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Gupta VK, Rajendraprasad S, Ozkan M, Ramachandran D, Ahmad S, Bakken JS, Laudanski K, Gajic O, Bauer B, Zec S, Freeman DW, Khanna S, Shah A, Skalski JH, Sung J, Karnatovskaia LV. Safety, feasibility, and impact on the gut microbiome of kefir administration in critically ill adults. BMC Med 2024; 22:80. [PMID: 38378568 PMCID: PMC10880344 DOI: 10.1186/s12916-024-03299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Dysbiosis of the gut microbiome is frequent in the intensive care unit (ICU), potentially leading to a heightened risk of nosocomial infections. Enhancing the gut microbiome has been proposed as a strategic approach to mitigate potential adverse outcomes. While prior research on select probiotic supplements has not successfully shown to improve gut microbial diversity, fermented foods offer a promising alternative. In this open-label phase I safety and feasibility study, we examined the safety and feasibility of kefir as an initial step towards utilizing fermented foods to mitigate gut dysbiosis in critically ill patients. METHODS We administered kefir in escalating doses (60 mL, followed by 120 mL after 12 h, then 240 mL daily) to 54 critically ill patients with an intact gastrointestinal tract. To evaluate kefir's safety, we monitored for gastrointestinal symptoms. Feasibility was determined by whether patients received a minimum of 75% of their assigned kefir doses. To assess changes in the gut microbiome composition following kefir administration, we collected two stool samples from 13 patients: one within 72 h of admission to the ICU and another at least 72 h after the first stool sample. RESULTS After administering kefir, none of the 54 critically ill patients exhibited signs of kefir-related bacteremia. No side effects like bloating, vomiting, or aspiration were noted, except for diarrhea in two patients concurrently on laxatives. Out of the 393 kefir doses prescribed for all participants, 359 (91%) were successfully administered. We were able to collect an initial stool sample from 29 (54%) patients and a follow-up sample from 13 (24%) patients. Analysis of the 26 paired samples revealed no increase in gut microbial α-diversity between the two timepoints. However, there was a significant improvement in the Gut Microbiome Wellness Index (GMWI) by the second timepoint (P = 0.034, one-sided Wilcoxon signed-rank test); this finding supports our hypothesis that kefir administration can improve gut health in critically ill patients. Additionally, the known microbial species in kefir were found to exhibit varying levels of engraftment in patients' guts. CONCLUSIONS Providing kefir to critically ill individuals is safe and feasible. Our findings warrant a larger evaluation of kefir's safety, tolerability, and impact on gut microbiome dysbiosis in patients admitted to the ICU. TRIAL REGISTRATION NCT05416814; trial registered on June 13, 2022.
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Affiliation(s)
- Vinod K Gupta
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sanu Rajendraprasad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mahmut Ozkan
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sumera Ahmad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Johan S Bakken
- Section of Infectious Diseases, St Luke's Hospital, Duluth, MN, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brent Bauer
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Simon Zec
- Department of Anesthesiology and Perioperative Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David W Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Sahil Khanna
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jaeyun Sung
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Sung J, Rajendraprasad SS, Philbrick KL, Bauer BA, Gajic O, Shah A, Laudanski K, Bakken JS, Skalski J, Karnatovskaia LV. The human gut microbiome in critical illness: disruptions, consequences, and therapeutic frontiers. J Crit Care 2024; 79:154436. [PMID: 37769422 PMCID: PMC11034825 DOI: 10.1016/j.jcrc.2023.154436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/23/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
With approximately 39 trillion cells and over 20 million genes, the human gut microbiome plays an integral role in both health and disease. Modern living has brought a widespread use of processed food and beverages, antimicrobial and immunomodulatory drugs, and invasive procedures, all of which profoundly disrupt the delicate homeostasis between the host and its microbiome. Of particular interest is the human gut microbiome, which is progressively being recognized as an important contributing factor in many aspects of critical illness, from predisposition to recovery. Herein, we describe the current understanding of the adverse impacts of standard intensive care interventions on the human gut microbiome and delve into how these microbial alterations can influence patient outcomes. Additionally, we explore the potential association between the gut microbiome and post-intensive care syndrome, shedding light on a previously underappreciated avenue that may enhance patient recuperation following critical illness. There is an impending need for future epidemiological studies to encompass detailed phenotypic analyses of gut microbiome perturbations. Interventions aimed at restoring the gut microbiome represent a promising therapeutic frontier in the quest to prevent and treat critical illnesses.
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Affiliation(s)
- Jaeyun Sung
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Brent A Bauer
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, USA
| | - Johan S Bakken
- Department of Infectious Diseases, St Luke's Hospital, Duluth, MN, United States of America
| | - Joseph Skalski
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN, USA
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Chang D, Gupta VK, Hur B, Cobo-López S, Cunningham KY, Han NS, Lee I, Kronzer VL, Teigen LM, Karnatovskaia LV, Longbrake EE, Davis JM, Nelson H, Sung J. Gut Microbiome Wellness Index 2 for Enhanced Health Status Prediction from Gut Microbiome Taxonomic Profiles. bioRxiv 2023:2023.09.30.560294. [PMID: 37873265 PMCID: PMC10592848 DOI: 10.1101/2023.09.30.560294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Recent advancements in human gut microbiome research have revealed its crucial role in shaping innovative predictive healthcare applications. We introduce Gut Microbiome Wellness Index 2 (GMWI2), an advanced iteration of our original GMWI prototype, designed as a robust, disease-agnostic health status indicator based on gut microbiome taxonomic profiles. Our analysis involved pooling existing 8069 stool shotgun metagenome data across a global demographic landscape to effectively capture biological signals linking gut taxonomies to health. GMWI2 achieves a cross-validation balanced accuracy of 80% in distinguishing healthy (no disease) from non-healthy (diseased) individuals and surpasses 90% accuracy for samples with higher confidence (i.e., outside the "reject option"). The enhanced classification accuracy of GMWI2 outperforms both the original GMWI model and traditional species-level α-diversity indices, suggesting a more reliable tool for differentiating between healthy and non-healthy phenotypes using gut microbiome data. Furthermore, by reevaluating and reinterpreting previously published data, GMWI2 provides fresh insights into the established understanding of how diet, antibiotic exposure, and fecal microbiota transplantation influence gut health. Looking ahead, GMWI2 represents a timely pivotal tool for evaluating health based on an individual's unique gut microbial composition, paving the way for the early screening of adverse gut health shifts. GMWI2 is offered as an open-source command-line tool, ensuring it is both accessible to and adaptable for researchers interested in the translational applications of human gut microbiome science.
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Affiliation(s)
- Daniel Chang
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - Vinod K Gupta
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Benjamin Hur
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Sergio Cobo-López
- Viral Information Institute, San Diego State University, San Diego, CA 92182, USA
| | - Kevin Y Cunningham
- Bioinformatics and Computational Biology Program, University of Minnesota, Minneapolis, MN 55455, USA
| | - Nam Soo Han
- Brain Korea 21 Center for Bio-Health Industry, Department of Food Science and Biotechnology, Chungbuk National University, Cheongju, South Korea
| | - Insuk Lee
- Department of Biotechnology, Yonsei University, Seoul 03722, South Korea
| | - Vanessa L Kronzer
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Levi M Teigen
- Department of Food Science and Nutrition, University of Minnesota, St. Paul, MN 55108, USA
| | | | - Erin E Longbrake
- Department of Neurology, Yale University, New Haven, CT 06510, USA
| | - John M Davis
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Heidi Nelson
- Emeritus, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Jaeyun Sung
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Ahmad SR, Rhudy L, Fogelson LA, LeMahieu AM, Barwise AK, Gajic O, Karnatovskaia LV. Humanizing the Intensive Care Unit: Perspectives of Patients and Families on the Get to Know Me Board. J Patient Exp 2023; 10:23743735231201228. [PMID: 37736130 PMCID: PMC10510354 DOI: 10.1177/23743735231201228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
In this qualitative study, we explored perspectives of patients in the intensive care unit (ICU) and their families on the Get to Know Me board (GTKMB). Of the 46 patients approached, 38 consented to participate. Of the 66 family members approached, 60 consented to participate. Most patients (26, 89%) and family members (52, 99%) expressed that GTKMB was important in recognizing patient's humanity. Most patients (20, 68%) and families (39, 74%) said that it helped to build a better relationship with the provider team. 60% of patients and families commented that the GTKMB was used as a platform by providers to interact with them. Up to 45 (85%) of the family members supported specific contents of the GTKMB. In structured interviews (11 patients, 7 family members), participants additionally commented on ways providers used the GTKMB to communicate, support patient's personhood, and on caveats in interacting with GTKMB. Critically ill patients and families found the GTKMB helpful in preserving personhood of patient, fostering communication, and building relationships with clinicians.
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Affiliation(s)
- Sumera R. Ahmad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lori Rhudy
- Department of Graduate Nursing, Winona State University, Rochester, MN, USA
| | | | | | - Amelia K. Barwise
- Department of Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Johnson KR, Temeyer JP, Schulte PJ, Nydahl P, Philbrick KL, Karnatovskaia LV. Aloud real- time reading of intensive care unit diaries: A feasibility study. Intensive Crit Care Nurs 2023; 76:103400. [PMID: 36706496 DOI: 10.1016/j.iccn.2023.103400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Memories of frightening/delusional intensive care unit experiences are a major risk factor for subsequent psychiatric morbidity of critical illness survivors; factual memories are protective. Systematically providing factual information during initial memory consolidation could mitigate the emotional character of the formed memories. We explored feasibility and obtained stakeholder feedback of a novel approach to intensive care unit diaries whereby entries were read aloud to the patients right after they were written to facilitate systematic real time orientation and formation of factual memories. RESEARCH METHODOLOGY Prospective interventional pilot study involving reading diary entries aloud. We have also interviewed involved stakeholders for feedback and collected exploratory data on psychiatric symptoms from patients right after the intensive care stay. SETTING Various intensive care units in a single academic center. MAIN OUTCOME MEASURES Feasibility was defined as intervention delivery on ≥80% of days following patient recruitment. Content analysis was performed on stakeholder interview responses. Questionnaire data were compared for patients who received real-time reading to the historical cohort who did not. RESULTS Overall, 57% (17 of 30) of patients achieved the set feasibility threshold. Following protocol adjustment, we achieved 86% feasibility in the last subset of patients. Patients reported the intervention as comforting and appreciated the reorientation aspect. Nurses overwhelmingly liked the idea; most common concern was not knowing what to write. Some therapists were unsure whether reading entries aloud might overwhelm the patients. There were no significant differences in psychiatric symptoms when compared to the historic cohort. CONCLUSION We encountered several implementation obstacles; once these were addressed, we achieved set feasibility target for the last group of patients. Reading diary entries aloud was welcomed by stakeholders. Designing a trial to assess efficacy of the intervention on psychiatric outcomes appears warranted. IMPLICATIONS FOR CLINICAL PRACTICE There is no recommendation to change current practice as benefits of the intervention are unproven.
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Affiliation(s)
- Kimberly R Johnson
- Department of Pulmonary and Critical Care, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Joseph P Temeyer
- Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Phillip J Schulte
- Department of Biostatistics, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Peter Nydahl
- Department of Anesthesia and Critical Care, Arnold-Heller-Str. 3, University Hospital Schleswig-Holstein, Kiel 24105, Germany
| | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, 200 First St SW, Mayo Clinic, Rochester, MN 55905, USA
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Ahmad SR, Tarabochia AD, Budahn L, LeMahieu AM, Karnatovskaia LV, Turnbull AE, Gajic O. Determining Goal Concordant Care in the Intensive Care Unit Using Electronic Health Records. J Pain Symptom Manage 2023; 65:e199-e205. [PMID: 36400406 PMCID: PMC10557174 DOI: 10.1016/j.jpainsymman.2022.11.002] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Goal concordant care (GCC) is the alignment of care to patient values and preferences. GCC is a major outcome of communication with patients and families in serious/critical illness. Using the electronic health record (EHR) to study the provision of GCC would be pragmatic and cost-effective for research and quality improvement efforts. RESEARCH QUESTION Do EHRs contain information to identify GCC? METHODS This is a feasibility retrospective chart review performed by two independent reviewers. An existing framework containing four questions for identifying GCC was adopted. Two clinicians reviewed multi-disciplinary notes and extracted pertinent information. The primary outcomes were whether the four key questions for determining goal concordance could be answered using information in the EHR. The secondary outcome was the type of goals identified. Cohen's kappa was used to measure agreement between two reviewers. RESULTS Patient care was considered goal concordant in 35 (85%) of 41 patients in a random sample comprising of 36 survivors and five who died in hospital. Inter-rater agreement on identifying data to determine GCC was excellent (Kappa 0.70). Patient goals were identified in 80% of charts reviewed. Note sources informative of patient preferences, included social work (39%), hospital progress notes (29%), palliative care (20%), and physical/occupational therapy (15%). "Returning home" and "getting better/ stronger" were among the most common patient goals captured in EHR. CONCLUSION The EHR can be used to understand patient goals, but the information is scattered across the multi-disciplinary notes. Improving EHR and external validation will facilitate ascertainment of goal concordance as an important outcome measure.
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Affiliation(s)
- Sumera R Ahmad
- Division of Pulmonary and Critical Care Medicine (S.R.A., L.k., O.G.), Mayo Clinic, Rochester, Minnesota.
| | - Alex D Tarabochia
- Department of Internal Medicine (A.D.T.), Mayo Clinic, Rochester, Minnesota
| | - LuAnn Budahn
- Anesthesia and Critical Care Research Unit (L.B.), Mayo Clinic, Rochester, Minnesota
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences (A.M.L.), Mayo Clinic, Rochester, Minnesota
| | - Lioudmila V Karnatovskaia
- Division of Pulmonary and Critical Care Medicine (S.R.A., L.k., O.G.), Mayo Clinic, Rochester, Minnesota
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine (A.E.T.), Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Bloomberg School of Public Health (A.E.T.), Johns Hopkins University, Baltimore, Maryland; Outcomes After Critical Illness and Surgery Research group (A.E.T.), Johns Hopkins University, Baltimore, Maryland
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine (S.R.A., L.k., O.G.), Mayo Clinic, Rochester, Minnesota
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Bieber ED, Philbrick KL, Shapiro JB, Karnatovskaia LV. Psychiatry's role in the prevention of post-intensive care mental health impairment: stakeholder survey. BMC Psychiatry 2022; 22:198. [PMID: 35303814 PMCID: PMC8933991 DOI: 10.1186/s12888-022-03855-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 09/15/2021] [Accepted: 02/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many critical illness survivors experience new or worsening mental health impairments. Psychiatry consultation services can provide a critical role in identifying, addressing, and preventing mental health challenges during and after admission to the acute medical care setting. However, psychiatry involvement in the ICU setting is lower than in other hospital settings and the conventional process in many hospitals requires other care providers to request consultation by psychiatry. Despite these differences, no studies have sought ICU provider perspectives on psychiatry consultation's current and desired role. We aimed to obtain stakeholder feedback on psychiatry's current and desired roles in the ICU, and potential benefits and drawbacks of increasing psychiatry's presence. METHODS A web-based survey obtained perspectives from 373 critical care physicians and advance practice providers, bedside nurses, physical and occupational therapists, pharmacists, and consultation-liaison psychiatry physicians and advance practice providers at a tertiary care center using multiple choice and open-ended questions. Descriptive information and content analysis of qualitative data provided information on stakeholder perspectives. RESULTS Psychiatry's primary current role was seen as assistance with management of mental health issues (38%) and suicide risk assessments (23%). 46% wished for psychiatry's increased involvement in the ICU. Perceived benefits of increased psychiatry presence in the ICU included early psychological support in parallel with medical care, identification of psychiatric factors impacting treatment, and facilitation of family understanding of the patient's mental state/delirium. An additional perceived benefit included reduction in provider burnout through processing difficult situations and decreasing family psychological distress. However, one concern included potential conflict among providers regarding treatment. CONCLUSIONS Those who work closely with the critically ill patients think that increased psychological support in the ICU would be beneficial. By contrast, psychiatry's current involvement is seen to be limited, perhaps driven by varying perceptions of what psychiatry's role is or should be.
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Affiliation(s)
- Ewa D. Bieber
- grid.66875.3a0000 0004 0459 167XDepartment of Psychiatry and Psychology, Mayo Clinic, Rochester, MN USA ,grid.413808.60000 0004 0388 2248Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Kemuel L. Philbrick
- grid.66875.3a0000 0004 0459 167XDepartment of Psychiatry and Psychology, Mayo Clinic, Rochester, MN USA
| | - Jenna B. Shapiro
- grid.413808.60000 0004 0388 2248Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Lioudmila V. Karnatovskaia
- grid.66875.3a0000 0004 0459 167XDepartment of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
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Karnatovskaia LV, Varga K, Niven AS, Schulte PJ, Mujic M, Gajic O, Bauer BA, Clark MM, Benzo RP, Philbrick KL. A pilot study of trained ICU doulas providing early psychological support to critically ill patients. Crit Care 2021; 25:446. [PMID: 34930440 PMCID: PMC8691072 DOI: 10.1186/s13054-021-03856-3] [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: 08/21/2021] [Accepted: 12/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background Over a third of critical illness survivors suffer from mental health problems following hospitalization. Memories of delusional experiences are a major risk factor. In this project, ICU doulas delivered a unique positive suggestion intervention targeting the vulnerable time period during critical illness when these memories are formed. Methods Adult critically ill patients were recruited for this single-arm, prospective pilot study. These ICU patients received a positive suggestion intervention daily during their ICU stay in parallel with their medical treatment. The intervention was designed to be delivered over a minimum of two sessions. Feasibility was defined as intervention delivery on ≥ 70% of ICU days after patient enrollment. As a secondary analysis, psychometric questionnaires were compared to those of a historic control cohort of patients receiving standard care in the ICU using adjusted linear regression models. Results Of the 97 patients who received the intervention and were alive at the end of their ICU course, 54 were excluded from analyses mostly for having received only one session because of a short ICU length of stay of < 2 days, transitioning to comfort care or not wanting to answer the study questionnaires. Forty-three patients who completed 2 or more sessions of the positive therapeutic suggestion intervention provided by two trained ICU doulas received it for a median of 4 days (IQR 3, 5), with each session lasting for a median of 20 min (IQR 14, 25). The intervention was delivered on 71% of days, meeting our pre-determined feasibility goal. Compared to historical controls (N = 299), patients receiving the intervention had higher severity of illness and longer length of stay. When adjusted for baseline differences, patients both with and without mechanical ventilation who received the intervention scored lower on the Hospital Anxiety and Depression Scale (HADS)—Depression subscale. The intervention was also associated with reduced HADS-Anxiety subscale among ventilated patients. Conclusions Positive therapeutic suggestion delivered by ICU doulas is feasible in the ICU setting. A randomized trial is warranted to better delineate the role that positive suggestion and ICU doulas may play in ongoing interprofessional efforts to humanize critical care medicine. The study was registered on clinicaltrials.gov (NCT03736954) on 03/14/2018 prior to the first patient enrollment https://clinicaltrials.gov/ct2/show/NCT03736954?cond=ICU+Doulas+Providing+Psychological+Support&draw=2&rank=1. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03856-3.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Katalin Varga
- Affective Psychology Department, Eötvös Loránd University, Budapest, Hungary
| | - Alexander S Niven
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Phillip J Schulte
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Midhat Mujic
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Brent A Bauer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Roberto P Benzo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Johnson MM, Karnatovskaia LV, Niven AS. In Reply-The Role of Stress Perception for Clinical Implications of Stress. Mayo Clin Proc 2021; 96:509-510. [PMID: 33549275 DOI: 10.1016/j.mayocp.2020.12.003] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Alexander S Niven
- Mayo Clinic, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rochester, MN
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Karnatovskaia LV, Johnson MM, Varga K, Highfield JA, Wolfrom BD, Philbrick KL, Ely EW, Jackson JC, Gajic O, Ahmad SR, Niven AS. Stress and Fear: Clinical Implications for Providers and Patients (in the Time of COVID-19 and Beyond). Mayo Clin Proc 2020; 95:2487-2498. [PMID: 33153636 PMCID: PMC7606075 DOI: 10.1016/j.mayocp.2020.08.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/13/2020] [Accepted: 08/25/2020] [Indexed: 12/27/2022]
Abstract
In light of the coronavirus disease 2019 pandemic, we explore the role of stress, fear, and the impact of positive and negative emotions on health and disease. We then introduce strategies to help mitigate stress within the health care team, and provide a rationale for their efficacy. Additionally, we identify strategies to optimize patient care and explain their heightened importance in today's environment.
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Affiliation(s)
| | | | - Katalin Varga
- Affective Psychology Department, Eötvös Loránd University, Budapest, Hungary
| | - Julie A Highfield
- Department of Clinical Psychology in Critical Care, University Hospital Wales, Cardiff, UK
| | - Brent D Wolfrom
- Department of Family Medicine, Queen's University, Kingston, Canada
| | | | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN
| | - James C Jackson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Freeman WD, Karnatovskaia LV, Dredla BK. How to Prepare and Protect Health-Care Teams During COVID-19: Know Thyself. Neurocrit Care 2020; 34:10-12. [PMID: 33108628 PMCID: PMC7590558 DOI: 10.1007/s12028-020-01135-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/14/2020] [Indexed: 11/23/2022]
Affiliation(s)
- W David Freeman
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA. .,Department of Neurology, Mayo Clinic, Jacksonville, FL, USA. .,Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
| | | | - Brynn K Dredla
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL, USA
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Tan Y, Gajic O, Schulte PJ, Clark MM, Philbrick KL, Karnatovskaia LV. Feasibility of a Behavioral Intervention to Reduce Psychological Distress in Mechanically Ventilated Patients. Int J Clin Exp Hypn 2020; 68:419-432. [PMID: 32730136 DOI: 10.1080/00207144.2020.1795663] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Many survivors of acute respiratory failure suffer from mood disorders following discharge from the hospital. We investigated the feasibility of intensivists delivering psychological support based on positive suggestion (PSBPS) to 20 intubated patients to reduce their psychological distress. Thirteen patients completed follow-up surveys. Of those, 9 remembered the intensive care unit physician talking to them, and 7 described it as comforting. Five patients (38%) met criteria for anxiety, depression, and acute stress. In comparison to historical controls, intervention may be associated with lower estimated odds of anxiety. PSBPS can be performed with patients in parallel with medical treatment to potentially reduce psychological morbidity and to humanize critical care. A larger randomized study is warranted to assess the efficacy of PSBPS.
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Affiliation(s)
- Yanni Tan
- National University Hospital , Singapore
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota, USA
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic , Rochester, Minnesota, USA
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic , Rochester, Minnesota, USA
| | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, Mayo Clinic , Rochester, Minnesota, USA
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Karnatovskaia LV, Schulte PJ, Philbrick KL, Johnson MM, Anderson BK, Gajic O, Clark MM. Psychocognitive sequelae of critical illness and correlation with 3 months follow up. J Crit Care 2019; 52:166-171. [PMID: 31078997 DOI: 10.1016/j.jcrc.2019.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/22/2019] [Accepted: 04/27/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE Over a third of critical illness survivors manifest significant psychocognitive impairments following discharge from the intensive care unit (ICU). It is not known which patient populations are at highest risk or if assessment at ICU discharge can guide outpatient treatment prioritization. MATERIALS AND METHODS Prospective single center study in an academic medical center encompassing six types of ICUs assessed prevalence of psychocognitive morbidity based on ICU type and associations between initial and 3 month follow-up evaluation. Adult patients with >48 h ICU stays completed the Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale-Revised (IES-R), and Montreal Cognitive Assessment-Blind (MoCA-blind). RESULTS Of 299 patients who underwent initial assessment, 174 (58%) completed follow-up. Length of stay, MoCA-Blind, HADS-A/D and IES-R scores were similar across ICUs. Most commonly observed impairment in-hospital was cognitive (58%) followed by anxiety (45%), acute stress (39%) and depression (37%). There were significant correlations between in-hospital and follow-up psychocognitive outcomes. CONCLUSIONS There was no significant difference in impairment by ICU type. Significant correlation between the initial assessment and follow-up scores suggests that early screening of high risk patients may identify those at greatest risk of sustained morbidity and facilitate timely intervention.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States of America
| | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States of America
| | - Margaret M Johnson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Brenda K Anderson
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN, United States of America
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States of America
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14
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Karnatovskaia LV, Johnson MM, Dockter TJ, Gajic O. Perspectives of physicians and nurses on identifying and treating psychological distress of the critically ill. J Crit Care 2016; 37:106-111. [PMID: 27676170 DOI: 10.1016/j.jcrc.2016.09.008] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/22/2016] [Accepted: 09/09/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Survivors of critical illness are frequently unable to return to their premorbid level of psychocognitive functioning following discharge. Therefore, we aimed to evaluate the burden of psychological trauma experienced by patients in the intensive care unit (ICU) as perceived by clinicians to assess factors that can impede its recognition and treatment in the ICU. MATERIALS AND METHODS Two distinct role-specific Web-based surveys were administered to critical care physicians and nurses in medical and surgical ICUs of 2 academic medical centers. Responses were analyzed in the domains of psychological trauma, exacerbating/mitigating factors, and provider-patient communication. RESULTS A survey was completed by 43 physicians and 55 nurses with a response rate of 62% and 37%, respectively. Among physicians, 65% consistently consider the psychological state of the patient in decision making; 77% think it is important to introduce a system to document psychological state of ICU patients; 56% would like to have more time to communicate with patients; 77% consistently spend extra time at bedside besides rounds and often hold patient's hand/reassure them. Notably, for the question about the average level of psychological stress experienced by a patient in the ICU (with 0=no stress and 100=worst stress imaginable) during initial treatment stage and by the end of the ICU stay, median assessment by both physicians and nurses was 80 for the initial stress level and 68 for the stress level by the end of the ICU stay. Among nurses, 69% always try to minimize noise and 73% actively promote patient's rest. Physicians and nurses provided multiple specific suggestions for improving ICU environment and communication. CONCLUSIONS Both physicians and nurses acknowledge that they perceive that critically ill patients experience a high level of psychological stress that persists throughout their period of illness. Improved understanding of this phenomenon is needed to design effective therapeutic interventions. Although the lack of time is identified as significant barrier to ameliorating patient's psychological stress, the majority of clinicians indicate that they attempt to provide interventions to achieve this goal.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| | - Margaret M Johnson
- Division of Pulmonary and Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Travis J Dockter
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Abstract
Survivors of critical illness often experience long-lasting impairments in mental, cognitive, and physical functioning. Acute stress reactions and delusional memories appear to play an important role in psychological morbidity following critical illness, and few interventions exist to address these symptoms. This review elucidates acute psychological stressors experienced by the critically ill. The effects of psychological stress and state of mind on disease are discussed using examples from the non-intensive care unit (ICU) literature, including a review of placebo and nocebo effects. After reviewing the effect of the mind on both psychological and physiological outcomes, we then focus on the role of memories-including their malleable nature and the consequences of false memories. Memory may play a role in the genesis of subsequent psychological trauma. Traumatic memories may begin forming even before the patient arrives in the ICU and during their state of unconsciousness in the ICU. Hence, practical interventions for redirecting patients' thoughts, such as positive suggestion techniques and actively involving patients in the treatment process as early as possible, are worthy of further investigation.
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Affiliation(s)
| | | | - Ann M Parker
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Karnatovskaia LV, Lee AS, Festic E, Kramer CL, Freeman WD. Effect of prolonged therapeutic hypothermia on intracranial pressure, organ function, and hospital outcomes among patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 21:451-61. [PMID: 24865270 DOI: 10.1007/s12028-014-9989-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Global cerebral edema (GCE) with subsequent refractory intracranial hypertension complicates some cases of aneurysmal subarachnoid hemorrhage (aSAH), and typically is associated with poorer outcome. Treatment options for refractory intracranial pressure (ICP) cases are limited to decompressive hemicraniectomy (DHC) and targeted temperature management (TTM) with induced hypothermia (32-34 °C). No outcomes comparison between patients treated with either or both forms of refractory ICP therapy exists, and data on the effect of prolonged hypothermia on ICP and organ function among patients with aSAH are limited. METHODS This is a retrospective study of aSAH patients who underwent DHC and/or prolonged hypothermia (greater than 48 h) for refractory ICP (i.e., ICP >20 mmHg after osmotherapy) in the intensive care unit of a single, tertiary-care academic center. RESULTS Nineteen individuals with aSAH underwent TTM with or without DHC; sixteen patients underwent DHC alone. The patients in TTM group were younger (median age 44 years) than the DHC without TTM population (median age 60 years). TTM was started on median day 2 with a median duration of 7 days. There were no significant group differences in survival to discharge (59 % vs. 69 %) or in the mean modified Rankin score on follow-up (3.6 vs. 3.7), despite the TTM group having longer hospital length of stay (24 vs. 19 days, p = 0.03), longer duration of mechanical ventilation (20 vs. 9 days, p = 0.04), a higher cumulative fluid balance (12.8 vs. 5.1 L, p = 0.01), and higher APACHEII scores. The median maximal ICP decreased from 23.5 to 21 mmHg within 24 h of hypothermia initiation. There were no significant differences in other markers of end-organ function (respiratory, hematologic, renal, liver, and cardiac), infection rate, or adverse events between groups. CONCLUSIONS Use of prolonged TTM among aSAH patients with GCE and refractory ICP elevations is associated with a longer duration of mechanical ventilation but is not different in terms of neurological outcomes measured by modified Rankin score or organ function outcomes compared to patients who received DHC alone.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Davis Building E-7A, Jacksonville, FL, 32224, USA,
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17
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Cable CA, Freeman WD, Rubin MN, Khoor A, Karnatovskaia LV. A 51-year-old man with seizures and progressive behavioral changes. Chest 2015; 147:e86-e89. [PMID: 25732477 DOI: 10.1378/chest.14-1572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A 51-year-old man was admitted for evaluation of new-onset generalized seizures in the context of progressive and significant behavioral change. His medical history was only notable for previous outbreaks of genital herpes. He took no medications. He had occasional social alcohol use and no illicit drug use but was a 35-pack-year current smoker. The patient had no relevant occupational exposure history but had recently traveled to Panama. Initially, the patient's significant other noticed a progressive flattening of his affect. The patient then started to experience episodes of "passing out" that led to injuries prompting ED visits. He was prescribed antiseizure medications and scheduled for an outpatient workup. However, with progressive gait instability, lethargy, and an increase in frequency of generalized seizures, the patient was admitted for treatment of suspected viral encephalitis. Despite initiation of antimicrobial and antiviral therapy, the patient's level of alertness continued to decline, ultimately leading to intubation for airway protection.
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Affiliation(s)
- Casey A Cable
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL.
| | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Neurosurgery, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
| | - Mark N Rubin
- Department of Neurology, Mayo Clinic, Jacksonville, FL
| | - Andras Khoor
- Department of Pathology, Mayo Clinic, Jacksonville, FL
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18
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Affiliation(s)
- William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida2Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida3Department of Critical Care, Mayo Clinic, Jacksonville, Florida
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Karnatovskaia LV, Khoor A, Mira-Avendano I. Sarcoid-like reaction in diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. Am J Respir Crit Care Med 2015; 190:e62-3. [PMID: 25398121 DOI: 10.1164/rccm.201403-0513im] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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
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Karnatovskaia LV, Johnson MM, Benzo RP, Gajic O. The spectrum of psychocognitive morbidity in the critically ill: A review of the literature and call for improvement. J Crit Care 2015; 30:130-7. [DOI: 10.1016/j.jcrc.2014.09.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/07/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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Karnatovskaia LV, Khoor A, Johnson MM, Kaplan J. A 60-year-old woman with PET scan-avid lung nodules and a history of a ruptured silicone breast implant. Chest 2014; 146:e138-e142. [PMID: 25288007 DOI: 10.1378/chest.14-0203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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
A 60-year-old woman was referred to the pulmonary clinic for evaluation of lung nodules. Her medical history was notable for hypothyroidism, anxiety, and a ruptured breast implant for which incomplete surgical resection and evacuation had been performed 10 years previously. She was a lifelong nonsmoker and worked as a gym instructor. The patient denied occupational exposures and had not traveled recently. Medications included levothyroxine and alprazolam. Except for a 1-month history of occasional dry cough, the review of systems was negative. The patient's physician queried whether the previously ruptured silicone breast implant may have played a role in the genesis of the nodules and referred the patient to our institution for further management. The lack of systemic symptoms relative to the degree of lung involvement provided an early diagnostic clue.
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Affiliation(s)
| | - Andras Khoor
- Department of Pathology, Mayo Clinic Florida, Jacksonville, FL
| | - Margaret M Johnson
- Departments of Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Joseph Kaplan
- Departments of Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL
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22
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Karnatovskaia LV, Gajic O, Bienvenu OJ, Stevenson JE, Needham DM. A holistic approach to the critically ill and Maslow's hierarchy. J Crit Care 2014; 30:210-1. [PMID: 25277078 DOI: 10.1016/j.jcrc.2014.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 09/07/2014] [Indexed: 10/24/2022]
Affiliation(s)
| | - Ognjen Gajic
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | - O Joseph Bienvenu
- Outcomes after Critical Illness and Surgery (OACIS) Group, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Jennifer E Stevenson
- Department of Rehabilitation Medicine, University of Washington/Harborview Medical Center, Seattle, WA.
| | - Dale M Needham
- OACIS Group, Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.
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Karnatovskaia LV, Wartenberg KE, Freeman WD. Therapeutic hypothermia for neuroprotection: history, mechanisms, risks, and clinical applications. Neurohospitalist 2014; 4:153-63. [PMID: 24982721 DOI: 10.1177/1941874413519802] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [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: 12/26/2022] Open
Abstract
The earliest recorded application of therapeutic hypothermia in medicine spans about 5000 years; however, its use has become widespread since 2002, following the demonstration of both safety and efficacy of regimens requiring only a mild (32°C-35°C) degree of cooling after cardiac arrest. We review the mechanisms by which hypothermia confers neuroprotection as well as its physiological effects by body system and its associated risks. With regard to clinical applications, we present evidence on the role of hypothermia in traumatic brain injury, intracranial pressure elevation, stroke, subarachnoid hemorrhage, spinal cord injury, hepatic encephalopathy, and neonatal peripartum encephalopathy. Based on the current knowledge and areas undergoing or in need of further exploration, we feel that therapeutic hypothermia holds promise in the treatment of patients with various forms of neurologic injury; however, additional quality studies are needed before its true role is fully known.
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Affiliation(s)
| | - Katja E Wartenberg
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Germany
| | - William D Freeman
- Departments of Neurology, Neurosurgery, Critical Care, Mayo Clinic, Jacksonville, FL, USA
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Karnatovskaia LV, Lee AS, Bender SP, Talmor D, Festic E. Obstructive sleep apnea, obesity, and the development of acute respiratory distress syndrome. J Clin Sleep Med 2014; 10:657-62. [PMID: 24932146 DOI: 10.5664/jcsm.3794] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) may increase the risk of respiratory complications and acute respiratory distress syndrome (ARDS) among surgical patients. OSA is more prevalent among obese individuals; obesity can predispose to ARDS. HYPOTHESIS It is unclear whether OSA independently contributes towards the risk of ARDS among hospitalized patients. METHODS This is a pre-planned retrospective subgroup analysis of the prospectively identified cohort of 5,584 patients across 22 hospitals with at least one risk factor for ARDS at the time of hospitalization from a trial by the US Critical Illness and Injury Trials Group designed to validate the Lung Injury Prediction Score. A total of 252 patients (4.5%) had a diagnosis of OSA at the time of hospitalization; of those, 66% were obese. Following multivariate adjustment in the logistic regression model, there was no significant relationship between OSA and development of ARDS (OR = 0.65, 95%CI = 0.32-1.22). However, body mass index (BMI) was associated with subsequent ARDS development (OR = 1.02, 95%CI = 1.00-1.04, p = 0.03). Neither OSA nor BMI affected mechanical ventilation requirement or mortality. CONCLUSIONS Prior diagnosis of OSA did not independently affect development of ARDS among patients with at least one predisposing condition, nor the need for mechanical ventilation or hospital mortality. Obesity appeared to independently increase the risk of ARDS.
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Affiliation(s)
| | - Augustine S Lee
- Division of Pulmonary and Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - S Patrick Bender
- Division of Anesthesiology, University of Vermont, Burlington, VT
| | - Daniel Talmor
- Division of Anesthesiology, Harvard University, Boston, MA
| | - Emir Festic
- Division of Pulmonary and Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
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Karnatovskaia LV, Festic E, Freeman WD, Lee AS. Effect of therapeutic hypothermia on gas exchange and respiratory mechanics: a retrospective cohort study. Ther Hypothermia Temp Manag 2014; 4:88-95. [PMID: 24840620 DOI: 10.1089/ther.2014.0004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Targeted temperature management (TTM) may improve respiratory mechanics and lung inflammation in acute respiratory distress syndrome (ARDS) based on animal and limited human studies. We aimed to assess the pulmonary effects of TTM in patients with respiratory failure following cardiac arrest. Retrospective review of consecutive cardiac arrest cases occurring out of hospital or within 24 hours of hospital admission (2002-2012). Those receiving TTM (n=44) were compared with those who did not (n=42), but required mechanical ventilation (MV) for at least 4 days following the arrest. There were no between-group differences in age, gender, body mass index, APACHE II, or fluid balance during the study period. The TTM group had lower ejection fraction, Glasgow Coma Score, and more frequent use of paralytics. Matched data analyses (change at day 4 compared with baseline of the individual subject) showed favorable, but not statistically significant trends in respiratory mechanics endpoints (airway pressure, compliance, tidal volume, and PaO2/FiO2) in the TTM group. The PaCO2 decreased significantly more in the TTM group, as compared with controls (-12 vs. -5 mmHg, p=0.02). For clinical outcomes, the TTM group consistently, although not significantly, did better in survival (59% vs. 43%) and hospital length of stay (12 vs. 15 days). The MV duration and Cerebral Performance Category score on discharge were significantly lower in the TTM group (7.3 vs. 10.7 days, p=0.04 and 3.2 vs. 4, p=0.01). This small retrospective cohort suggests that the effect of TTM ranges from equivalent to favorable, compared with controls, for the specific respiratory and clinical outcomes in patients with respiratory failure following cardiac arrest.
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Abstract
Sepsis represents a major challenge in medicine. It begins as a systemic response to infection that can affect virtually any organ system, including the central and peripheral nervous systems. Akin to management of stroke, early recognition and treatment of sepsis are just as crucial to a successful outcome. Sepsis can precipitate myasthenic crisis and lead to encephalopathy and critical illness neuropathy. Stroke and traumatic brain injury can predispose a patient to develop sepsis, whereas Guillain-Barré syndrome is similarly not uncommon following infection. This review article will first describe the essential principles of sepsis recognition, pathophysiology, and management and will then briefly cover the neurologic aspects associated with sepsis. Vigilant awareness of the clinical features of sepsis and timeliness of intervention can help clinicians prevent progression of this disease to a multisystem organ failure, which can be difficult to reverse even after the original source of infection is under control.
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