PLT after ICU admission to affect the prognosis in patients with ARDS.
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Affiliation(s)
- Yongyue Wei
- 1 Department of Environmental Health and.,2 Department of Biostatistics, School of Public Health and.,3 China International Cooperation Center for Environment and Human Health, Nanjing Medical University, Nanjing, China; and
| | | | | | - Ruyang Zhang
- 1 Department of Environmental Health and.,2 Department of Biostatistics, School of Public Health and
| | - Feng Chen
- 2 Department of Biostatistics, School of Public Health and.,3 China International Cooperation Center for Environment and Human Health, Nanjing Medical University, Nanjing, China; and
| | - Li Su
- 1 Department of Environmental Health and
| | - Xihong Lin
- 4 Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Ednan K Bajwa
- 5 Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - B Taylor Thompson
- 5 Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David C Christiani
- 1 Department of Environmental Health and.,3 China International Cooperation Center for Environment and Human Health, Nanjing Medical University, Nanjing, China; and.,5 Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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10
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Laffey JG, Madotto F, Bellani G, Pham T, Fan E, Brochard L, Amin P, Arabi Y, Bajwa EK, Bruhn A, Cerny V, Clarkson K, Heunks L, Kurahashi K, Laake JH, Lorente JA, McNamee L, Nin N, Palo JE, Piquilloud L, Qiu H, Jiménez JIS, Esteban A, McAuley DF, van Haren F, Ranieri M, Rubenfeld G, Wrigge H, Slutsky AS, Pesenti A. Geo-economic variations in epidemiology, patterns of care, and outcomes in patients with acute respiratory distress syndrome: insights from the LUNG SAFE prospective cohort study. Lancet Respir Med 2017. [PMID: 28624388 DOI: 10.1016/s2213-2600(17)30213-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little information is available about the geo-economic variations in demographics, management, and outcomes of patients with acute respiratory distress syndrome (ARDS). We aimed to characterise the effect of these geo-economic variations in patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE). METHODS LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensive-care units in 50 countries across six continents. Inclusion criteria were admission to a participating intensive-care unit (including transfers) within the enrolment window and receipt of invasive or non-invasive ventilation. One of the trial's secondary aims was to characterise variations in the demographics, management, and outcome of patients with ARDS. We used the 2016 World Bank countries classification to define three major geo-economic groupings, namely European high-income countries (Europe-High), high-income countries in the rest of the world (rWORLD-High), and middle-income countries (Middle). We compared patient outcomes across these three groupings. LUNG SAFE is registered with ClinicalTrials.gov, number NCT02010073. FINDINGS Of the 2813 patients enrolled in LUNG SAFE who fulfilled ARDS criteria on day 1 or 2, 1521 (54%) were recruited from Europe-High, 746 (27%) from rWORLD-High, and 546 (19%) from Middle countries. We noted significant geographical variations in demographics, risk factors for ARDS, and comorbid diseases. The proportion of patients with severe ARDS or with ratios of the partial pressure of arterial oxygen (PaO2) to the fractional concentration of oxygen in inspired air (FiO2) less than 150 was significantly lower in rWORLD-High countries than in the two other regions. Use of prone positioning and neuromuscular blockade was significantly more common in Europe-High countries than in the other two regions. Adjusted duration of invasive mechanical ventilation and length of stay in the intensive-care unit were significantly shorter in patients in rWORLD-High countries than in Europe-High or Middle countries. High gross national income per person was associated with increased survival in ARDS; hospital survival was significantly lower in Middle countries than in Europe-High or rWORLD-High countries. INTERPRETATION Important geo-economic differences exist in the severity, clinician recognition, and management of ARDS, and in patients' outcomes. Income per person and outcomes in ARDS are independently associated. FUNDING European Society of Intensive Care Medicine, St Michael's Hospital, University of Milan-Bicocca.
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Affiliation(s)
- John G Laffey
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada; Department of Critical Care Medicine, St Michael's Hospital, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Fabiana Madotto
- Research Center on Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Research Center on Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Pravin Amin
- Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Yaseen Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Respiratory Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ednan K Bajwa
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J E Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic; Department of Research and Development, and Department of Anesthesiology and Intensive Care, Charles University in Prague, Prague, Czech Republic; Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Kevin Clarkson
- Department of Anaesthesia, Galway University Hospitals and National University of Ireland, Galway, Galway, Ireland
| | - Leo Heunks
- Department of Intensive Care, VU University Medical Centre Amsterdam, Netherlands
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Jon Henrik Laake
- Division of Critical Care, Department of Anaesthesiology, Rikshospitalet Medical Centre, Oslo University Hospital, Oslo, Norway
| | - Jose A Lorente
- CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain
| | - Lia McNamee
- Centre for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland, UK; Wellcome-Wolfson Institute for Experimental Medicine, Belfast, Northern Ireland, UK; Regional Intensive Care Unit, Royal Victoria Hospital A&E, Grosvenor Road, Belfast, Northern Ireland, UK
| | - Nicolas Nin
- CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain; Hospital Español, Montevideo, Uruguay
| | - Jose Emmanuel Palo
- Section of Adult Critical Care, Department of Medicine, The Medical City, Pasig, Philippines
| | - Lise Piquilloud
- Adult Intensive Care and Burn Unit, University Hospital of Lausanne, Lausanne, Switzerland; Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Juan Ignacio Silesky Jiménez
- Department of Intensive Care, Hospital San Juan de Dios, and Department of Intensive Care, Hospital CIMA San Jose, Council of Critical Medicine, University of Costa Rica, San Pedro Montes de Oca, Costa Rica
| | - Andres Esteban
- CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain; Hospital Español, Montevideo, Uruguay
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland, UK; Wellcome-Wolfson Institute for Experimental Medicine, Belfast, Northern Ireland, UK; Regional Intensive Care Unit, Royal Victoria Hospital A&E, Grosvenor Road, Belfast, Northern Ireland, UK
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; Australian National University, Canberra, ACT, Australia
| | - Marco Ranieri
- Sapienza Università di Roma, Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Rome, Italy
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Program in Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico and Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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11
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Zhang R, Wang Z, Tejera P, Frank AJ, Wei Y, Su L, Zhu Z, Guo Y, Chen F, Bajwa EK, Thompson BT, Christiani DC. Late-onset moderate to severe acute respiratory distress syndrome is associated with shorter survival and higher mortality: a two-stage association study. Intensive Care Med 2016; 43:399-407. [PMID: 28032130 DOI: 10.1007/s00134-016-4638-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 09/14/2016] [Accepted: 11/23/2016] [Indexed: 01/04/2023]
Abstract
PURPOSE To evaluate the association between acute respiratory distress syndrome (ARDS) onset time and prognosis. METHODS Patients with moderate to severe ARDS (N = 876) were randomly assigned into derivation (N = 520) and validation (N = 356) datasets. Both 28-day and 60-day survival times after ARDS onset were analyzed. A data-driven cutoff point between early- and late-onset ARDS was determined on the basis of mortality risk effects of onset times. We estimated the hazard ratio (HR) and odds ratio (OR) of late-onset ARDS using a multivariate Cox proportional hazards model of survival time and a multivariate logistic regression model of mortality rate, respectively. RESULTS Late-onset ARDS, defined as onset over 48 h after intensive care unit (ICU) admission (N = 273, 31%), was associated with shorter 28-day survival time: HR = 2.24, 95% CI 1.48-3.39, P = 1.24 × 10-4 (derivation); HR = 2.16, 95% CI 1.33-3.51, P = 1.95 × 10-3 (validation); and HR = 2.00, 95% CI 1.47-2.72, P = 1.10 × 10-5 (combined dataset). Late-onset ARDS was also associated with shorter 60-day survival time: HR = 1.70, 95% CI 1.16-2.48, P = 6.62 × 10-3 (derivation); HR = 1.78, 95% CI 1.15-2.75, P = 9.80 × 10-3 (validation); and HR = 1.59, 95% CI 1.20-2.10, P = 1.22 × 10-3 (combined dataset). Meanwhile, late-onset ARDS was associated with higher 28-day mortality rate (OR = 1.46, 95% CI 1.04-2.06, P = 0.0305) and 60-day mortality rate (OR = 1.44, 95% CI 1.03-2.02, P = 0.0313). CONCLUSIONS Late-onset moderate to severe ARDS patients had both shorter survival time and higher mortality rate in 28-day and 60-day observations.
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Affiliation(s)
- Ruyang Zhang
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA
- Department of Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
- Joint Laboratory of Health and Environmental Risk Assessment (HERA), Nanjing Medical University School of Public Health/Harvard School of Public Health, Nanjing, China
| | - Zhaoxi Wang
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA
| | - Paula Tejera
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA
| | - Angela J Frank
- Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yongyue Wei
- Department of Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
- Joint Laboratory of Health and Environmental Risk Assessment (HERA), Nanjing Medical University School of Public Health/Harvard School of Public Health, Nanjing, China
| | - Li Su
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA
| | - Zhaozhong Zhu
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA
| | - Yichen Guo
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA
| | - Feng Chen
- Department of Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
- Joint Laboratory of Health and Environmental Risk Assessment (HERA), Nanjing Medical University School of Public Health/Harvard School of Public Health, Nanjing, China
| | - Ednan K Bajwa
- Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B Taylor Thompson
- Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David C Christiani
- Department of Environmental Health, Harvard School of Public Health, Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 665 Hunting Avenue, Building I Room 1401, Boston, MA, 02115, USA.
- Joint Laboratory of Health and Environmental Risk Assessment (HERA), Nanjing Medical University School of Public Health/Harvard School of Public Health, Nanjing, China.
- Pulmonary and Critical Care Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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12
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Zhou DW, Westover MB, McClain LM, Nagaraj SB, Bajwa EK, Quraishi SA, Akeju O, Cobb JP, Purdon PL. Clustering analysis to identify distinct spectral components of encephalogram burst suppression in critically ill patients. Annu Int Conf IEEE Eng Med Biol Soc 2016; 2015:7258-61. [PMID: 26737967 DOI: 10.1109/embc.2015.7320067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Millions of patients are admitted each year to intensive care units (ICUs) in the United States. A significant fraction of ICU survivors develop life-long cognitive impairment, incurring tremendous financial and societal costs. Delirium, a state of impaired awareness, attention and cognition that frequently develops during ICU care, is a major risk factor for post-ICU cognitive impairment. Recent studies suggest that patients experiencing electroencephalogram (EEG) burst suppression have higher rates of mortality and are more likely to develop delirium than patients who do not experience burst suppression. Burst suppression is typically associated with coma and deep levels of anesthesia or hypothermia, and is defined clinically as an alternating pattern of high-amplitude "burst" periods interrupted by sustained low-amplitude "suppression" periods. Here we describe a clustering method to analyze EEG spectra during burst and suppression periods. We used this method to identify a set of distinct spectral patterns in the EEG during burst and suppression periods in critically ill patients. These patterns correlate with level of patient sedation, quantified in terms of sedative infusion rates and clinical sedation scores. This analysis suggests that EEG burst suppression in critically ill patients may not be a single state, but instead may reflect a plurality of states whose specific dynamics relate to a patient's underlying brain function.
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13
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Zhu Z, Zhang R, Liang L, Su L, Lu Q, Baccarelli AA, Bajwa EK, Thompson BT, Christiani DC. Whole blood microRNAs as a prognostic classifier for acute respiratory distress syndrome 28-day mortality. Intensive Care Med 2016; 42:1824-1825. [PMID: 27506755 DOI: 10.1007/s00134-016-4462-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Zhaozhong Zhu
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ruyang Zhang
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Environmental Health, Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Liming Liang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Li Su
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Quan Lu
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrea A Baccarelli
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ednan K Bajwa
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B Taylor Thompson
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David C Christiani
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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14
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Mahato B, Otero TMN, Holland CA, Giguere PT, Bajwa EK, Camargo CA, Quraishi SA. Addition of 25-hydroxyvitamin D levels to the Deyo-Charlson Comorbidity Index improves 90-day mortality prediction in critically ill patients. J Intensive Care 2016; 4:40. [PMID: 27330812 PMCID: PMC4912797 DOI: 10.1186/s40560-016-0165-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 03/21/2016] [Accepted: 06/15/2016] [Indexed: 02/05/2023] Open
Abstract
Background The Deyo-Charlson Comorbidity Index (DCCI) has low predictive value in the intensive care unit (ICU). Our goal was to determine whether addition of 25-hydroxyvitamin D (25OHD) levels to the DCCI improved 90-day mortality prediction in critically ill patients. Methods Plasma 25OHD levels, DCCI, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were assessed within 24 h of admission in 310 ICU patients. Receiver operating characteristic curves of the prediction scores, without and with the addition of 25OHD levels, for 90-day mortality were constructed and the areas under the curve (AUC) were compared for equality. Results Mean (standard deviation) plasma 25OHD levels, DCCI, and APACHE II score were 19 (SD 8) ng/mL, 4 (SD 3), and 17 (SD 9), respectively. Overall 90-day mortality was 19 %. AUC for DCCI vs. DCCI + 25OHD was 0.68 (95 % CI 0.58–0.77) vs. 0.75 (95 % CI 0.67–0.83); p < 0.001. AUC for APACHE II vs. APACHE II + 25OHD was 0.81 (95 % CI 0.73–0.88) vs. 0.82 (95 % CI 0.75–0.89); p < 0.001. There was a significant difference between the AUC for DCCI + 25OHD and APACHE II + 25OHD (p = 0.04) but not between the AUC for DCCI + 25OHD and APACHE II (p = 0.12). Conclusions In our cohort of ICU patients, the addition of 25OHD levels to the DCCI improved 90-day mortality prediction compared to the DCCI alone. Moreover, the predictive capability of DCCI + 25OHD was comparable to that of APACHE II. Future prospective studies are needed to validate our findings and to determine whether the use of DCCI + 25OHD can influence clinical decision-making.
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Affiliation(s)
- Bisundev Mahato
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRJ 402, Boston, MA USA ; Harvard Medical School, Boston, MA USA ; Department of Anesthesiology & Perioperative Care, University of California - Irvine, Orange, CA USA
| | - Tiffany M N Otero
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRJ 402, Boston, MA USA ; Tufts University School of Medicine, Boston, MA USA
| | - Carrie A Holland
- Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Patrick T Giguere
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRJ 402, Boston, MA USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA USA ; Department of Medicine, Harvard Medical School, Boston, MA USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA USA ; Department of Medicine, Harvard Medical School, Boston, MA USA ; Department of Epidemiology, Harvard School of Public Health, Boston, MA USA
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRJ 402, Boston, MA USA ; Department of Anaesthesia, Harvard Medical School, Boston, MA USA
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15
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Otero TMN, Yeh DD, Bajwa EK, Azocar RJ, Tsai AL, Belcher DM, Quraishi SA. Elevated Red Cell Distribution Width Is Associated With Decreased Ventilator-Free Days in Critically Ill Patients. J Intensive Care Med 2016; 33:241-247. [PMID: 27251107 DOI: 10.1177/0885066616652612] [Citation(s) in RCA: 10] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients. METHODS We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao2/Fio2 ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine. RESULTS A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001). CONCLUSIONS We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.
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Affiliation(s)
- Tiffany M N Otero
- 1 Tufts University School of Medicine, Boston, MA, USA.,2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - D Dante Yeh
- 3 Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
| | - Ednan K Bajwa
- 4 Harvard Medical School, Boston, MA, USA.,5 Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ruben J Azocar
- 6 Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
| | - Andrea L Tsai
- 6 Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
| | - Donna M Belcher
- 7 Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, MA
| | - Sadeq A Quraishi
- 2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
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16
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Cardinal-Fernández P, Bajwa EK, Dominguez-Calvo A, Menéndez JM, Papazian L, Thompson BT. The Presence of Diffuse Alveolar Damage on Open Lung Biopsy Is Associated With Mortality in Patients With Acute Respiratory Distress Syndrome. Chest 2016; 149:1155-64. [DOI: 10.1016/j.chest.2016.02.635] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 01/29/2016] [Accepted: 02/04/2016] [Indexed: 12/12/2022] Open
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Abstract
In this Series paper, we review the current evidence for the use of high-flow oxygen therapy, inhaled gases, and aerosols in the care of critically ill patients. The available evidence supports the use of high-flow nasal cannulae for selected patients with acute hypoxaemic respiratory failure. Heliox might prevent intubation or improve gas flow in mechanically ventilated patients with severe asthma. Additionally, it might improve the delivery of aerosolised bronchodilators in obstructive lung disease in general. Inhaled nitric oxide might improve outcomes in a subset of patients with postoperative pulmonary hypertension who had cardiac surgery; however, it has not been shown to provide long-term benefit in patients with acute respiratory distress syndrome (ARDS). Inhaled prostacyclins, similar to inhaled nitric oxide, are not recommended for routine use in patients with ARDS, but can be used to improve oxygenation in patients who are not adequately stabilised with traditional therapies. Aerosolised bronchodilators are useful in mechanically ventilated patients with asthma and chronic obstructive pulmonary disease, but are not recommended for those with ARDS. Use of aerosolised antibiotics for ventilator-associated pneumonia and ventilator-associated tracheobronchitis shows promise, but the delivered dose can be highly variable if proper attention is not paid to the delivery method.
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Affiliation(s)
- Sean D Levy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jehan W Alladina
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathryn A Hibbert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Scott Harris
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ednan K Bajwa
- Division of Pulmonary, Critical Care, and Sleep Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dean R Hess
- Respiratory Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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18
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Reddy KP, Bajwa EK, Parker RA, Onderdonk AB, Walensky RP. Relationship Between Upper Respiratory Tract Influenza Test Result and Clinical Outcomes Among Critically Ill Influenza Patients. Open Forum Infect Dis 2016; 3:ofw023. [PMID: 26966696 PMCID: PMC4784015 DOI: 10.1093/ofid/ofw023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 01/12/2016] [Accepted: 01/31/2016] [Indexed: 12/30/2022] Open
Abstract
Among critically ill patients with lower respiratory tract (LRT)-confirmed influenza, we retrospectively observed worse 28-day clinical outcomes in upper respiratory tract (URT)-negative versus URT-positive subjects. This finding may reflect disease progression and highlights the need for influenza testing of both URT and LRT specimens to improve diagnostic yield and possibly inform prognosis.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center; Division of Pulmonary and Critical Care Medicine; Division of Pulmonary and Critical Care Medicine; Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School, Boston, Massachusetts
| | - Ednan K Bajwa
- Division of Pulmonary and Critical Care Medicine; Harvard Medical School, Boston, Massachusetts
| | - Robert A Parker
- Medical Practice Evaluation Center; Division of General Internal Medicine; Biostatistics Center; Harvard Medical School, Boston, Massachusetts
| | | | - Rochelle P Walensky
- Medical Practice Evaluation Center; Division of General Internal Medicine; Division of Infectious Disease, Massachusetts General Hospital; Division of Infectious Disease, Brigham and Women's Hospital; Harvard Medical School, Boston, Massachusetts
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Rudolf JW, Lewandrowski EL, Lewandrowski KB, Januzzi JL, Bajwa EK, Baron JM. ST2 Predicts Mortality and Length of Stay in a Critically Ill Noncardiac Intensive Care Unit Population. Am J Clin Pathol 2016; 145:203-10. [PMID: 26857195 DOI: 10.1093/ajcp/aqv082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 01/30/2023] Open
Abstract
OBJECTIVES The biomarker suppression of tumorigenicity 2 (ST2) is a well-established clinical biomarker of cardiac strain and is frequently elevated in a variety of cardiac conditions. Here, we sought to evaluate the prognostic value of ST2 in critically ill medical intensive care unit (MICU) patients without primary cardiac illness. METHODS We measured ST2 and high-sensitivity troponin T (hsTnT) on plasma specimens collected on 441 patients following admission to a noncardiac MICU and evaluated the prognostic power of ST2 both alone and in multivariate models. RESULTS Of these critically ill patients, 96% exhibited ST2 concentrations above the reference interval. ST2 concentrations were highly predictive of intensive care unit and hospital length of stay, as well as in-hospital mortality, with high concentrations predicting a poor prognosis. Rates of in-hospital mortality were more than four times higher in patients with ST2 concentrations in the highest compared with the lowest quartile. In multivariate analysis, ST2 remained an important predictor of death after adjustment for age, hsTnT, and common diagnoses. CONCLUSIONS ST2 is increased and predictive of prognosis in critically ill patients without primary cardiac disease, suggesting that critically ill patients may often have unrecognized cardiac injury. Clinical decision support algorithms incorporating ST2 and hsTnT results may be useful in patient risk stratification.
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Affiliation(s)
- Joseph W Rudolf
- From the Department of Pathology and Divisions of Harvard Medical School, Boston, MA
| | | | - Kent B Lewandrowski
- From the Department of Pathology and Divisions of Harvard Medical School, Boston, MA
| | | | - Ednan K Bajwa
- Harvard Medical School, Boston, MA. Pulmonary/Critical Care, Massachusetts General Hospital
| | - Jason M Baron
- From the Department of Pathology and Divisions of Harvard Medical School, Boston, MA.
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Ambrus DB, Benjamin EJ, Bajwa EK, Hibbert KA, Walkey AJ. Corrigendum to: "Risk factors and outcomes associated with new-onset atrial fibrillation during acute respiratory distress syndrome" [J Crit Care 2015;30(5):994-997]. J Crit Care 2015; 30:1421. [PMID: 26719064 DOI: 10.1016/j.jcrc.2015.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel B Ambrus
- Department of Internal Medicine, Section of Hospital Medicine, Umass Memorial Medical Center, Worcester, MA; Department of Medicine, Division of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Emelia J Benjamin
- Department of Medicine, Section of Cardiovascular Medicine and Preventive Medicine, Boston University School of Medicine, Boston, MA
| | - Ednan K Bajwa
- Department of Medicine, Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA
| | - Kathryn A Hibbert
- Department of Medicine, Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA
| | - Allan J Walkey
- Department of Medicine, Section of Pulmonary and Critical Care, The Pulmonary Center, Boston University School of Medicine, Boston, MA.
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21
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Biddinger PD, Hooper DC, Shenoy ES, Bajwa EK, Robbins GK, Branda JA. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 28-2015. A 32-Year-Old Man with Fever, Headache, and Myalgias after Traveling from Liberia. N Engl J Med 2015; 373:1060-7. [PMID: 26352818 DOI: 10.1056/nejmcpc1503828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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22
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Wei Y, Wang Z, Su L, Chen F, Tejera P, Bajwa EK, Wurfel MM, Lin X, Christiani DC. Platelet count mediates the contribution of a genetic variant in LRRC16A to ARDS risk. Chest 2015; 147:607-617. [PMID: 25254322 DOI: 10.1378/chest.14-1246] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Platelets are believed to be critical in pulmonary-origin ARDS as mediators of endothelial damage through their interactions with fibrinogen and multiple signal transduction pathways. A prior meta-analysis identified five loci for platelet count (PLT): BAD, LRRC16A, CD36, JMJD1C, and SLMO2. This study aims to validate the quantitative trait loci (QTLs) of PLT within BAD, LRRC16A, CD36, JMJD1C, and SLMO2 among critically ill patients and to investigate the associations of these QTLs with ARDS risk that may be mediated through PLT. METHODS ARDS cases and at-risk control subjects were recruited from the intensive care unit of the Massachusetts General Hospital. Exome-wide genotyping data of 629 ARDS cases and 1,026 at-risk control subjects and genome-wide gene expression profiles of 18 at-risk control subjects were generated for analysis. RESULTS Single-nucleotide polymorphism (SNP) rs7766874 within LRRC16A was a significant locus for PLT among at-risk control subjects (β = -13.00; 95% CI, -23.22 to -2.77; P = .013). This association was validated using LRRC16A gene expression data from at-risk control subjects (β = 77.03 per 1 SD increase of log2-transformed expression; 95% CI, 27.26-126.80; P = .005). Further, rs7766874 was associated with ARDS risk conditioned on PLT (OR = 0.68; 95% CI, 0.51-0.90; P = .007), interacting with PLT (OR = 1.15 per effect allele per 100 × 103/μL of PLT; 95% CI, 1.03-1.30; P = .015), and mediated through PLT (indirect OR = 1.045; 95% CI, 1.007-1.085; P = .021). CONCLUSIONS Our findings support the role of LRRC16A in platelet formation and suggest the importance of LRRC16A in ARDS pathophysiology by interacting with, and being mediated through, platelets.
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Affiliation(s)
- Yongyue Wei
- Department of Environmental Health, Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Zhaoxi Wang
- Department of Environmental Health, Harvard School of Public Health, Boston, MA
| | - Li Su
- Department of Environmental Health, Harvard School of Public Health, Boston, MA
| | - Feng Chen
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory for Modern Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Paula Tejera
- Department of Environmental Health, Harvard School of Public Health, Boston, MA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark M Wurfel
- Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Seattle, WA
| | - Xihong Lin
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - David C Christiani
- Department of Environmental Health, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Abstract
In recent years, numerous studies have focused on the use of soluble ST2 (sST2) as a clinical biomarker for cardiovascular disease. However, much preclinical data points to involvement of the ST2 pathway in inflammation, and specifically in pulmonary inflammation. This report summarizes the current body of clinical data suggesting the potential role of the ST2 pathway in clinical disease, including evidence that sST2 could be a useful biomarker in both allergic and nonallergic pulmonary disease.
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Affiliation(s)
- Ednan K Bajwa
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, University of Paris Diderot, Paris, France
| | - James L Januzzi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Lee J, Geyer B, Naraghi L, Kaafarani HMA, Eikermann M, Yeh DD, Bajwa EK, Cobb JP, Raja AS. Advanced imaging use in intensive care units has decreased, resulting in lower charges without negative effects on patient outcomes. J Crit Care 2014; 30:460-4. [PMID: 25596998 DOI: 10.1016/j.jcrc.2014.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 09/22/2014] [Revised: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE There has been both greater recognition and scrutiny of the increased use of advanced imaging. Our aim was to determine whether there has been a change over time in the use of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US) modalities in the intensive care units (ICUs). MATERIALS AND METHODS A retrospective review of 75657 admissions to 20 ICUs was conducted. Results were analyzed with multivariate linear, negative binomial, and Poisson regressions. Primary outcomes were rates of use of CT, MRI, and US per 1000 ICU admissions every 6 months. Secondary outcomes were changes in radiology use associated with impacts on mortality, hospital length of stay (LOS), ICU LOS, and hospital charges. RESULTS The rate of imaging use decreased by 13.5% between 2007 and 2011 (incidence rate ratio [IRR], 0.982; P < .001). Most of this decrease was by CTs (21.0%; IRR, 0.973; P < .001). Use of MRI decreased by 6.0% (IRR, 0.991; P = .04), whereas US increased by 18.9% (IRR, 1.012; P < .001). The charges associated with imaging decreased by $74 per ICU admission, which would save an estimated $1.2 million in charges during 2011. Decreased imaging was not associated with changes in mortality, hospital, and ICU LOS. CONCLUSION Advanced imaging use decreased for 5 years in the ICUs, resulting in decreased charges without negative effects on patient outcomes.
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Affiliation(s)
- Jarone Lee
- Departments of Surgery and Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Brian Geyer
- Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA.
| | - Leily Naraghi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - D Dante Yeh
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Ednan K Bajwa
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - J Perren Cobb
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA.
| | - Ali S Raja
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
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Wilson JG, Liu KD, Zhuo H, Caballero L, McMillan M, Fang X, Cosgrove K, Vojnik R, Calfee CS, Lee JW, Rogers AJ, Levitt J, Wiener-Kronish J, Bajwa EK, Leavitt A, McKenna D, Thompson BT, Matthay MA. Mesenchymal stem (stromal) cells for treatment of ARDS: a phase 1 clinical trial. Lancet Respir Med 2014; 3:24-32. [PMID: 25529339 DOI: 10.1016/s2213-2600(14)70291-7] [Citation(s) in RCA: 542] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND No effective pharmacotherapy for acute respiratory distress syndrome (ARDS) exists, and mortality remains high. Preclinical studies support the efficacy of mesenchymal stem (stromal) cells (MSCs) in the treatment of lung injury. We aimed to test the safety of a single dose of allogeneic bone marrow-derived MSCs in patients with moderate-to-severe ARDS. METHODS The STem cells for ARDS Treatment (START) trial was a multicentre, open-label, dose-escalation, phase 1 clinical trial. Patients were enrolled in the intensive care units at University of California, San Francisco, CA, USA, Stanford University, Stanford, CA, USA, and Massachusetts General Hospital, Boston, MA, USA, between July 8, 2013, and Jan 13, 2014. Patients were included if they had moderate-to-severe ARDS as defined by the acute onset of the need for positive pressure ventilation by an endotracheal or tracheal tube, a PaO2:FiO2 less than 200 mm Hg with at least 8 cm H2O positive end-expiratory airway pressure (PEEP), and bilateral infiltrates consistent with pulmonary oedema on frontal chest radiograph. The first three patients were treated with low dose MSCs (1 million cells/kg predicted bodyweight [PBW]), the next three patients received intermediate dose MSCs (5 million cells/kg PBW), and the final three patients received high dose MSCs (10 million cells/kg PBW). Primary outcomes included the incidence of prespecified infusion-associated events and serious adverse events. The trial is registered with ClinicalTrials.gov, number NCT01775774. FINDINGS No prespecified infusion-associated events or treatment-related adverse events were reported in any of the nine patients. Serious adverse events were subsequently noted in three patients during the weeks after the infusion: one patient died on study day 9, one patient died on study day 31, and one patient was discovered to have multiple embolic infarcts of the spleen, kidneys, and brain that were age-indeterminate, but thought to have occurred before the MSC infusion based on MRI results. None of these severe adverse events were thought to be MSC-related. INTERPRETATION A single intravenous infusion of allogeneic, bone marrow-derived human MSCs was well tolerated in nine patients with moderate to severe ARDS. Based on this phase 1 experience, we have proceeded to phase 2 testing of MSCs for moderate to severe ARDS with a primary focus on safety and secondary outcomes including respiratory, systemic, and biological endpoints. FUNDING The National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Jennifer G Wilson
- Departments of Emergency Medicine and Anesthesia, University of California, San Francisco, CA, USA
| | - Kathleen D Liu
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Hanjing Zhuo
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Lizette Caballero
- Clinical Laboratories, Blood and Marrow Transplant Laboratory, University of California, San Francisco, CA, USA
| | - Melanie McMillan
- Clinical Laboratories, Blood and Marrow Transplant Laboratory, University of California, San Francisco, CA, USA
| | - Xiaohui Fang
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Katherine Cosgrove
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, MA, USA
| | - Rosemary Vojnik
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Carolyn S Calfee
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Jae-Woo Lee
- Department of Anesthesia, University of California, San Francisco, CA, USA
| | - Angela J Rogers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Joseph Levitt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jeanine Wiener-Kronish
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Cambridge, MA, USA
| | - Ednan K Bajwa
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, MA, USA
| | - Andrew Leavitt
- Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - David McKenna
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, MA, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, CA, USA.
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Baron JM, Lewandrowski EL, Januzzi JL, Bajwa EK, Thompson BT, Lewandrowski KB. Measurement of high-sensitivity troponin T in noncardiac medical intensive care unit patients. Correlation to mortality and length of stay. Am J Clin Pathol 2014; 141:488-93. [PMID: 24619748 DOI: 10.1309/ajcplvqqy35xtfvn] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 10/25/2022] Open
Abstract
OBJECTIVES To assess the frequency, magnitude, and prognostic significance of elevations in cardiac troponin T in noncardiac critically ill patients, including elevations at levels below the limit of detection of traditional assays. METHODS Using a high-sensitivity assay, we measured troponin T (high-sensitivity troponin T [hsTnT]) in 451 unique patients within 12 hours of their admission to a noncardiac medical intensive care unit. Outcomes of patients, grouped by hsTnT level, were compared. RESULTS Overall, 98% of the study patients had detectable levels of hsTnT (>3 ng/L), and 33% had levels above the diagnostic cutoff of a traditional fourth-generation cardiac troponin T assay. Patient groups with higher hsTnT levels had markedly higher rates of in-hospital mortality (P < .001) and longer stays in the hospital and intensive care unit (P < .01). CONCLUSIONS In noncardiac critically ill patients, cardiac troponin T elevations are common but often at levels undetectable by traditional assays. hsTnT elevations predict a more complex clinical course and an increased risk of death.
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Affiliation(s)
- Jason M. Baron
- Department of Pathology and Divisions of Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elizabeth L. Lewandrowski
- Department of Pathology and Divisions of Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
| | - James L. Januzzi
- Harvard Medical School, Boston, MA
- Cardiology, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Ednan K. Bajwa
- Harvard Medical School, Boston, MA
- Pulmonary/Critical Care, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - B. Taylor Thompson
- Harvard Medical School, Boston, MA
- Pulmonary/Critical Care, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Kent B. Lewandrowski
- Department of Pathology and Divisions of Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
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Nejad SH, Schaefer PW, Bajwa EK, Smith FA. Case records of the Massachusetts General Hospital. Case 39-2012. A 55-year-old man with alcoholism, recurrent seizures, and agitation. N Engl J Med 2012; 367:2428-34. [PMID: 23252529 DOI: 10.1056/nejmcpc1114035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Shamim H Nejad
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA
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Abstract
Obstructive sleep apnea (OSA) is a condition of repetitive upper airway collapse, which occurs during sleep. Recent literature has emphasized the role of OSA in contributing to glucose intolerance, dyslipidemia, and hypertension. OSA is associated with the development of cardiovascular disease, although definitive data are sparse with regard to the prevention of cardiovascular disease and CPAP therapy. CPAP provides effective treatment for OSA, but patient adherence remains challenging. Aside from daytime symptom improvement, it is difficult to monitor the adequacy of treatment response. Thus, the search for a biomarker becomes critical. The discovery of an ideal biomarker for OSA has the potential to provide information related to diagnosis, severity, prognosis, and response to treatment. In addition, because large-scale randomized controlled trials are both ethically and logistically challenging in assessing hard cardiovascular outcomes, certain biomarkers may be reasonable surrogate outcome measures. This article reviews the literature related to potential biomarkers of OSA with the recognition that an ideal biomarker does not exist at this time.
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Affiliation(s)
- Sydney B Montesi
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
| | - Ednan K Bajwa
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Atul Malhotra
- Department of Sleep Medicine, Brigham and Women's Hospital, Boston, MA
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McCannon JB, O'Donnell WJ, Thompson BT, El-Jawahri A, Chang Y, Ananian L, Bajwa EK, Currier PF, Parikh M, Temel JS, Cooper Z, Wiener RS, Volandes AE. Augmenting communication and decision making in the intensive care unit with a cardiopulmonary resuscitation video decision support tool: a temporal intervention study. J Palliat Med 2012; 15:1382-7. [PMID: 23098632 DOI: 10.1089/jpm.2012.0215] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Effective communication between intensive care unit (ICU) providers and families is crucial given the complexity of decisions made regarding goals of therapy. Using video images to supplement medical discussions is an innovative process to standardize and improve communication. In this six-month, quasi-experimental, pre-post intervention study we investigated the impact of a cardiopulmonary resuscitation (CPR) video decision support tool upon knowledge about CPR among surrogate decision makers for critically ill adults. METHODS We interviewed surrogate decision makers for patients aged 50 and over, using a structured questionnaire that included a four-question CPR knowledge assessment similar to those used in previous studies. Surrogates in the post-intervention arm viewed a three-minute video decision support tool about CPR before completing the knowledge assessment and completed questions about perceived value of the video. RESULTS We recruited 23 surrogates during the first three months (pre-intervention arm) and 27 surrogates during the latter three months of the study (post-intervention arm). Surrogates viewing the video had more knowledge about CPR (p=0.008); average scores were 2.0 (SD 1.1) and 2.9 (SD 1.2) (out of a total of 4) in pre-intervention and post-intervention arms. Surrogates who viewed the video were comfortable with its content (81% very) and 81% would recommend the video. CPR preferences for patients at the time of ICU discharge/death were distributed as follows: pre-intervention: full code 78%, DNR 22%; post-intervention: full code 59%, DNR 41% (p=0.23).
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Rivara MB, Bajwa EK, Januzzi JL, Gong MN, Thompson BT, Christiani DC. Prognostic significance of elevated cardiac troponin-T levels in acute respiratory distress syndrome patients. PLoS One 2012; 7:e40515. [PMID: 22808179 PMCID: PMC3395687 DOI: 10.1371/journal.pone.0040515] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [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: 02/08/2012] [Accepted: 06/11/2012] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Elevated levels of biochemical markers of myocardial necrosis have been associated with worsened outcomes in Acute Respiratory Distress Syndrome (ARDS), but there are few prospective data on this relationship. We investigated elevated cardiac troponin T (cTnT) levels and their relationship with outcome in patients with ARDS. METHODS A prospective cohort study of patients with ARDS was conducted at a tertiary-care academic medical center. Patients had blood taken within 48 hours of ARDS onset and assayed for cTnT. Patients were followed for the outcomes of 60-day mortality, number of organ failures, and days free of mechanical ventilation. Echocardiographic and electrocardiographic (ECG) data were analyzed for signs of myocardial ischemia, infarction, or other myocardial dysfunction. RESULTS 177 patients were enrolled, 70 of whom died (40%). 119 patients had detectable cTnT levels (67%). Median cTnT level was 0.03 ng/mL, IQR 0-0.10 ng/mL, and levels were higher among non-survivors (P = .008). Increasing cTnT level was significantly associated with increasing mortality (P = .008). The association between increasing cTnT level and mortality remained significant after adjustment in a multivariate model (HR(adj) = 1.45, 95% CI 1.17-1.81, P = .001). Elevated cTnT level was also associated with increased number of organ failures (P = .002), decreased number of days free of mechanical ventilation (P = .03), echocardiographic wall motion abnormalities (P = 0.001), and severity of tricuspid regurgitation (P = .04). There was no association between ECG findings of myocardial ischemia or infarction and elevated cTnT. CONCLUSIONS Elevated cTnT levels are common in patients with ARDS, and are associated with worsened clinical outcomes and certain echocardiographic abnormalities. No association was seen between cTnT levels and ECG evidence of coronary ischemia.
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Affiliation(s)
- Matthew B. Rivara
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Ednan K. Bajwa
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - James L. Januzzi
- Cardiology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Michelle N. Gong
- Critical Care Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - B. Taylor Thompson
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David C. Christiani
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, United States of America
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Bajwa EK. Acute lung injury: time to find a way that works. Respir Care 2011; 56:714-5. [PMID: 21669107 DOI: 10.4187/respcare.01350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sheu CC, Gong MN, Zhai R, Chen F, Bajwa EK, Clardy PF, Gallagher DC, Thompson BT, Christiani DC. Clinical characteristics and outcomes of sepsis-related vs non-sepsis-related ARDS. Chest 2010; 138:559-67. [PMID: 20507948 DOI: 10.1378/chest.09-2933] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND ARDS may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS, but little is known about the differences between sepsis-related and non-sepsis-related ARDS. METHODS A total of 2,786 patients with ARDS-predisposing conditions were enrolled consecutively into a prospective cohort, of which 736 patients developed ARDS. We defined sepsis-related ARDS as ARDS developing in patients with sepsis and non-sepsis-related ARDS as ARDS developing after nonseptic injuries, such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. RESULTS Compared with patients with non-sepsis-related ARDS (n = 62), patients with sepsis-related ARDS (n = 524) were more likely to be women and to have diabetes, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (median, 78 vs 65, P < .0001). There were no differences in lung injury score, blood pH, Pao(2)/Fio(2) ratio, and Paco(2) on ARDS diagnosis. However, patients with sepsis-related ARDS had significantly lower Pao(2)/Fio(2) ratios than patients with non-sepsis-related ARDS patients on ARDS day 3 (P = .018), day 7 (P = .004), and day 14 (P = .004) (repeated-measures analysis, P = .011). Compared with patients with non-sepsis-related ARDS, those with sepsis-related had a higher 60-day mortality (38.2% vs 22.6%; P = .016), a lower successful extubation rate (53.6% vs 72.6%; P = .005), and fewer ICU-free days (P = .0001) and ventilator-free days (P = .003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality (hazard ratio, 1.26; 95% CI, 0.71-2.22). CONCLUSION Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ARDS. Worse clinical outcomes in sepsis-related ARDS appear to be driven by disease severity and comorbidities.
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Affiliation(s)
- Chau-Chyun Sheu
- Department of Environmental Health, Harvard School of Public Health, Boston, MA 02115, USA
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Sheu CC, Gong MN, Zhai R, Bajwa EK, Chen F, Thompson BT, Christiani DC. The influence of infection sites on development and mortality of ARDS. Intensive Care Med 2010; 36:963-70. [PMID: 20229040 DOI: 10.1007/s00134-010-1851-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 12/14/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Infection is the most frequent cause of acute respiratory distress syndrome (ARDS). However, little is known about the influence of infection sites on ARDS. This study aimed to assess the associations of infection sites with ARDS development and mortality in critically ill infected patients. DESIGN Prospective observational study. SETTING Adult intensive care units (ICUs) of an academic medical center. PATIENTS Study population included 1,973 consecutive patients admitted to ICUs with bacteremia, pneumonia or sepsis. During follow-up, 549 patients developed ARDS and 212 of them died within 60 days. MAIN RESULTS The distribution of infection sites in ARDS patients was: lung (77.2%), abdomen (19.3%), skin/soft tissues (6.0%), urinary tract (4.7%), unknown (2.6%), and multiple sites (17.7%). On multivariate analysis, lung was the only infection site associated with increased ARDS risk [adjusted odds ratio (OR) 3.49]. Urinary tract (adjusted OR 0.43), skin/soft tissue (adjusted OR 0.64), and unknown-site infections (adjusted OR 0.38) were associated with decreased risk. No association was found between individual infection site and ARDS mortality. However, unknown-site [adjusted hazard ratio (HR) 3.08] and multiple-site infections (adjusted HR 1.63) were associated with increased ARDS mortality. When grouping patients into pulmonary, nonpulmonary, and combined infections, nonpulmonary infection was associated with decreased ARDS risk (adjusted OR 0.28) and combined infections was associated with increased ARDS mortality (adjusted HR 1.69), compared with pulmonary infection. CONCLUSIONS In critically ill infected patients, pulmonary infection is associated with higher risk of ARDS development than are infections at other sites. Pulmonary versus nonpulmonary infection significantly affects ARDS development but not mortality.
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Affiliation(s)
- Chau-Chyun Sheu
- Department of Environmental Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
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Gong MN, Bajwa EK, Thompson BT, Christiani DC. Body mass index is associated with the development of acute respiratory distress syndrome. Thorax 2009; 65:44-50. [PMID: 19770169 DOI: 10.1136/thx.2009.117572] [Citation(s) in RCA: 230] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The relationship between body mass index (BMI) and development of acute respiratory distress syndrome (ARDS) is unknown. METHODS A cohort study of critically ill patients at risk for ARDS was carried out. BMI was calculated from admission height and weight. Patients were screened daily for AECC (American European Consensus Committee)-defined ARDS and 60-day ARDS mortality. RESULTS Of 1795 patients, 83 (5%) patients were underweight (BMI <18.5 kg/m(2)), 627 (35%) normal (BMI 18.5-24.9), 605 (34%) overweight (BMI 25-29.9), 364 (20%) obese (BMI 30-39.9) and 116 (6%) severely obese (BMI > or =40). Increasing weight was associated with younger age (p<0.001), diabetes (p<0.0001), higher blood glucose (p<0.0001), lower prevalence of direct pulmonary injury (p<0.0001) and later development of ARDS (p = 0.01). BMI was associated with ARDS on multivariate analysis (OR(adj) 1.24 per SD increase; 95% CI 1.11 to 1.39). Similarly, obesity was associated with ARDS compared with normal weight (OR(adj) 1.66; 95% CI 1.21 to 2.28 for obese; OR(adj) 1.78; 95% CI 1.12 to 2.92 for severely obese). Exploratory analysis in a subgroup of intubated patients without ARDS on admission (n = 1045) found that obese patients received higher peak (p<0.0001) and positive end-expiratory pressures (p<0.0001) than non-obese patients. Among patients with ARDS, increasing BMI was associated with increased length of stay (p = 0.007) but not with mortality (OR(adj) 0.89 per SD increase; 95% CI 0.71 to 1.12). CONCLUSION BMI was associated with increased risk of ARDS in a weight-dependent manner and with increased length of stay, but not with mortality. Additional studies are needed to determine whether differences in initial ventilator settings may contribute to ARDS development in the obese.
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Affiliation(s)
- M N Gong
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
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Bajwa EK, Khan UA, Januzzi JL, Gong MN, Thompson BT, Christiani DC. Plasma C-reactive protein levels are associated with improved outcome in ARDS. Chest 2009; 136:471-480. [PMID: 19411291 DOI: 10.1378/chest.08-2413] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND C-reactive protein (CRP) has been studied as a marker of systemic inflammation and outcome in a number of diseases, but little is known about its characteristics in ARDS. We sought to examine plasma levels of CRP in patients with ARDS and their relationship to outcome and measures of illness severity. METHODS We measured CRP levels in 177 patients within 48 h of disease onset and tested the association of protein level with 60-day mortality, 28-day daily organ dysfunction scores, and number of ventilator-free days. RESULTS We found that CRP levels were significantly lower in nonsurvivors when compared with survivors (p = 0.02). Mortality rate decreased with increasing CRP decile (p = 0.02). An increasing CRP level was associated with a significantly higher probability of survival at 60 days (p = 0.005). This difference persisted after adjustment for age and severity of illness in a multivariable model (p = 0.009). Multivariable models were also used to show that patients in the group with higher CRP levels had significantly lower organ dysfunction scores (p = 0.001) and more ventilator-free days (p = 0.02). CONCLUSIONS Increasing plasma levels of CRP within 48 h of ARDS onset are associated with improved survival, lower organ failure scores, and fewer days of mechanical ventilation. These data appear to be contrary to the established view that CRP is solely a marker of systemic inflammation.
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Affiliation(s)
- Ednan K Bajwa
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Uzma A Khan
- Department of Environmental Health, Harvard School of Public Health, Boston, MA
| | - James L Januzzi
- Cardiology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michelle N Gong
- Pulmonary and Critical Care Division, Mount Sinai School of Medicine, New York, NY
| | - B Taylor Thompson
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David C Christiani
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Environmental Health, Harvard School of Public Health, Boston, MA.
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Abstract
Individual genetic factors have long been suspected of playing a major role in susceptibility to acute lung injury and acute respiratory distress syndrome. Flores and colleagues evaluate the quality of published studies testing the relationships between variation in candidate genes and susceptibility to lung injury syndromes or worsened outcome in patients with these conditions. Their results demonstrate that while important advances have been made in this area, attention should be paid to improving the methodology of future studies in order to minimize the chances of publishing false-positive results.
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Affiliation(s)
- Ednan K Bajwa
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Abstract
OBJECTIVE Pre-B-cell colony-enhancing factor (PBEF) levels are elevated in bronchoalveolar lavage fluid and serum of patients with acute lung injury. There are several suspected functional polymorphisms of the corresponding PBEF gene. We hypothesized that variations in PBEF gene polymorphisms alter the risk of developing acute respiratory distress syndrome (ARDS). DESIGN Nested case-control study. SETTING Tertiary academic medical center. PATIENTS We studied 375 patients with ARDS and 787 at-risk controls genotyped for the PBEF T-1001G and C-1543T polymorphisms. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients with the -1001G (variant) allele had significantly greater odds of developing ARDS than wild-type homozygotes (odds ratio, 1.35; 95% confidence interval, 1.02-1.78). Patients with the -1543T (variant) allele did not have significantly different odds of developing ARDS than wild-type homozygotes (odds ratio, 0.86; 95% confidence interval, 0.65-1.13). When analysis was stratified by ARDS risk factor, -1543T was associated with decreased odds of developing ARDS in septic shock patients (odds ratio, 0.66; 95% confidence interval, 0.45-0.97). Also, -1001G was associated with increased hazard of intensive care unit mortality, whereas -1543T was associated with decreased hazard of 28-day and 60-day ARDS mortality, as well as shorter duration of mechanical ventilation. Similar results were found in analyses of the related GC (-1001G:-1543C) and TT (-1001T:-1543T) haplotypes. CONCLUSIONS The PBEFT-1001G variant allele and related haplotype are associated with increased odds of developing ARDS and increased hazard of intensive care unit mortality among at-risk patients, whereas the C-1543T variant allele and related haplotype are associated with decreased odds of ARDS among patients with septic shock and better outcomes among patients with ARDS.
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Affiliation(s)
- Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
CONTEXT Despite the investigation of multiple therapeutic options, idiopathic pulmonary fibrosis (IPF) remains a devastating, progressively fatal disease. Much interest has focused on the use of interferon (IFN)-gamma1b therapy, but the efficacy of this treatment has not been proven. OBJECTIVE To determine whether IFN treatment reduces mortality in patients with IPF. DESIGN A meta-analysis of randomized controlled trials evaluating the use of IFN-gamma1b as treatment for IPF. MAIN OUTCOME MEASURE Mortality in patients treated with IFN-gamma1b was compared to mortality in patients treated with control therapies. RESULTS A total of three studies involving 390 patients was included in the analysis. IFN-gamma1b therapy was associated with reduced mortality (hazard ratio [HR], 0.418; 95% confidence interval [CI], 0.253 to 0.690; p = 0.0003). A comparison of mortality at different time points revealed that IFN-gamma1b therapy was associated with significantly reduced mortality at 1 year (0.0861; 95% CI, 0.0244 to 0.1478; p = 0.0063), 18 months (0.1682; 95% CI, 0.1065 to 0.2299; p < 0.0001), 650 days (0.1939; 95% CI, 0.1386 to 0.2492; p < 0.0001), and 2 years (0.2652; 95% CI, 0.1652 to 0.3652; p < 0.0001). CONCLUSION When the results of multiple studies are combined in a meta-analysis, IFN-gamma1b therapy is associated with reduced mortality.
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Affiliation(s)
- Ednan K Bajwa
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Abstract
Intensive monitoring is a crucial component of the management of shock. However, there is little consensus about optimal strategies for monitoring. Although the pulmonary artery catheter has been widely used, conflicting data exist about the utility of this device. A variety of other techniques have been developed in hopes of providing clinically useful information about myocardial function, intravascular volume, and indices of organ function. In addition, there is evolving evidence that targeting and monitoring certain physiological goals may be most important early in the course of shock. In this chapter, we examine many of the available monitoring techniques and the evidence supporting their use.
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Affiliation(s)
- Ednan K. Bajwa
- Massachusetts General Hospital, Pulmonary and Critical Care Unit, Boston, Massachusetts
| | | | - B. Taylor Thompson
- Massachusetts General Hospital, Pulmonary and Critical Care Unit, Boston, Massachusetts
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