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Riley L, Sriram A, Brantly M, Lascano J. Testing Patterns and Disparities for Alpha-1 Antitrypsin Deficiency. Am J Med 2023; 136:1011-1017. [PMID: 37451388 DOI: 10.1016/j.amjmed.2023.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/06/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency is an under-recognized genetic cause of chronic lung and liver disease; it remains unclear what the testing frequency and disparities are for alpha-1 antitrypsin deficiency. METHODS This is a retrospective cohort study of people with newly diagnosed chronic obstructive pulmonary disease and liver disease identified at the University of Florida between January 1, 2012 and December 31, 2021. We performed incidence and prevalence analysis for alpha-1 antitrypsin (AAT) testing and point-biserial correlation analysis for tobacco use and AAT testing. We evaluated characteristics with AAT testing using adjusted multivariable logistic regression. RESULTS Among 75,810 subjects with newly diagnosed chronic obstructive pulmonary disease and liver disease between 2012 and 2021, 4248 (5.6%) were tested for AAT deficiency. All subjects had an AAT level performed, while 1654 (39%) had phenotype testing. Annual incidence of testing increased for subjects with newly diagnosed chronic obstructive pulmonary disease or liver disease from 2.8% and 5.4%, respectively, in 2012 to 4.1% and 11.3%, respectively, in 2021. Adjusted multivariable regression analysis showed factors favoring AAT testing were White race, and concomitant chronic obstructive pulmonary disease and liver disease. Increasing age, non-White race, current tobacco use, and being a male with chronic obstructive pulmonary disease had lower odds of AAT testing. CONCLUSION Although slowly improving, testing for AAT deficiency continues to have a low uptake in the clinical setting despite guidelines recommending broader testing. Individuals of White race and those with concomitant chronic obstructive pulmonary disease and liver disease are more likely to be tested, while older subjects, individuals of non-White race, current tobacco use, and men with chronic obstructive pulmonary disease are less favored to be tested.
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Affiliation(s)
- Leonard Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Kansas City Veterans Affairs Medical Center, Mo.
| | | | - Mark Brantly
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville
| | - Jorge Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville
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Campos M, Hagenlocker B, Lascano J, Riley L. Impact of a Computerized Clinical Decision Support System to Improve Chronic Obstructive Pulmonary Disease Diagnosis and Testing for Alpha-1 Antitrypsin Deficiency. Ann Am Thorac Soc 2023; 20:1116-1123. [PMID: 36989247 DOI: 10.1513/annalsats.202211-954oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/29/2023] [Indexed: 03/30/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) and alpha-1 antitrypsin deficiency (AATD) are underrecognized diseases. This is in part due to the underdiagnosis and lack of confirmation of COPD but also from poor adherence to AATD screening recommendations. Objectives: A clinical decision support system (CDSS) to guide primary care providers improves spirometry testing and confirmation of COPD diagnosis in subjects at risk and improves AATD screening in patients with confirmed COPD. Methods: A CDSS was created to be applied to all Veterans attending single-center Veterans Affairs primary care clinics. The CDSS had an algorithmic dialogue with components executed in phases during different clinic visits: screening for COPD risk using the COPD population screening (COPD-PS) questionnaire, spirometry recommendation, and ordering tool for subjects with a prior diagnosis of COPD or subjects considered high risk by the COPD-PS, dialogue to confirm or discard the diagnosis of COPD, and recommendations for AATD screening in subjects with confirmed COPD. The latter was performed by ordering alpha-1 antitrypsin (AAT) serum levels. Each step of the CDSS algorithm approach was recorded and available to be retrieved at a later date for analysis. Results: Over 6 years, a total of 6,235 Veterans >40 years of age completed the CDSS. According to the COPD-PS questionnaire, 962 (18.5%) subjects were identified as high risk for COPD. An additional 579 subjects with a prior diagnosis of COPD also entered the subsequent steps of the CDSS algorithm. Of the high-risk cohort, the CDSS led to an increase in spirometry testing from 24% to 83% and led to a new diagnosis of COPD in 342 (43%). In the prior COPD diagnosis group, spirometry testing increased from 58% to 84%, leading to COPD reconfirmation in only 326 (67%). A total of 489 (68%) subjects with confirmed COPD completed AAT testing prompted by the CDSS, with 23 subjects identified with AATD and one with severe AATD. Conclusions: In the Veterans Affairs system, the use of a clinical decision support system algorithm that incorporates screening for COPD and AATD improves COPD over- and underdiagnosis and screening rates of AATD in a primary care setting.
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Affiliation(s)
- Michael Campos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami, Miami, Florida
- Pulmonary Section, Department of Medicine, and
| | - Brian Hagenlocker
- Department of Primary Care Medicine, Miami Veterans Affairs Medical Center, Miami, Florida
| | - Jorge Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida; and
| | - Leonard Riley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
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Lascano J, Riley L, Khodayari N, Brantly M. Augmentation Therapy Modulates Systemic Inflammation in Individuals with Alpha-1 Antitrypsin Deficiency and Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2023; 10:308-316. [PMID: 37363834 PMCID: PMC10484495 DOI: 10.15326/jcopdf.2023.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 06/28/2023]
Abstract
Background Alpha-1 antitrypsin (AAT) deficiency is a genetic disorder that leads to chronic obstructive pulmonary disease (COPD) and lower circulating levels of AAT, which is a protease inhibitor with potent anti-inflammatory effects. In order to better understand the presence of systemic inflammation in AAT-deficient individuals with COPD, we investigatedthe plasma levels of C-reactive protein (CRP). Methods AAT-deficient individuals and a matched cohort with a normal AAT genotype were recruited from the Alpha-1 Foundation DNA and Tissue Bank. AAT genotypes were determined by a combination of a Taqman-based assay. AAT and CRP levels were determined by nephelometry. Comparisons were determined by unpaired t-test and standard Pearson's correlation. Results Our study included 40 control participants and 742 AAT-deficient participants, of which 498 received augmentation therapy. In the AAT-deficient participants, the plasma AAT was 20.2±11.6µM and 4.5±1.3µM (P<0.0001) with and without augmentation therapy, respectively, and the CRP was 0.32±0.53mg/dL and 0.69±1.97mg/dL (P=0.0169), respectively. There was a negative correlation between the percentage predicted of forced expiratory volume in 1 second and CRP in the group not receiving augmentation therapy (r=-0.2528, P<0.05), and there was no correlation in participants receiving augmentation therapy. Conclusion Compared to healthy individuals, AAT-deficient individuals with COPD have higher levels of circulating CRP, suggesting increased systemic inflammation. However, AAT-deficient individuals receiving augmentation therapy had lower plasma CRP levels compared to those who are not.
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Affiliation(s)
- J Lascano
- University of Florida, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, Florida, United States
| | - L Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri, United States
| | - N Khodayari
- University of Florida, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, Florida, United States
| | - M Brantly
- University of Florida, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, Florida, United States
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Rowe SM, Zuckerman JB, Dorgan D, Lascano J, McCoy K, Jain M, Schechter MS, Lommatzsch S, Indihar V, Lechtzin N, McBennett K, Callison C, Brown C, Liou TG, MacDonald KD, Nasr SZ, Bodie S, Vaughn M, Meltzer EB, Barbier AJ. Inhaled mRNA therapy for treatment of cystic fibrosis: Interim results of a randomized, double-blind, placebo-controlled phase 1/2 clinical study. J Cyst Fibros 2023; 22:656-664. [PMID: 37121795 PMCID: PMC10524666 DOI: 10.1016/j.jcf.2023.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND MRT5005, a codon-optimized CFTR mRNA, delivered by aerosol in lipid nanoparticles, was designed as a genotype-agnostic treatment for CF lung disease. METHODS This was a randomized, double-blind, placebo-controlled Phase 1/2 study performed in the US. Adults with 2 severe class I and/or II CFTR mutations and baseline ppFEV1 values between 50 and 90% were randomized 3:1 (MRT5005: placebo). Six dose levels of MRT5005 (4, 8, 12, 16, 20, and 24 mg) or placebo (0.9% Sodium Chloride) were administered by nebulization. The single ascending dose cohort was treated over a range from 8 to 24 mg; the multiple ascending dose cohort received five weekly doses (range 8-20 mg); and the daily dosing cohort received five daily doses (4 mg). RESULTS A total of 42 subjects were assigned to MRT5005 [31] or placebo [11]. A total of 14 febrile reactions were observed in 10 MRT5005-treated participants, which were mild [3] or moderate [11] in severity; two subjects discontinued related to these events. Additionally, two MRT5005-treated patients experienced hypersensitivity reactions, which were managed conservatively. The most common treatment emergent adverse events were cough and headache. No consistent effects on FEV1 were noted. CONCLUSIONS MRT5005 was generally safe and well tolerated through 28 days of follow-up after the last dose, though febrile and hypersensitivity reactions were noted. The majority of these reactions resolved within 1-2 days with supportive care allowing continued treatment with MRT5005 and careful monitoring. In this small first-in-human study, FEV1 remained stable after treatment, but no beneficial effects on FEV1 were observed.
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Affiliation(s)
- S M Rowe
- University of Alabama at Birmingham, USA
| | | | - D Dorgan
- Perelman School of Medicine, University of Pennsylvania, USA
| | - J Lascano
- University of Florida, Gainesville, USA
| | - K McCoy
- Nationwide Children's Hospital/the Ohio State University, USA
| | - M Jain
- Northwestern University Feinberg School of Medicine, USA
| | - M S Schechter
- Children's Hospital of Richmond at Virginia Commonwealth University, USA
| | | | | | | | - K McBennett
- University Hospitals, Cleveland Medical Center, USA
| | - C Callison
- University of Tennessee Medical Center, Knoxville, USA
| | - C Brown
- Indiana University School of Medicine, USA
| | - T G Liou
- University of Utah, Salt Lake City, USA
| | | | - S Z Nasr
- University of Michigan, Ann Arbor, USA
| | - S Bodie
- Translate Bio Inc, Lexington, MA, USA
| | - M Vaughn
- Translate Bio Inc, Lexington, MA, USA
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Katz JB, Shah P, Trillo CA, Alshaer MH, Peloquin C, Lascano J. Therapeutic drug monitoring in cystic fibrosis and associations with pulmonary exacerbations and lung function. Respir Med 2023; 212:107237. [PMID: 37030586 DOI: 10.1016/j.rmed.2023.107237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/20/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy have resulted in longer life expectancies, yet pulmonary exacerbations remain a leading cause of morbidity. Intravenous antibiotics is the mainstay treatment, however achieving adequate concentrations remains challenging. The effect of therapeutic drug monitoring (TDM) of beta-lactams on exacerbations and lung function has not been studied. METHODS Patient demographics, antibiotic regimens, forced expiratory volume 1 second (FEV1), and exacerbation history was obtained from 32 patients with cystic fibrosis admitted for exacerbations. All patients were colonized with Pseudomonas aeruginosa, received CFTR therapy for at least one year, and had 3-month interval follow ups. Plasma concentrations, FEV1, and exacerbation history was obtained before and after therapeutic drug monitoring. This included peak and trough plasma concentrations of piperacillin-tazobactam and cefepime using liquid chromatography with mass spectrometry. T-test and Mann-Whitney U test were used to compare medians/means of FEV1 and pulmonary exacerbations pre and post-TDM as well as free trough-to-minimum inhibitory concentration ratio (fCmin/MIC) ≥1 and ≥ 4. RESULTS TDM was associated with decreased exacerbations/year from 1.91 to 1.31 (p = 0.04) and among the cohort with >/ = 2 exacerbations per year, there was a longer exacerbation free interval after TDM (196.2 vs 103.7 days, p = 0.02). The decline in FEV1% predicted after therapeutic drug monitoring to the first exacerbation was -4.9 compared to -9.7 prior (p = 0.03). CONCLUSIONS TDM for cystic fibrosis pulmonary exacerbations results in decreased pulmonary exacerbations, longer intervals to pulmonary exacerbation, and lower decline in FEV1% predicted.
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Affiliation(s)
- Jason Brandon Katz
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Purav Shah
- Department of Internal Medicine, Pulmonary and Critical Care Division, Emory, Atlanta, GA, 30322, USA.
| | - Cesar A Trillo
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Jorge Lascano
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
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Kokturk N, Khodayari N, Lascano J, Riley EL, Brantly ML. Lung Inflammation in alpha-1-antitrypsin deficient individuals with normal lung function. Respir Res 2023; 24:40. [PMID: 36732772 PMCID: PMC9893669 DOI: 10.1186/s12931-023-02343-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/24/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Alpha-1-antitrypsin deficient (AATD) individuals are prone to develop early age of onset chronic obstructive pulmonary disease (COPD) more severe than non-genetic COPD. Here, we investigated the characteristics of lower respiratory tract of AATD individuals prior to the onset of clinically significant COPD. METHODS Bronchoalveolar lavage was performed on 22 AATD with normal lung function and 14 healthy individuals. Cell counts and concentrations of proteases, alpha-1-antitrypsin and proinflammatory mediators were determined in the bronchoalveolar lavage fluid from study subjects. In order to determine the airway inflammation, we also analyzed immune cell components of the large airways from bronchial biopsies using immunohistochemistry in both study subjects. Finally, we made comparisons between airway inflammation and lung function rate of decline using four repeated lung function tests over one year in AATD individuals. RESULTS AATD individuals with normal lung function had 3 folds higher neutrophil counts, 2 folds increase in the proteases levels, and 2-4 folds higher levels of IL-8, IL-6, IL-1β, and leukotriene B4 in their epithelial lining fluid compared to controls. Neutrophil elastase levels showed a positive correlation with the levels of IL-8 and neutrophils in AATD epithelial lining fluid. AATD individuals also showed a negative correlation of baseline FEV1 with neutrophil count, neutrophil elastase, and cytokine levels in epithelial lining fluid (p < 0.05). In addition, we observed twofold increase in the number of lymphocytes, macrophages, neutrophils, and mast cells of AATD epithelial lining fluid as compared to controls. CONCLUSION Mild inflammation is present in the lower respiratory tract and airways of AATD individuals despite having normal lung function. A declining trend was also noticed in the lung function of AATD individuals which was correlated with pro-inflammatory phenotype of their lower respiratory tract. This results suggest the presence of proinflammatory phenotype in AATD lungs. Therefore, early anti-inflammatory therapies may be a potential strategy to prevent progression of lung disease in AATD individuals.
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Affiliation(s)
- Nurdan Kokturk
- Division of Pulmonary, Critical Care and Sleep Medicine, J. Hillis Miller Health Science Center, University of Florida College of Medicine, P.O. Box 100225, Gainesville, FL, 32610-0225, USA
- Department of Pulmonary and Critical Care, Gazi University School of Medicine, Ankara, Turkey
| | - Nazli Khodayari
- Division of Pulmonary, Critical Care and Sleep Medicine, J. Hillis Miller Health Science Center, University of Florida College of Medicine, P.O. Box 100225, Gainesville, FL, 32610-0225, USA
| | - Jorge Lascano
- Division of Pulmonary, Critical Care and Sleep Medicine, J. Hillis Miller Health Science Center, University of Florida College of Medicine, P.O. Box 100225, Gainesville, FL, 32610-0225, USA
| | | | - Mark L Brantly
- Division of Pulmonary, Critical Care and Sleep Medicine, J. Hillis Miller Health Science Center, University of Florida College of Medicine, P.O. Box 100225, Gainesville, FL, 32610-0225, USA.
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Moguillansky D, Sharaf OM, Jin P, Samra R, Bryan J, Moguillansky NI, Lascano J, Kattan JN. Evaluation of Clinical Predictors for Major Outcomes in Patients Hospitalized With COVID-19: The Potential Role of the Rothman Index. Cureus 2022; 14:e28769. [PMID: 36225401 PMCID: PMC9531714 DOI: 10.7759/cureus.28769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The Rothman Index (RI, PeraHealth, Inc. Charlotte, NC, USA) is a predictive model intended to provide continuous monitoring of a patient's clinical status. There is limited data to support its use in the risk stratification of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We hypothesized that low admission RI scores would correlate with higher rates of adverse outcomes in patients hospitalized for coronavirus disease 2019 (COVID-19). Methods Medical records of adult patients admitted to a single 1,200-bed tertiary academic center were retrospectively reviewed for demographic data, baseline characteristics, RI scores, admission to intensive care unit (ICU), need for mechanical ventilation, and inpatient mortality. Statistical analyses were performed using STATA statistical software, version 17 (Stata Corp LLC, College Station, TX, USA). Continuous variables were analyzed using the Mann-Whitney test, and categorical variables were analyzed using Fisher’s exact test. Both univariate and multivariate analyses were performed. A p-value <0.05 was considered statistically significant. Results Median admission RI score for the entire cohort was 63.0 (IQR 45.0 - 77.1). The cohort was divided by admission RI into a low-risk group (RI ≥70; n=70) and a high-risk group (RI <70; n=107). Compared to patients with low-risk RI, patients with high-risk RI had higher mortality (95.2%, 95% CI: 85.8 - 105 vs 4.8%, 95% CI: -5 - 14.2, p < 0.01), were more likely to require ICU admission (90.2%, 95% CI: 81.9 - 98.5 vs 9.8%, 95% CI: 1.5 - 18.1, p < 0.01) and mechanical ventilation (89.7%, 95% CI: 78.3 - 101 vs 10.3%, 95% CI: -1 - 21.7, p < 0.01), and had a longer median hospital length of stay (12 days, 95% CI: 9 - 14 vs 5 days, 95% CI: 4 - 7, p < 0.01). Conclusions High-risk RI was associated with increased admission to the ICU, mechanical ventilation, and mortality. These results suggest that it may be used as a tool to aid provider judgment in the setting of COVID-19.
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Nichols DP, Singh PK, Baines A, Caverly LJ, Chmiel JF, GIbson RL, Lascano J, Morgan SJ, Retsch-Bogart G, Saiman L, Sadeghi H, Billings JL, Heltshe SL, Kirby S, Kong A, Nick JA, Mayer-Hamblett N. Testing the effects of combining azithromycin with inhaled tobramycin for P. aeruginosa in cystic fibrosis: a randomised, controlled clinical trial. Thorax 2022; 77:581-588. [PMID: 34706982 PMCID: PMC9043040 DOI: 10.1136/thoraxjnl-2021-217782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/30/2021] [Indexed: 11/03/2022]
Abstract
RATIONALE Inhaled tobramycin and oral azithromycin are common chronic therapies in people with cystic fibrosis and Pseudomonas aeruginosa airway infection. Some studies have shown that azithromycin can reduce the ability of tobramycin to kill P. aeruginosa. This trial was done to test the effects of combining azithromycin with inhaled tobramycin on clinical and microbiological outcomes in people already using inhaled tobramycin. We theorised that those randomised to placebo (no azithromycin) would have greater improvement in forced expiratory volume in one second (FEV1) and greater reduction in P. aeruginosa sputum in response to tobramycin. METHODS A 6-week prospective, randomised, placebo-controlled, double-blind trial testing oral azithromycin versus placebo combined with clinically prescribed inhaled tobramycin in individuals with cystic fibrosis and P. aeruginosa airway infection. RESULTS Over a 6-week period, including 4 weeks of inhaled tobramycin, the relative change in FEV1 did not statistically significantly differ between groups (azithromycin (n=56) minus placebo (n=52) difference: 3.44%; 95% CI: -0.48 to 7.35; p=0.085). Differences in secondary clinical outcomes, including patient-reported symptom scores, weight and need for additional antibiotics, did not significantly differ. Among the 29 azithromycin and 35 placebo participants providing paired sputum samples, the 6-week change in P. aeruginosa density differed in favour of the placebo group (difference: 0.75 log10 CFU/mL; 95% CI: 0.03 to 1.47; p=0.043). CONCLUSIONS Despite having greater reduction in P. aeruginosa density in participants able to provide sputum samples, participants randomised to placebo with inhaled tobramycin did not experience significantly greater improvements in lung function or other clinical outcomes compared with those randomised to azithromycin with tobramycin.
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Affiliation(s)
- David P Nichols
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Pradeep K Singh
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Arthur Baines
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Chmiel
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ronald L GIbson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jorge Lascano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Sarah J Morgan
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - George Retsch-Bogart
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Hossein Sadeghi
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Joanne L Billings
- Department of Medicine, Pulmonary, Allergy and Critical Care Division, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Shannon Kirby
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Ada Kong
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jerry A Nick
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
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Jung F, Riley L, Lascano J. Outcomes and Survival Following Lung Transplantation in Non-Cystic Fibrosis Bronchiectasis. ERJ Open Res 2022; 8:00607-2021. [PMID: 35174245 PMCID: PMC8841986 DOI: 10.1183/23120541.00607-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
Disease-specific outcomes in patients with non-cystic fibrosis bronchiectasis following lung transplantation are not well described. We performed a retrospective analysis to describe outcomes in these patients. Patients with non-cystic fibrosis bronchiectasis who have undergone lung transplantation in the USA were identified using the Organ Procurement and Transplant Network database. Survival data were analysed for the post-lung allocation score period with Kaplan–Meier curves, and a log-rank test was conducted to compare survival data among an age-, sex- and activation date-matched non-cystic fibrosis bronchiectasis cohort. 721 patients with non-cystic fibrosis bronchiectasis were listed for lung transplantation between March 1992 and September 2019. 407 patients received lung transplantation with a median age at listing of 47 years. The Kaplan–Meier survival analysis for lung transplantation recipient non-cystic fibrosis bronchiectasis patients during the post-lung allocation score period at 1, 5 and 10 years was 87%, 53% and 16%, respectively. The median survival time post-lung transplantation is 6.0 years (interquartile range: 2.3–11.9 years), which is similar to an age- and sex-matched cohort (p=0.86). This retrospective analysis demonstrates that median survival after lung transplantation in non-cystic fibrosis bronchiectasis was similar to other lung transplantation recipients over the study period. We suggest that the development of specific criteria for lung transplantation in non-cystic fibrosis bronchiectasis may improve patient selection and benefit a larger group of patients with this therapy. A retrospective analysis using UNOS data showed that median survival post-LT for patients with non-CF bronchiectasis is 6.0 years, which is similar to an age- and sex-matched cohorthttps://bit.ly/3eSv95p
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Benninger LA, Trillo C, Lascano J. CFTR modulator use in post lung transplant recipients. J Heart Lung Transplant 2021; 40:1498-1501. [PMID: 34538541 DOI: 10.1016/j.healun.2021.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022] Open
Abstract
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulator therapy has previously been contraindicated in solid organ transplant recipients. This was due to lack of data and concern for interactions with immunosuppressive drug regimens. However, in post-lung transplant recipients, CFTR modulators may improve extrapulmonary manifestations of cystic fibrosis without impacting graft function or immunosuppressive drug levels. Herein, we present our single center experience with the use of elexacaftor/tezacaftor/ivacaftor, Trikafta, in adult post-lung transplant recipients.
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Affiliation(s)
- Lauryn A Benninger
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Cesar Trillo
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Jorge Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida.
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Lascano J, Katz J, Cearras M, Campos M. Association of Systemic Endothelial-Derived and Platelet-Derived Microparticles With Clinical Outcomes in Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2021; 8:382-395. [PMID: 34062638 PMCID: PMC8428587 DOI: 10.15326/jcopdf.2021.0211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Endothelial and platelet microparticles (eMPs and pMPs), markers of cellular activation, dysfunction, or apoptosis, have been associated with multiple cardiovascular conditions. Chronic obstructive pulmonary disease (COPD) is associated with cardiovascular comorbidities and platelet/endothelial dysfunction. We analyzed whether eMPs and pMPs are associated with COPD status and/or severity. PATIENTS AND METHODS A total of 58 COPD patients and 19 controls were enrolled and followed for an average of 1.17 years. Characterization of COPD included lung function, Body mass index-airflow Obstruction-Dyspnea-Exercise (BODE) scores, health-related quality of life, exacerbations, comorbidities, and mortality. Plasma collection to measure eMPs and pMPs via flow cytometry was performed at enrollment as well as during acute exacerbation in 17 participants. We measured pMPs (CD31+, CD41+31+, CD 62P+), eMPs (ULEX lectin+, CD51+, CD54+, CD62E+), the apoptotic CD62E+/CD31+ ratio, and Annexin V MP. RESULTS As a group, COPD participants had no difference in all MP levels studied compared with controls. No significant correlations with diffusion capacity for carbon monoxide, quality of life, and exacerbation status were found in all MPs studied. However, the eMP ULEX and the pMP CD 62P+ were higher among COPD Global initiative for chronic Obstructive Lung Disease (GOLD) stage 3 patients compared to controls. The CD62E+/CD31+ ratio was lower in controls and GOLD stage 1 COPD participants compared with GOLD stage 2/3 COPD participants, suggesting increased apoptosis. eMP ULEX lectin+ decreased during acute exacerbations and pMP41+31+ significantly increased as BODE score increased. CONCLUSIONS After adjusting for comorbidities, most eMPs and pMPs studied do not correlate significantly with COPD status or severity.
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Affiliation(s)
- Jorge Lascano
- Pulmonary and Critical Care Division, Department of Internal Medicine, UF Health-Shands Hospital, University of Florida, Gainesville, Florida, United States
| | - Jason Katz
- Pulmonary and Critical Care Division, Department of Internal Medicine, UF Health-Shands Hospital, University of Florida, Gainesville, Florida, United States
| | - Martin Cearras
- Advent Health Medical Group, Central Florida Division, Orlando, Florida, United States
| | - Michael Campos
- Pulmonary and Critical Care Division, Department of Internal Medicine, University of Miami Health Systems, Miami, Florida, United States
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Riley LE, Lascano J. Gender and racial disparities in lung transplantation in the United States. J Heart Lung Transplant 2021; 40:963-969. [PMID: 34246564 DOI: 10.1016/j.healun.2021.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 04/20/2021] [Accepted: 06/08/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Lung transplant (LT) allocation utilizes a scoring system to prioritize patients, although data evaluating the access by gender and race remains limited. The study objective was to determine whether gender and racial disparities exist in patients listed for LT. METHODS This was a retrospective analysis using the Organ Procurement and Transplant Network database of patients listed for a LT from 1984 until 2019. Nominal multivariate logistic regression analysis was performed to evaluate LT allocation by gender, race, and primary lung disease. Kaplan-Meier curves were constructed to compare rates of mortality over time. RESULTS Sixty thousand eight hundred and forty-seven patients were listed between February 1984 and September 2019. Males comprised the majority of listed and transplanted patients at 51.7% and 55.8% respectively. In the LAS era, the median waiting list time for transplanted males was 43 days (interquartile range [IQR] 13-126), and females waited a median of 80 days (IQR 24-233) (p < .001). Persons of White race accounted for 82.6% and 84.3% of listed and transplanted patients respectively. Logistic regression analysis found that in the LAS era, males had an increased odds for LT allocation (OR 1.19, CI 1.12-1.27, p < .001) compared to females, and persons of White race (OR 1.23, CI 1.16-1.32, p < .001) compared to all other races combined. CONCLUSIONS The majority of listed and transplanted patients in the United States were males and persons of White race. Also, being a male or person of White race had an outcome favoring lung transplant allocation compared to an appropriately matched person of another gender or race.
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Affiliation(s)
- Leonard E Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida.
| | - Jorge Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida
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13
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Devereux G, Wrolstad D, Bourke SJ, Daines CL, Doe S, Dougherty R, Franco R, Innes A, Kopp BT, Lascano J, Layish D, MacGregor G, Murray L, Peckham D, Lucidi V, Lovie E, Robertson J, Fraser-Pitt DJ, O'Neil DA. Oral cysteamine as an adjunct treatment in cystic fibrosis pulmonary exacerbations: An exploratory randomized clinical trial. PLoS One 2020; 15:e0242945. [PMID: 33370348 PMCID: PMC7769283 DOI: 10.1371/journal.pone.0242945] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Emerging data suggests a possible role for cysteamine as an adjunct treatment for pulmonary exacerbations of cystic fibrosis (CF) that continue to be a major clinical challenge. There are no studies investigating the use of cysteamine in pulmonary exacerbations of CF. This exploratory randomized clinical trial was conducted to answer the question: In future pivotal trials of cysteamine as an adjunct treatment in pulmonary exacerbations of CF, which candidate cysteamine dosing regimens should be tested and which are the most appropriate, clinically meaningful outcome measures to employ as endpoints? METHODS AND FINDINGS Multicentre double-blind randomized clinical trial. Adults experiencing a pulmonary exacerbation of CF being treated with standard care that included aminoglycoside therapy were randomized equally to a concomitant 14-day course of placebo, or one of 5 dosing regimens of cysteamine. Outcomes were recorded on days 0, 7, 14 and 21 and included sputum bacterial load and the patient reported outcome measures (PROMs): Chronic Respiratory Infection Symptom Score (CRISS), the Cystic Fibrosis Questionnaire-Revised (CFQ-R); FEV1, blood leukocyte count, and inflammatory markers. Eighty nine participants in fifteen US and EU centres were randomized, 78 completed the 14-day treatment period. Cysteamine had no significant effect on sputum bacterial load, however technical difficulties limited interpretation. The most consistent findings were for cysteamine 450mg twice daily that had effects additional to that observed with placebo, with improved symptoms, CRISS additional 9.85 points (95% CI 0.02, 19.7) p = 0.05, reduced blood leukocyte count by 2.46x109 /l (95% CI 0.11, 4.80), p = 0.041 and reduced CRP by geometric mean 2.57 nmol/l (95% CI 0.15, 0.99), p = 0.049. CONCLUSION In this exploratory study cysteamine appeared to be safe and well-tolerated. Future pivotal trials investigating the utility of cysteamine in pulmonary exacerbations of CF need to include the cysteamine 450mg doses and CRISS and blood leukocyte count as outcome measures. CLINICAL TRIAL REGISTRATION NCT03000348; www.clinicaltrials.gov.
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Affiliation(s)
- Graham Devereux
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Danielle Wrolstad
- Precision for Medicine, Oncology and Rare Disease, Carlsbad, CA, United States of America
| | | | - Cori L. Daines
- Banner University of Arizona Medical Center, Tucson, Arizona, United States of America
| | - Simon Doe
- Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Ryan Dougherty
- San Francisco Critical Care Medical Group California Pacific Medical Center, San Francisco, United States of America
| | - Rose Franco
- The Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin, United States of America
| | | | - Benjamin T. Kopp
- Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Jorge Lascano
- University of Florida, Gainesville, Florida, United States of America
| | - Daniel Layish
- Central Florida Pulmonary Group, Orlando, Florida, United States of America
| | | | | | | | - Vincenzina Lucidi
- Ospedale Padiatrico Bambino Gesu Centro Fibrosi Cistica, Rome, Italy
| | - Emma Lovie
- NovaBiotics Ltd, Aberdeen, United Kingdom
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Ladna M, Villanueva F, Maharrey P, Lascano J. Post-transplant patients with COVID-19 associated acute respiratory distress syndrome, a role for Tociluzumab: A case series. Respir Med Case Rep 2020; 32:101319. [PMID: 33318918 PMCID: PMC7724995 DOI: 10.1016/j.rmcr.2020.101319] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 12/27/2022] Open
Abstract
COVID-19 is the disease caused by SARS-CoV-2 that portends both a relatively high mortality rate as well as high rate of intensive care admission amongst all age groups; however effective therapy remains poorly characterized. Post-transplant patients are especially high risk and underrepresented in the literature. In these patients, cytokine release may play a significant role in the development of acute respiratory distress syndrome, raising the hypothesis that interleukin-6 inhibitors such as tocilizumab may be of benefit. Here, we describe two high-risk post-transplant patients who were treated with single-dose tocilizumab after intubation for moderate acute respiratory distress syndrome secondary to confirmed COVID-19 infection. Both patients recovered rapidly and were successfully extubated and discharged from the hospital without need for supplemental oxygen shortly thereafter, and their clinical improvement correlated with response in interleukin-6 levels. Tocilizumab appears to hold promise for critically ill COVID-19 patients who require mechanical ventilation when given shortly after intubation.
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Affiliation(s)
- M. Ladna
- Division of Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - F.L. Villanueva
- Division of Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - P.B. Maharrey
- Division of Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - J. Lascano
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States
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15
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Riley L, Lascano J. Clinical outcomes and survival following lung transplantation in patients with Alpha-1 antitrypsin deficiency. Respir Med 2020; 172:106145. [PMID: 32911139 DOI: 10.1016/j.rmed.2020.106145] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The primary intention of our study is to describe disease-specific outcomes in patients with alpha-1 antitrypsin deficiency (AATD) following lung transplantation (LT). METHODS We reviewed the Organ Procurement and Transplant Network database to identify AATD patients who have undergone LT in the United States. RESULTS Two thousand two hundred and thirteen patients with AATD underwent LT between March 1992 and September 2019. A total of 1556 patients received LT with a median age at listing was 51 years. The median time spent on the LT waitlist was 263 days. The median ischemic time was 4.75 h. The Kaplan-Meier survival analysis following LT for AATD patients at 1-, 5-, and 10 years was 82%, 56%, and 34%, at 1-, 5-, and 10 years, respectively. The median survival time post-LT is 6.4 years (Interquartile range 5.6-6.8 years). The post-LT survival was significantly better in double LT compared to single LT (Median 7.7 vs 4.4 years, p < 0.001). Increasing age, presence of CMV mismatch, reintubation prior to discharge, and requiring treatment for rejection within one year of transplantation did impact post-LT mortality. CONCLUSION The median survival after LT in AATD is 6.4 years and is similar to other lung diseases. When compared to usual COPD LT, AATD patients have increased post-LT mortality due to infections and liver disease. Recipients of a double lung transplant had a favorable outcome compared to single lung transplant.
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Affiliation(s)
- Leonard Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Jorge Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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16
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Bertrán-López J, Abbott A, Archibald LK, Benninger L, Lascano J, Kalyatanda G. Disseminated Nocardia beijingensis Masquerading as Pulmonary Tuberculosis in a Patient With Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome. Open Forum Infect Dis 2020; 7:ofaa186. [PMID: 32548208 PMCID: PMC7284007 DOI: 10.1093/ofid/ofaa186] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 02/28/2020] [Accepted: 05/15/2020] [Indexed: 11/14/2022] Open
Abstract
Case of disseminated Nocardia beijingensis, initially diagnosed and treated by health department as tuberculosis, presented with worsening symptoms and new lesions. Adjustment to antinocardial treatment resulted in significant clinical and radiographic improvement. Maintain a high index of suspicion for Nocardia in patients diagnosed with tuberculosis with worsening lesions despite therapy.
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Affiliation(s)
- Jovanna Bertrán-López
- Division of Infectious Diseases and Global Health, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew Abbott
- Division of Infectious Diseases and Global Health, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lennox K Archibald
- Malcolm Randall Veterans Health Administration Medical Centre, Gainesville, Florida, USA
| | - Lauryn Benninger
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jorge Lascano
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Gautam Kalyatanda
- Division of Infectious Diseases and Global Health, University of Florida College of Medicine, Gainesville, Florida, USA
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17
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Kalra SS, Innabi A, Runnstrom M, Lascano J, Patel DC. Response to: Severe hypertriglyceridemia, acute pancreatitis and chyloptysis. QJM 2020; 113:300-301. [PMID: 31633758 DOI: 10.1093/qjmed/hcz269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/13/2022] Open
Affiliation(s)
- S S Kalra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610
| | - A Innabi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610
| | - M Runnstrom
- Division of Internal Medicine, Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - J Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610
| | - D C Patel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610
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18
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Affiliation(s)
- M Runnstrom
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - S S Kalra
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - J Lascano
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - D C Patel
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
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Abstract
BACKGROUND This study was designed to evaluate the patient characteristics and outcomes of in-hospital cardiac arrest (IHCA). MATERIALS AND METHODS We carried out a single-center, 5-year, retrospective chart review and analysis of resuscitation data for age, gender, body mass index (BMI), length of stay (LOS) until cardiac arrest, survival of initial IHCA, survival to hospital discharge, primary medical service, and determination of the etiology of cardiac arrest. RESULTS A total of 500 cases occurred with a mean LOS of 8.5 days until the initial IHCA. Overall, 79.5% survived the initial IHCA and 32.4% survived to discharge. As LOS increased, there was an increase in the proportion of pulmonary and metabolic etiologies. Logistic regression analysis adjusting for BMI, gender, age, LOS, and primary medical service were on a surgical service significant for survival to discharge (p = 0.0007) and LOS <9 days significant for survival of IHCA (p = 0.018). CONCLUSION There are a number of causes of IHCA, and the incidence of death and respiratory related IHCA etiologies increase with LOS. Length of stay carries the highest weight when predicting survival of IHCA. Also, there is a higher rate of survival to discharge when on a primary surgical service. HOW TO CITE THIS ARTICLE Riley LE, Mehta HJ, Lascano J. Single-center In-hospital Cardiac Arrest Outcomes. Indian J Crit Care Med 2020;24(1):44-48.
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Affiliation(s)
- Leonard E Riley
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Hiren J Mehta
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Jorge Lascano
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
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20
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Kalra SS, Innabi A, Runnstrom M, Lascano J, Patel DC. Severe hypertriglyceridemia, acute pancreatitis and chyloptysis. QJM 2020; 113:47-48. [PMID: 31529077 DOI: 10.1093/qjmed/hcz236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/03/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- S S Kalra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - A Innabi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - M Runnstrom
- Division of Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - J Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - D C Patel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
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21
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Ayoub F, Li H, Blay C, Trillo‐Alvarez C, Lascano J, Morelli G. Multidisciplinary Care for Cystic Fibrosis Liver Disease: Where Does the Adult Hepatologist Fit In? Clin Liver Dis (Hoboken) 2019; 14:187-190. [PMID: 31879562 PMCID: PMC6924965 DOI: 10.1002/cld.845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/08/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Fares Ayoub
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - Hechu Li
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - Charles Blay
- Department of MedicineUniversity of FloridaGainesvilleFL
| | - Cesar Trillo‐Alvarez
- Division of Pulmonary, Critical Care & Sleep MedicineUniversity of FloridaGainesvilleFL
| | - Jorge Lascano
- Division of Pulmonary, Critical Care & Sleep MedicineUniversity of FloridaGainesvilleFL
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology & NutritionUniversity of FloridaGainesvilleFL
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22
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Shah P, Kay D, Benninger L, Lascano J, Kirst M. ANALYSIS OF EXHALED BREATH CONDENSATE AT BASELINE AND DURING EXACERBATIONS IN SUBJECTS WITH CYSTIC FIBROSIS. Chest 2019. [DOI: 10.1016/j.chest.2019.08.1439] [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: 10/25/2022] Open
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23
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Khan S, Bhattal GK, Shah NH, Lascano J, Karki A. Neuroborreliosis with Unusual Presentation: A Case Report. Cureus 2019; 11:e5758. [PMID: 31723517 PMCID: PMC6825459 DOI: 10.7759/cureus.5758] [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] [Indexed: 11/05/2022] Open
Abstract
Lyme disease is the most common vector-borne disease in the northern hemisphere. Neurological complications usually manifest in patients who do not receive treatment for Lyme disease. Neurological involvement may be early or late, depending on the duration of the symptoms. Early neuroborreliosis presents with symptoms such as headache and meningism; late neuroborreliosis can present with signs and symptoms of encephalopathy and stroke-like symptoms. The diagnosis is based on clinical manifestations and lumbar puncture finding. Treatment consists of intravenous antibiotics for a period of three to four weeks. Patients who receive early treatment usually have an excellent prognosis, with very few patients developing post-treatment Lyme disease syndrome. Here, we report an unusual case of Lyme disease with extremely high cerebrospinal fluid protein level and devastating neurological sequelae. The diagnosis of neuroborreliosis is based on neurological symptoms and lumbar puncture findings.
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Affiliation(s)
- Salman Khan
- Internal Medicine, Guthrie Clinic/Robert Packer Hospital, Sayre, USA
| | | | | | - Jorge Lascano
- Internal Medicine, University of Florida, Gainesville, USA
| | - Apurwa Karki
- Internal Medicine - Critical Care, Guthrie Clinic/Robert Packer Hospital, Sayre, USA
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24
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Devereux G, Bourke S, Daines C, Doe S, Dougherty R, Franco R, Innes A, Kopp B, Lascano J, Layish D, McGregor G, Murray L, Peckham D, Smith T, Lucidi V, Volpi S, Lovie E, Robertson J, Fraser-Pitt D, O'Neil D. WS12-6 Evaluating appropriate PROMs in CARE-CF-1 trial: Lynovex® (cysteamine) an oral adjunct to SOC interventions in cystic fibrosis infectious exacebations. J Cyst Fibros 2019. [DOI: 10.1016/s1569-1993(19)30191-2] [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: 10/26/2022]
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25
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Riley L, Lascano J, Ataya A. Elongated Mitral Valve Vegetation. Am J Med 2018; 131:e193-e194. [PMID: 29410198 DOI: 10.1016/j.amjmed.2017.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/13/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Leonard Riley
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville.
| | - Jorge Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville
| | - Ali Ataya
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville
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Ayoub F, Trillo-Alvarez C, Morelli G, Lascano J. Risk factors for hepatic steatosis in adults with cystic fibrosis: Similarities to non-alcoholic fatty liver disease. World J Hepatol 2018; 10:34-40. [PMID: 29399276 PMCID: PMC5787682 DOI: 10.4254/wjh.v10.i1.34] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the clinical, biochemical and imaging characteristics of adult cystic fibrosis (CF) patients with hepatic steatosis as compared to normal CF controls.
METHODS We performed a retrospective review of adult CF patients in an academic outpatient setting during 2016. Baseline characteristics, genetic mutation analysis as well as laboratory values were collected. Abdominal imaging (ultrasound, computed tomography, magnetic resonance) was used to determine presence of hepatic steatosis. We compare patients with hepatic steatosis to normal controls.
RESULTS Data was collected on 114 patients meeting inclusion criteria. Seventeen patients (14.9%) were found to have hepatic steatosis on imaging. Being overweight (BMI > 25) (P = 0.019) and having a higher ppFEV1 (75 vs 53, P = 0.037) were significantly associated with hepatic steatosis. Patients with hepatic steatosis had a significantly higher median alanine aminotransferase level (27 vs 19, P = 0.048). None of the hepatic steatosis patients had frank CF liver disease, cirrhosis or portal hypertension. We found no significant association with pancreatic insufficiency or CF related diabetes.
CONCLUSION Hepatic steatosis appears to be a clinically and phenotypically distinct entity from CF liver disease. The lack of association with malnourishment and the significant association with higher BMI and higher ppFEV1 demonstrate similarities with non-alcoholic fatty liver disease. Long term prospective studies are needed to ascertain whether CF hepatic steatosis progresses to fibrosis and cirrhosis.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Cesar Trillo-Alvarez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Jorge Lascano
- Department of Medicine, Adult Cystic Fibrosis Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
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Yagnik KJ, Skelton WP, Olson A, Trillo CA, Lascano J. A rare case of disseminated Sporothrix schenckii with bone marrow involvement in a patient with idiopathic CD4 lymphocytopenia. IDCases 2017; 9:70-72. [PMID: 28706855 PMCID: PMC5503829 DOI: 10.1016/j.idcr.2017.06.012] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 06/27/2017] [Accepted: 06/27/2017] [Indexed: 11/04/2022] Open
Abstract
Sporothrix schenckii is a pathogen with a predilection for dissemination in immunocompromised individuals, often with HIV. We report a case of disseminated sporotrichosis in an unfortunate 25 year old male (without HIV) who was originally treated for presumed pneumonia. The patient continued to worsen clinically and further work-up eventually revealed Sporothrix schenckii species with involvement of multiple organs including the skin, heart, lungs and bone marrow. Despite treatment with multiple antibacterials and antifungals, he ultimately passed away. This case illustrates the aggressive nature of this disease along with the importance of early/proper diagnosis and treatment.
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Affiliation(s)
- Kruti J Yagnik
- Department of Internal Medicine, University of Florida, Gainesville, FL, United States
| | - William Paul Skelton
- Department of Internal Medicine, University of Florida, Gainesville, FL, United States
| | - Angela Olson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, FL, United States
| | - Cesar A Trillo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, FL, United States
| | - Jorge Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, FL, United States
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Abstract
Subjects with alpha-1 antitrypsin deficiency who develop pulmonary disease are managed following general treatment guidelines, including disease management interventions. In addition, administration of intravenous infusions of alpha-1 proteinase inhibitor (augmentation therapy) at regular schedules is a specific therapy for individuals with AATD with pulmonary involvement.This chapter summarizes the manufacturing differences of commercially available formulations and the available evidence of the effects of augmentation therapy. Biologically, there is clear evidence of in vivo local antiprotease effects in the lung and systemic immunomodulatory effects. Clinically, there is cumulative evidence of slowing lung function decline and emphysema progression. The optimal dose of augmentation therapy is being revised as well as more individualized assessment of who needs this therapy.
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Affiliation(s)
- Michael Campos
- Division of Pulmonary, Sleep and Critical Care Medicine, Miller School of Medicine, University of Miami, RMSB Room 7043 A (R-47), 1600 NW 10th Ave., Miami, FL, 33136, USA.
| | - Jorge Lascano
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Miami, FL, USA
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Ayoub F, Lascano J, Morelli G. Proton Pump Inhibitor Use Is Associated With an Increased Frequency of Hospitalization in Patients With Cystic Fibrosis. Gastroenterology Res 2017; 10:288-293. [PMID: 29118869 PMCID: PMC5667694 DOI: 10.14740/gr917w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/12/2017] [Indexed: 11/24/2022] Open
Abstract
Background Proton pump inhibitors (PPIs) are among the most commonly prescribed medications in clinical practice. PPI use has been associated with the development of community-acquired pneumonia. With a reported prevalence of gastroesophageal reflux disease (GERD) and PPI use that is higher than the general population, patients with cystic fibrosis (CF) are particularly vulnerable to PPI adverse effects. We sought to explore whether PPI use was associated with a higher number of hospitalizations for CF pulmonary exacerbation. Methods We conducted a longitudinal retrospective review in an academic outpatient setting. Patients > 18 years of age with a diagnosis of CF and at least 1 year of follow-up were eligible for inclusion. Baseline characteristics, PPI use, and details of hospitalization through 1 year of follow-up were collected. Results One hundred fourteen patients met inclusion criteria. Fifty-nine patients (51.7%) were hospitalized at least once in the follow-up year, mean number of hospitalizations was 2.17 (± 1.9). At least 6 months of PPI use was observed in 59 patients (51.7%). In univariate analysis, PPI use was associated with a significantly higher mean number of hospitalizations (0.9 vs. 1.4, P = 0.009). In a multi-variable regression model, PPI use remained significantly associated with a higher number of hospitalizations (P = 0.03), while controlling for risk factors traditionally associated with increased pulmonary exacerbations. Conclusion PPI use is highly prevalent in CF patients. Exposure to PPI therapy is independently associated with a higher number of hospitalizations for pulmonary exacerbation in CF patients.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, USA
- Corresponding Author: Department of Medicine, University of Florida, Gainesville, FL 32608, USA.
| | - Jorge Lascano
- Adult Cystic Fibrosis Center, Division of Pulmonary, Critical Care & Sleep Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Giuseppe Morelli
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, FL 32608, USA
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Chertoff J, Chisum M, Simmons L, King B, Walker M, Lascano J. Prognostic utility of plasma lactate measured between 24 and 48 h after initiation of early goal-directed therapy in the management of sepsis, severe sepsis, and septic shock. J Intensive Care 2016; 4:13. [PMID: 26877875 PMCID: PMC4751685 DOI: 10.1186/s40560-016-0142-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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: 10/13/2015] [Accepted: 02/05/2016] [Indexed: 12/11/2022] Open
Abstract
Background Based on the proven efficacy of lactate in predicting mortality and morbidity in sepsis when measured early in the resuscitative protocol, our group hypothesized that this utility extends later in the course of care. This study sought to investigate the prognostic potential of plasma lactate clearance measured 24–48 h after the initiation of treatment for nonsurgical patients with sepsis, severe sepsis, and septic shock. Methods Plasma lactate values, measured 24–48 h after the initiation of treatment, were collected in nonsurgical septic, severe septic, and septic shock patients. The primary outcome was 30-day mortality, while secondary outcomes included requirements for vasopressors and boluses of intravenous fluids. Analysis of these three outcomes was performed while controlling for clinical severity as measured by Sequential Organ Failure Assessment (SOFA), renal dysfunction, and hepatic dysfunction. Lactate clearance was defined as the percent change in plasma lactate levels measured after 24–48 h of treatment from the plasma lactate level at initial presentation. Results Two hundred twenty-nine nonsurgical patients were divided into two groups, clearers (above median lactate clearance [31.6 %]) and nonclearers (below median lactate clearance [31.6 %]). The adjusted odds ratio of mortality in clearers compared to nonclearers was 0.39 (CI 0.20–0.76) (p = 0.006). For vasopressor requirement, the adjusted odds ratio was 0.41 (CI 0.21–0.79) in clearers compared to nonclearers (p = 0.008). For intravenous fluid bolus requirement, the adjusted odds ratio was 0.81 (CI 0.48–1.39) in clearers compared to nonclearers (p = 0.45). Conclusions Lower plasma lactate clearance 24–48 h after the initiation of treatment is associated with higher 30-day mortality and requirements for vasopressors in nonsurgical septic patients and may be a useful noninvasive measurement for guiding late-sepsis treatment. Further investigation looking at mechanisms and therapeutic targets to improve lactate clearance in late sepsis may improve patient mortality and outcomes.
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Affiliation(s)
- Jason Chertoff
- Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32608 USA
| | - Michael Chisum
- Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32608 USA
| | - Lauren Simmons
- Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32608 USA
| | - Brent King
- Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32608 USA
| | - Michael Walker
- Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32608 USA
| | - Jorge Lascano
- Division of Pulmonary Critical Care, University of Florida, Gainesville, FL USA
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Abstract
α1 Antitrypsin deficiency (AATD) increases the risk of chronic obstructive pulmonary disease (COPD), liver disease and other conditions. Although it is not a rare disease, it is a condition rarely diagnosed because of unawareness by most healthcare providers who manage subjects at risk. Testing recommendations have been published and strongly suggest testing all subjects with confirmed COPD, cryptogenic liver cirrhosis, subjects with incompletely reversible airflow obstruction and siblings of affected individuals. Testing strategies usually imply a combination of measures of α1 antitrypsin (AAT) levels, phenotyping and genotyping, techniques that have been facilitated for in-office use by development of testing kits using dried blood spots. Early detection of subjects is crucial to apply effective preventive measures and early institution of therapy. The only specific Food and Drug Administration - approved therapy for this condition is lifelong weekly intravenous AAT replacement (augmentation therapy). Observational studies strongly suggest a beneficial effect of augmentation therapy in slowing lung function decline and randomized trials suggest a beneficial effect in slowing the progression of emphysema over time as measured by computed tomography. In addition, augmentation therapy has been shown to modulate systemic inflammatory responses and affect markers of elastin degradation. As new markers of disease progression are discovered, new doses of AAT replacement are tested and sub-phenotypes of disease are described, treatment recommendations are likely to change towards a more individualized therapeutic approach.
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Affiliation(s)
- Michael A Campos
- Associate Professor of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami School of Medicine, PO Box 016960 (R-47), Miami, FL 33101, USA
| | - Jorge Lascano
- Assistant Professor, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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Del Carpio F, Chirinos JA, Jimenez J, Lascano J, Jy W, Jimenez JJ, Horstman L, Mallon S, Ahn YS. Endothelial Microparticle Binding to Leukocytes as Determinants of Leukocyte Activation and Leukocyte Nitric Oxide Levels in Patients with Congestive Heart Failure. J Card Fail 2006. [DOI: 10.1016/j.cardfail.2006.06.135] [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: 10/24/2022]
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