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Bramante CT, Beckman KB, Mehta T, Karger AB, Odde DJ, Tignanelli CJ, Buse JB, Johnson DM, Watson RHB, Daniel JJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Anderson B, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Fricton RD, Lee S, Griffiths G, Pullen MF, Thompson JL, Sherwood NE, Murray TA, Rose MR, Boulware DR, Huling JD. Favorable Antiviral Effect of Metformin on Severe Acute Respiratory Syndrome Coronavirus 2 Viral Load in a Randomized, Placebo-Controlled Clinical Trial of Coronavirus Disease 2019. Clin Infect Dis 2024:ciae159. [PMID: 38690892 DOI: 10.1093/cid/ciae159] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Metformin has antiviral activity against RNA viruses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The mechanism appears to be suppression of protein translation via targeting the host mechanistic target of rapamycin pathway. In the COVID-OUT randomized trial for outpatient coronavirus disease 2019 (COVID-19), metformin reduced the odds of hospitalizations/death through 28 days by 58%, of emergency department visits/hospitalizations/death through 14 days by 42%, and of long COVID through 10 months by 42%. METHODS COVID-OUT was a 2 × 3 randomized, placebo-controlled, double-blind trial that assessed metformin, fluvoxamine, and ivermectin; 999 participants self-collected anterior nasal swabs on day 1 (n = 945), day 5 (n = 871), and day 10 (n = 775). Viral load was quantified using reverse-transcription quantitative polymerase chain reaction. RESULTS The mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95% confidence interval [CI], -1.05 to -.06; P = .027). Those who received metformin were less likely to have a detectable viral load than placebo at day 5 or day 10 (odds ratio [OR], 0.72; 95% CI, .55 to .94). Viral rebound, defined as a higher viral load at day 10 than day 5, was less frequent with metformin (3.28%) than placebo (5.95%; OR, 0.68; 95% CI, .36 to 1.29). The metformin effect was consistent across subgroups and increased over time. Neither ivermectin nor fluvoxamine showed effect over placebo. CONCLUSIONS In this randomized, placebo-controlled trial of outpatient treatment of SARS-CoV-2, metformin significantly reduced SARS-CoV-2 viral load, which may explain the clinical benefits in this trial. Metformin is pleiotropic with other actions that are relevant to COVID-19 pathophysiology. CLINICAL TRIALS REGISTRATION NCT04510194.
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Affiliation(s)
- Carolyn T Bramante
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth B Beckman
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tanvi Mehta
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Darrell M Johnson
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ray H B Watson
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jerry J Daniel
- Genomics Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - David M Liebovitz
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacinda M Nicklas
- General Internal Medicine, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, Minnesota, USA
| | - Michael A Puskarich
- Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View-University of California, Los Angeles, California, USA
| | - Lianne K Siegel
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katrina M Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Via Rao
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Aubrey A Hagen
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah L Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nandini Avula
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neha V Reddy
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Spencer M Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Regina D Fricton
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Samuel Lee
- General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Gwendolyn Griffiths
- General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Thomas A Murray
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael R Rose
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jared D Huling
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Knack SKS, Scott N, Driver BE, Prekker ME, Black LP, Hopson C, Maruggi E, Kaus O, Tordsen W, Puskarich MA. Early Physician Gestalt Versus Usual Screening Tools for the Prediction of Sepsis in Critically Ill Emergency Patients. Ann Emerg Med 2024:S0196-0644(24)00099-4. [PMID: 38530675 DOI: 10.1016/j.annemergmed.2024.02.009] [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] [Received: 11/27/2023] [Revised: 02/02/2024] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
STUDY OBJECTIVE Compare physician gestalt to existing screening tools for identifying sepsis in the initial minutes of presentation when time-sensitive treatments must be initiated. METHODS This prospective observational study conducted with consecutive encounter sampling took place in the emergency department (ED) of an academic, urban, safety net hospital between September 2020 and May 2022. The study population included ED patients who were critically ill, excluding traumas, transfers, and self-evident diagnoses. Emergency physician gestalt was measured using a visual analog scale (VAS) from 0 to 100 at 15 and 60 minutes after patient arrival. The primary outcome was an explicit sepsis hospital discharge diagnosis. Clinical data were recorded for up to 3 hours to compare Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA), Modified Early Warning Score (MEWS), and a logistic regression machine learning model using Least Absolute Shrinkage and Selection Operator (LASSO) for variable selection. The screening tools were compared using receiver operating characteristic analysis and area under the curve calculation (AUC). RESULTS A total of 2,484 patient-physician encounters involving 59 attending physicians were analyzed. Two hundred seventy-five patients (11%) received an explicit sepsis discharge diagnosis. When limited to available data at 15 minutes, initial VAS (AUC 0.90; 95% confidence interval [CI] 0.88, 0.92) outperformed all tools including LASSO (0.84; 95% CI 0.82 to 0.87), qSOFA (0.67; 95% CI 0.64 to 0.71), SIRS (0.67; 95% 0.64 to 0.70), SOFA (0.67; 95% CI 0.63 to 0.70), and MEWS (0.66; 95% CI 0.64 to 0.69). Expanding to data available at 60 minutes did not meaningfully change results. CONCLUSION Among adults presenting to an ED with an undifferentiated critical illness, physician gestalt in the first 15 minutes of the encounter outperformed other screening methods in identifying sepsis.
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Affiliation(s)
| | | | | | | | - Lauren Page Black
- University of Florida, College of Medicine, Jacksonville, FL; Northwestern University, Feinberg School of Medicine, Chicago, IL
| | | | | | | | | | - Michael A Puskarich
- Hennepin Healthcare, Minneapolis, MN; University of Minnesota, Minneapolis, MN.
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3
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Black LP, Hopson C, Puskarich MA, Modave F, Booker SQ, DeVos E, Fernandez R, Garvan C, Guirgis FW. Racial disparities in septic shock mortality: a retrospective cohort study. Lancet Reg Health Am 2024; 29:100646. [PMID: 38162256 PMCID: PMC10757245 DOI: 10.1016/j.lana.2023.100646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
Background Patients with septic shock have the highest risk of death from sepsis, however, racial disparities in mortality outcomes in this cohort have not been rigorously investigated. Our objective was to describe the association between race/ethnicity and mortality in patients with septic shock. Methods Our study is a retrospective cohort study of adult patients in the OneFlorida Data Trust (Florida, United States of America) admitted with septic shock between January 2012 and July 2018. We identified patients as having septic shock if they received vasopressors during their hospital encounter and had either an explicit International Classification of Disease (ICD) code for sepsis, or had an infection ICD code and received intravenous antibiotics. Our primary outcome was 90-day mortality. Our secondary outcome was in-hospital mortality. Multiple logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) for variable selection was used to assess associations. Findings There were 13,932 patients with septic shock in our cohort. The mean age was 61 years (SD 16), 68% of the cohort identified as White (n = 9419), 28% identified as Black (n = 3936), 2% (n = 294) identified as Hispanic ethnicity, and 2% as other races not specified in the previous groups (n = 283). In our logistic regression model for 90-day mortality, patients identified as Black had 1.57 times the odds of mortality (95% CI 1.07-2.29, p = 0.02) compared to White patients. Other significant predictors included mechanical ventilation (OR 3.66, 95% CI 3.35-4.00, p < 0.01), liver disease (OR 1.75, 95% CI 1.59-1.93, p < 0.01), laboratory components of the Sequential Organ Failure Assessment score (OR 1.18, 95% CI 1.16-1.21, p < 0.01), lactate (OR 1.10, 95% CI 1.08-1.12, p < 0.01), congestive heart failure (OR 1.19, 95% CI 1.10-1.30, p < 0.01), human immunodeficiency virus (OR 1.35, 95% CI 1.04-1.75, p = 0.03), age (OR 1.04, 95% CI 1.04-1.04, p < 0.01), and the interaction between age and race (OR 0.99, 95% CI 0.99-1.00, p < 0.01). Among younger patients (<45 years), patients identified as Black accounted for a higher proportion of the deaths. Results were similar in the in-hospital mortality model. Interpretation In this retrospective study of septic shock patients, we found that patients identified as Black had higher odds of mortality compared to patients identified as non-Hispanic White. Our findings suggest that the greatest disparities in mortality are among younger Black patients with septic shock. Funding National Institutes of Health National Center for Advancing Translational Sciences (1KL2TR001429); National Institute of Health National Institute of General Medical Sciences (1K23GM144802).
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Affiliation(s)
- Lauren P. Black
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, 211 Ontario Street, Suite 200, Chicago, IL, 60611, USA
| | - Charlotte Hopson
- Department of Emergency Medicine, University of Florida College of Medicine, 1329 SW 16th St, Suite 5270, Gainesville, FL, 32603, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Francois Modave
- Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32610, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, 1225 Center Dr, Gainesville, FL, 32610, USA
| | - Elizabeth DeVos
- Department of Emergency Medicine, University of Florida College of Medicine – Jacksonville, 655 West 8th Street Jacksonville, FL, 32207, USA
| | - Rosemarie Fernandez
- Department of Emergency Medicine, University of Florida College of Medicine, 1329 SW 16th St, Suite 5270, Gainesville, FL, 32603, USA
| | - Cynthia Garvan
- Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL, 32610, USA
| | - Faheem W. Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, 1329 SW 16th St, Suite 5270, Gainesville, FL, 32603, USA
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Jennaro TS, Puskarich MA, Flott TL, McLellan LA, Jones AE, Pai MP, Stringer KA. Kidney function as a key driver of the pharmacokinetic response to high-dose L-carnitine in septic shock. Pharmacotherapy 2023; 43:1240-1250. [PMID: 37775945 PMCID: PMC10841498 DOI: 10.1002/phar.2882] [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: 05/12/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 10/01/2023]
Abstract
STUDY OBJECTIVE Levocarnitine (L-carnitine) has shown promise as a metabolic-therapeutic for septic shock, where mortality approaches 40%. However, high-dose (≥ 6 grams) intravenous supplementation results in a broad range of serum concentrations. We sought to describe the population pharmacokinetics (PK) of high-dose L-carnitine, test various estimates of kidney function, and assess the correlation of PK parameters with pre-treatment metabolites in describing drug response for patients with septic shock. DESIGN Population PK analysis was done with baseline normalized concentrations using nonlinear mixed effect models in the modeling platform Monolix. Various estimates of kidney function, patient demographics, dose received, and organ dysfunction were tested as population covariates. DATA SOURCE We leveraged serum samples and metabolomics data from a phase II trial of L-carnitine in vasopressor-dependent septic shock. Serum was collected at baseline (T0); end-of-infusion (T12); and 24, 48, and 72 h after treatment initiation. PATIENTS AND INTERVENTION Patients were adaptively randomized to receive intravenous L-carnitine (6 grams, 12 grams, or 18 grams) or placebo. MEASUREMENTS AND MAIN RESULTS The final dataset included 542 serum samples from 130 patients randomized to L-carnitine. A two-compartment model with linear elimination and a fixed volume of distribution (17.1 liters) best described the data and served as a base structural model. Kidney function estimates as a covariate on the elimination rate constant (k) reliably improved model fit. Estimated glomerular filtration rate (eGFR), based on the 2021 Chronic Kidney Disease Epidemiology collaboration (CKD-EPI) equation with creatinine and cystatin C, outperformed creatinine clearance (Cockcroft-Gault) and older CKD-EPI equations that use an adjustment for self-identified race. CONCLUSIONS High-dose L-carnitine supplementation is well-described by a two-compartment population PK model in patients with septic shock. Kidney function estimates that leverage cystatin C provided superior model fit. Future investigations into high-dose L-carnitine supplementation should consider baseline metabolic status and dose adjustments based on renal function over a fixed or weight-based dosing paradigm.
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Affiliation(s)
- Theodore S. Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Thomas L. Flott
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura A. McLellan
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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5
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Avula N, Kakach D, Tignanelli CJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Buse JB, Klatt NR, Anderson B, Karger AB, Hartman KM, Patel B, Fenno SL, Reddy NV, Erickson SM, Boulware DR, Murray TA, Bramante CT. Strategies used for the COVID-OUT decentralized trial of outpatient treatment of SARS-CoV-2. J Clin Transl Sci 2023; 7:e242. [PMID: 38033705 PMCID: PMC10685265 DOI: 10.1017/cts.2023.668] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/20/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
The COVID-19 pandemic accelerated the development of decentralized clinical trials (DCT). DCT's are an important and pragmatic method for assessing health outcomes yet comprise only a minority of clinical trials, and few published methodologies exist. In this report, we detail the operational components of COVID-OUT, a decentralized, multicenter, quadruple-blinded, randomized trial that rapidly delivered study drugs nation-wide. The trial examined three medications (metformin, ivermectin, and fluvoxamine) as outpatient treatment of SARS-CoV-2 for their effectiveness in preventing severe or long COVID-19. Decentralized strategies included HIPAA-compliant electronic screening and consenting, prepacking investigational product to accelerate delivery after randomization, and remotely confirming participant-reported outcomes. Of the 1417 individuals with the intention-to-treat sample, the remote nature of the study caused an additional 94 participants to not take any doses of study drug. Therefore, 1323 participants were in the modified intention-to-treat sample, which was the a priori primary study sample. Only 1.4% of participants were lost to follow-up. Decentralized strategies facilitated the successful completion of the COVID-OUT trial without any in-person contact by expediting intervention delivery, expanding trial access geographically, limiting contagion exposure, and making it easy for participants to complete follow-up visits. Remotely completed consent and follow-up facilitated enrollment.
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Affiliation(s)
- Nandini Avula
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Dustin Kakach
- Investigational Drug Service, Fairview Health Services, University of Minnesota Medical Center, Minneapolis, MN, USA
| | | | - David M. Liebovitz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jacinda M. Nicklas
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Kenneth Cohen
- UnitedHealth Group, Optum Health, Minnetonka, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Hrishikesh K. Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - John B. Buse
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Nichole R. Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M. Hartman
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L. Fenno
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Neha V. Reddy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Spencer M. Erickson
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - David R. Boulware
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A. Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn T. Bramante
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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Yang K, Kang Z, Guan W, Lotfi-Emran S, Mayer ZJ, Guerrero CR, Steffen BT, Puskarich MA, Tignanelli CJ, Lusczek E, Safo SE. Developing A Baseline Metabolomic Signature Associated with COVID-19 Severity: Insights from Prospective Trials Encompassing 13 U.S. Centers. Metabolites 2023; 13:1107. [PMID: 37999202 PMCID: PMC10672920 DOI: 10.3390/metabo13111107] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 11/25/2023] Open
Abstract
Metabolic disease is a significant risk factor for severe COVID-19 infection, but the contributing pathways are not yet fully elucidated. Using data from two randomized controlled trials across 13 U.S. academic centers, our goal was to characterize metabolic features that predict severe COVID-19 and define a novel baseline metabolomic signature. Individuals (n = 133) were dichotomized as having mild or moderate/severe COVID-19 disease based on the WHO ordinal scale. Blood samples were analyzed using the Biocrates platform, providing 630 targeted metabolites for analysis. Resampling techniques and machine learning models were used to determine metabolomic features associated with severe disease. Ingenuity Pathway Analysis (IPA) was used for functional enrichment analysis. To aid in clinical decision making, we created baseline metabolomics signatures of low-correlated molecules. Multivariable logistic regression models were fit to associate these signatures with severe disease on training data. A three-metabolite signature, lysophosphatidylcholine a C17:0, dihydroceramide (d18:0/24:1), and triacylglyceride (20:4_36:4), resulted in the best discrimination performance with an average test AUROC of 0.978 and F1 score of 0.942. Pathways related to amino acids were significantly enriched from the IPA analyses, and the mitogen-activated protein kinase kinase 5 (MAP2K5) was differentially activated between groups. In conclusion, metabolites related to lipid metabolism efficiently discriminated between mild vs. moderate/severe disease. SDMA and GABA demonstrated the potential to discriminate between these two groups as well. The mitogen-activated protein kinase kinase 5 (MAP2K5) regulator is differentially activated between groups, suggesting further investigation as a potential therapeutic pathway.
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Affiliation(s)
- Kaifeng Yang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
| | - Zhiyu Kang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
| | - Sahar Lotfi-Emran
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Zachary J. Mayer
- Center for Metabolomics and Proteomics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Candace R. Guerrero
- Center for Metabolomics and Proteomics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Brian T. Steffen
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA (E.L.)
| | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55455, USA
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA (E.L.)
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN 55455, USA
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA (E.L.)
| | - Sandra E. Safo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA (S.E.S.)
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7
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Bramante CT, Buse JB, Liebovitz DM, Nicklas JM, Puskarich MA, Cohen K, Belani HK, Anderson BJ, Huling JD, Tignanelli CJ, Thompson JL, Pullen M, Wirtz EL, Siegel LK, Proper JL, Odde DJ, Klatt NR, Sherwood NE, Lindberg SM, Karger AB, Beckman KB, Erickson SM, Fenno SL, Hartman KM, Rose MR, Mehta T, Patel B, Griffiths G, Bhat NS, Murray TA, Boulware DR. Outpatient treatment of COVID-19 and incidence of post-COVID-19 condition over 10 months (COVID-OUT): a multicentre, randomised, quadruple-blind, parallel-group, phase 3 trial. Lancet Infect Dis 2023; 23:1119-1129. [PMID: 37302406 DOI: 10.1016/s1473-3099(23)00299-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/30/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Post-COVID-19 condition (also known as long COVID) is an emerging chronic illness potentially affecting millions of people. We aimed to evaluate whether outpatient COVID-19 treatment with metformin, ivermectin, or fluvoxamine soon after SARS-CoV-2 infection could reduce the risk of long COVID. METHODS We conducted a decentralised, randomised, quadruple-blind, parallel-group, phase 3 trial (COVID-OUT) at six sites in the USA. We included adults aged 30-85 years with overweight or obesity who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days before enrolment. Participants were randomly assigned via 2 × 3 parallel factorial randomisation (1:1:1:1:1:1) to receive metformin plus ivermectin, metformin plus fluvoxamine, metformin plus placebo, ivermectin plus placebo, fluvoxamine plus placebo, or placebo plus placebo. Participants, investigators, care providers, and outcomes assessors were masked to study group assignment. The primary outcome was severe COVID-19 by day 14, and those data have been published previously. Because the trial was delivered remotely nationwide, the a priori primary sample was a modified intention-to-treat sample, meaning that participants who did not receive any dose of study treatment were excluded. Long COVID diagnosis by a medical provider was a prespecified, long-term secondary outcome. This trial is complete and is registered with ClinicalTrials.gov, NCT04510194. FINDINGS Between Dec 30, 2020, and Jan 28, 2022, 6602 people were assessed for eligibility and 1431 were enrolled and randomly assigned. Of 1323 participants who received a dose of study treatment and were included in the modified intention-to-treat population, 1126 consented for long-term follow-up and completed at least one survey after the assessment for long COVID at day 180 (564 received metformin and 562 received matched placebo; a subset of participants in the metformin vs placebo trial were also randomly assigned to receive ivermectin or fluvoxamine). 1074 (95%) of 1126 participants completed at least 9 months of follow-up. 632 (56·1%) of 1126 participants were female and 494 (43·9%) were male; 44 (7·0%) of 632 women were pregnant. The median age was 45 years (IQR 37-54) and median BMI was 29·8 kg/m2 (IQR 27·0-34·2). Overall, 93 (8·3%) of 1126 participants reported receipt of a long COVID diagnosis by day 300. The cumulative incidence of long COVID by day 300 was 6·3% (95% CI 4·2-8·2) in participants who received metformin and 10·4% (7·8-12·9) in those who received identical metformin placebo (hazard ratio [HR] 0·59, 95% CI 0·39-0·89; p=0·012). The metformin beneficial effect was consistent across prespecified subgroups. When metformin was started within 3 days of symptom onset, the HR was 0·37 (95% CI 0·15-0·95). There was no effect on cumulative incidence of long COVID with ivermectin (HR 0·99, 95% CI 0·59-1·64) or fluvoxamine (1·36, 0·78-2·34) compared with placebo. INTERPRETATION Outpatient treatment with metformin reduced long COVID incidence by about 41%, with an absolute reduction of 4·1%, compared with placebo. Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost, and safe. FUNDING Parsemus Foundation; Rainwater Charitable Foundation; Fast Grants; UnitedHealth Group Foundation; National Institute of Diabetes, Digestive and Kidney Diseases; National Institutes of Health; and National Center for Advancing Translational Sciences.
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Affiliation(s)
- Carolyn T Bramante
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View, University of California, Los Angeles, CA, USA
| | - Blake J Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA; Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sarah M Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | | | - Spencer M Erickson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rose
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gwendolyn Griffiths
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Neeta S Bhat
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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8
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Di Stefano L, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Bengtson CD, Gadomski A, Geriak M, Puskarich MA, Salathe MA, Schutte AE, Tignanelli CJ, Victory J, Bierer BE, Hanley DF, Freilich DA. Losartan in hospitalized patients with COVID-19 in North America: An individual participant data meta-analysis. Medicine (Baltimore) 2023; 102:e33904. [PMID: 37335665 PMCID: PMC10256351 DOI: 10.1097/md.0000000000033904] [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: 12/30/2022] [Accepted: 05/11/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) have been hypothesized to benefit patients with COVID-19 via the inhibition of viral entry and other mechanisms. We conducted an individual participant data (IPD) meta-analysis assessing the effect of starting the ARB losartan in recently hospitalized COVID-19 patients. METHODS We searched ClinicalTrials.gov in January 2021 for U.S./Canada-based trials where an angiotensin-converting enzyme inhibitors/ARB was a treatment arm, targeted outcomes could be extrapolated, and data sharing was allowed. Our primary outcome was a 7-point COVID-19 ordinal score measured 13 to 16 days post-enrollment. We analyzed data by fitting multilevel Bayesian ordinal regression models and standardizing the resulting predictions. RESULTS 325 participants (156 losartan vs 169 control) from 4 studies contributed IPD. Three were randomized trials; one used non-randomized concurrent and historical controls. Baseline covariates were reasonably balanced for the randomized trials. All studies evaluated losartan. We found equivocal evidence of a difference in ordinal scores 13-16 days post-enrollment (model-standardized odds ratio [OR] 1.10, 95% credible interval [CrI] 0.76-1.71; adjusted OR 1.15, 95% CrI 0.15-3.59) and no compelling evidence of treatment effect heterogeneity among prespecified subgroups. Losartan had worse effects for those taking corticosteroids at baseline after adjusting for covariates (ratio of adjusted ORs 0.29, 95% CrI 0.08-0.99). Hypotension serious adverse event rates were numerically higher with losartan. CONCLUSIONS In this IPD meta-analysis of hospitalized COVID-19 patients, we found no convincing evidence for the benefit of losartan versus control treatment, but a higher rate of hypotension adverse events with losartan.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, CO
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Charles D. Bengtson
- Department of Internal Medicine, University of Kansas Medical Center, KS City, KS
| | - Anne Gadomski
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | | | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthias A. Salathe
- Department of Internal Medicine, University of Kansas Medical Center, KS City, KS
| | - Aletta E. Schutte
- School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel A. Freilich
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, NY
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9
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Bramante CT, Beckman KB, Mehta T, Karger AB, Odde DJ, Tignanelli CJ, Buse JB, Johnson DM, Watson RHB, Daniel JJ, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Anderson B, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Fricton RD, Lee S, Griffiths G, Pullen MF, Thompson JL, Sherwood N, Murray TA, Rose MR, Boulware DR, Huling JD. Metformin reduces SARS-CoV-2 in a Phase 3 Randomized Placebo Controlled Clinical Trial. medRxiv 2023:2023.06.06.23290989. [PMID: 37333243 PMCID: PMC10275003 DOI: 10.1101/2023.06.06.23290989] [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: 06/20/2023]
Abstract
Current antiviral treatment options for SARS-CoV-2 infections are not available globally, cannot be used with many medications, and are limited to virus-specific targets.1-3 Biophysical modeling of SARS-CoV-2 replication predicted that protein translation is an especially attractive target for antiviral therapy.4 Literature review identified metformin, widely known as a treatment for diabetes, as a potential suppressor of protein translation via targeting of the host mTor pathway.5 In vitro, metformin has antiviral activity against RNA viruses including SARS-CoV-2.6,7 In the COVID-OUT phase 3, randomized, placebo-controlled trial of outpatient treatment of COVID-19, metformin had a 42% reduction in ER visits/hospitalizations/death through 14 days; a 58% reduction in hospitalizations/death through 28 days, and a 42% reduction in Long COVID through 10 months.8,9 Here we show viral load analysis of specimens collected in the COVID-OUT trial that the mean SARS-CoV-2 viral load was reduced 3.6-fold with metformin relative to placebo (-0.56 log10 copies/mL; 95%CI, -1.05 to -0.06, p=0.027) while there was no virologic effect for ivermectin or fluvoxamine vs placebo. The metformin effect was consistent across subgroups and with emerging data.10,11 Our results demonstrate, consistent with model predictions, that a safe, widely available,12 well-tolerated, and inexpensive oral medication, metformin, can be repurposed to significantly reduce SARS-CoV-2 viral load.
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Affiliation(s)
| | | | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | | | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC
| | | | - Ray H B Watson
- Genomics Center, University of Minnesota, Minneapolis, MN
| | - Jerry J Daniel
- Genomics Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Hrishikesh K Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Via Rao
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Aubrey A Hagen
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah L Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Nandini Avula
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Neha V Reddy
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | | | - Samuel Lee
- General Internal Medicine, Northwestern University, Chicago, IL
| | | | - Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Michael R Rose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
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10
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Kraus CK, Nguyen HB, Jacobsen RC, Ledeboer NA, May LS, O'Neal HR, Puskarich MA, Rice TW, Self WH, Rothman RE. Rapid identification of sepsis in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e12984. [PMID: 37284425 PMCID: PMC10239543 DOI: 10.1002/emp2.12984] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
Objectives Recent research has helped define the complex pathways in sepsis, affording new opportunities for advancing diagnostics tests. Given significant advances in the field, a group of academic investigators from emergency medicine, intensive care, pathology, and pharmacology assembled to develop consensus around key gaps and potential future use for emerging rapid host response diagnostics assays in the emergency department (ED) setting. Methods A modified Delphi study was conducted that included 26 panelists (expert consensus panel) from multiple specialties. A smaller steering committee first defined a list of Delphi statements related to the need for and future potential use of a hypothetical sepsis diagnostic test in the ED. Likert scoring was used to assess panelists agreement or disagreement with statements. Two successive rounds of surveys were conducted and consensus for statements was operationally defined as achieving agreement or disagreement of 75% or greater. Results Significant gaps were identified related to current tools for assessing risk of sepsis in the ED. Strong consensus indicated the need for a test providing an indication of the severity of dysregulated host immune response, which would be helpful even if it did not identify the specific pathogen. Although there was a relatively high degree of uncertainty regarding which patients would most benefit from the test, the panel agreed that an ideal host response sepsis test should aim to be integrated into ED triage and thus should produce results in less than 30 minutes. The panel also agreed that such a test would be most valuable for improving sepsis outcomes and reducing rates of unnecessary antibiotic use. Conclusion The expert consensus panel expressed strong consensus regarding gaps in sepsis diagnostics in the ED and the potential for new rapid host response tests to help fill these gaps. These finding provide a baseline framework for assessing key attributes of evolving host response diagnostic tests for sepsis in the ED.
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Affiliation(s)
- Chadd K. Kraus
- Department of Emergency MedicineGeisinger Medical CenterDanvillePennsylvaniaUSA
| | - H. Bryant Nguyen
- Department of MedicinePulmonary and Critical Care DivisionLoma Linda UniversityLoma LindaCaliforniaUSA
| | - Ryan C. Jacobsen
- Department of Emergency MedicineUniversity of Kansas HospitalKansas CityKansasUSA
| | - Nathan A. Ledeboer
- Department of Pathology & Laboratory MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Larissa S. May
- Department of Emergency MedicineUC Davis HealthDavisCaliforniaUSA
| | - Hollis R. O'Neal
- Department of Critical Care MedicineLouisiana State UniversityBaton RougeLouisianaUSA
| | - Michael A. Puskarich
- Department of Emergency MedicineHennepin County Medical CenterUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Sciences and Division of AllergyPulmonary and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Sciences and Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Richard E. Rothman
- Department of Emergency MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
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11
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Jennaro TS, Puskarich MA, Evans CR, Karnovsky A, Flott TL, McLellan LA, Jones AE, Stringer KA. Sustained Perturbation of Metabolism and Metabolic Subphenotypes Are Associated With Mortality and Protein Markers of the Host Response. Crit Care Explor 2023; 5:e0881. [PMID: 36998529 PMCID: PMC10047616 DOI: 10.1097/cce.0000000000000881] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Perturbed host metabolism is increasingly recognized as a pillar of sepsis pathogenesis, yet the dynamic alterations in metabolism and its relationship to other components of the host response remain incompletely understood. We sought to identify the early host-metabolic response in patients with septic shock and to explore biophysiological phenotyping and differences in clinical outcomes among metabolic subgroups. DESIGN We measured serum metabolites and proteins reflective of the host-immune and endothelial response in patients with septic shock. SETTING We considered patients from the placebo arm of a completed phase II, randomized controlled trial conducted at 16 U.S. medical centers. Serum was collected at baseline (within 24 hr of the identification of septic shock), 24-hour, and 48-hour postenrollment. Linear mixed models were built to assess the early trajectory of protein analytes and metabolites stratified by 28-day mortality status. Unsupervised clustering of baseline metabolomics data was conducted to identify subgroups of patients. PATIENTS Patients with vasopressor-dependent septic shock and moderate organ dysfunction that were enrolled in the placebo arm of a clinical trial. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty-one metabolites and 10 protein analytes were measured longitudinally in 72 patients with septic shock. In the 30 patients (41.7%) who died prior to 28 days, systemic concentrations of acylcarnitines and interleukin (IL)-8 were elevated at baseline and persisted at T24 and T48 throughout early resuscitation. Concentrations of pyruvate, IL-6, tumor necrosis factor-α, and angiopoietin-2 decreased at a slower rate in patients who died. Two groups emerged from clustering of baseline metabolites. Group 1 was characterized by higher levels of acylcarnitines, greater organ dysfunction at baseline and postresuscitation (p < 0.05), and greater mortality over 1 year (p < 0.001). CONCLUSIONS Among patients with septic shock, nonsurvivors exhibited a more profound and persistent dysregulation in protein analytes attributable to neutrophil activation and disruption of mitochondrial-related metabolism than survivors.
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Affiliation(s)
- Theodore S Jennaro
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Charles R Evans
- Department of Emergency Medicine and the Weil Institute of Critical Care Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
- Michigan Regional Comprehensive Metabolomics Resource Core ([MRC]), Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Alla Karnovsky
- Michigan Regional Comprehensive Metabolomics Resource Core ([MRC]), Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
- Department of Computational Medicine and Bioinformatics, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Thomas L Flott
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Laura A McLellan
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kathleen A Stringer
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine and the Weil Institute of Critical Care Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
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12
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Driver BE, Prekker ME, Wagner E, Cole JB, Puskarich MA, Stang J, DeVries P, Maruggi E, Miner JR. Recall of Awareness During Paralysis Among ED Patients Undergoing Tracheal Intubation. Chest 2023; 163:313-323. [PMID: 36089069 DOI: 10.1016/j.chest.2022.08.2232] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 06/28/2022] [Revised: 08/16/2022] [Accepted: 08/31/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Critically ill patients sometimes remember periods of neuromuscular blockade. RESEARCH QUESTION What is the prevalence of recalled awareness during paralysis in patients who underwent emergency tracheal intubation and mechanical ventilation, and what clinical variables are associated with this outcome? STUDY DESIGN AND METHODS This study analyzed data from a prospectively collected continuous quality improvement database of emergency tracheal intubation in an urban, county hospital. Patients who received a neuromuscular blocking agent to facilitate emergency tracheal intubation in the ED were included. The database contained details of intubation management, including medications received and patient mental status prior to intubation. Patient recall of awareness of paralysis was assessed by trained staff during an in-person interview following extubation using a modified Brice questionnaire. For this analysis, three expert reviewers used these data to adjudicate whether patients may have had awareness of paralysis, the primary outcome. A logistic regression model was constructed to determine whether clinical variables were associated with the primary outcome. RESULTS A total of 886 patients were analyzed. There were 66 patients (7.4%; 95% CI, 5.8-9.4) determined to possibly (61 patients) or definitely (5 patients) have experienced and recalled awareness of paralysis. A logistic regression model revealed that a decreased level of consciousness prior to intubation was associated with lower odds of awareness (adjusted OR, 0.39; 95% CI, 0.22-0.69), whereas the class of neuromuscular blocking agent used, sedative used, preintubation shock index, and postintubation sedation were not significantly associated with recall of this outcome. INTERPRETATION Among patients intubated emergently using a neuromuscular blocking agent, 7.4% of patients recalled awareness without being able to move, which was more likely when patients had a normal level of consciousness prior to intubation.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN
| | - Emily Wagner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jamie Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Paige DeVries
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Ellen Maruggi
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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13
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Neprash HT, McGlave CC, Cross DA, Virnig BA, Puskarich MA, Huling JD, Rozenshtein AZ, Nikpay SS. Trends in Ransomware Attacks on US Hospitals, Clinics, and Other Health Care Delivery Organizations, 2016-2021. JAMA Health Forum 2022; 3:e224873. [PMID: 36580326 PMCID: PMC9856685 DOI: 10.1001/jamahealthforum.2022.4873] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Importance Anecdotal evidence suggests that health care delivery organizations face a growing threat from ransomware attacks that are designed to disrupt care delivery and may consequently threaten patient outcomes. Objective To quantify the frequency and characteristics of ransomware attacks on health care delivery organizations. Design, Setting, and Participants This cohort study used data from the Tracking Healthcare Ransomware Events and Traits database to examine the number and characteristics of ransomware attacks on health care delivery organizations from 2016 to 2021. Logistic and negative binomial regression quantified changes over time in the characteristics of ransomware attacks that affected health care delivery organizations. Main Outcomes and Measures Date of ransomware attack, public reporting of ransomware attacks, personal health information (PHI) exposure, status of encrypted/stolen data following the attack, type of health care delivery organization affected, and operational disruption during the ransomware attack. Results From January 2016 to December 2021, 374 ransomware attacks on US health care delivery organizations exposed the PHI of nearly 42 million patients. From 2016 to 2021, the annual number of ransomware attacks more than doubled from 43 to 91. Almost half (166 [44.4%]) of ransomware attacks disrupted the delivery of health care, with common disruptions including electronic system downtime (156 [41.7%]), cancellations of scheduled care (38 [10.2%]), and ambulance diversion (16 [4.3%]). From 2016 to 2021, ransomware attacks on health care delivery organizations increasingly affected large organizations with multiple facilities (annual marginal effect [ME], 0.08; 95% CI, 0.05-0.10; P < .001), exposed the PHI of more patients (ME, 66 385.8; 95% CI, 3400.5-129 371.2; P = .04), were less likely to be restored from data backups (ME, -0.04; 95% CI, -0.06 to -0.01; P = .002), were more likely to exceed mandatory reporting timelines (ME, 0.06; 95% CI, 0.03-0.08; P < .001), and increasingly were associated with delays or cancellations of scheduled care (ME, 0.02; 95% CI, 0-0.05; P = .02). Conclusions and Relevance This cohort study of ransomware attacks documented growth in their frequency and sophistication. Ransomware attacks disrupt care delivery and jeopardize information integrity. Current monitoring/reporting efforts provide limited information and could be expanded to potentially yield a more complete view of how this growing form of cybercrime affects the delivery of health care.
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Affiliation(s)
- Hannah T. Neprash
- University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | - Claire C. McGlave
- University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | - Dori A. Cross
- University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | - Beth A. Virnig
- University of Florida, College of Public Health and Health Professions, Gainesville, Florida
| | | | - Jared D. Huling
- University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | | | - Sayeh S. Nikpay
- University of Minnesota, School of Public Health, Minneapolis, Minnesota
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14
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Bramante CT, Buse JB, Liebovitz D, Nicklas J, Puskarich MA, Cohen K, Belani H, Anderson B, Huling JD, Tignanelli C, Thompson J, Pullen M, Siegel L, Proper J, Odde DJ, Klatt N, Sherwood N, Lindberg S, Wirtz EL, Karger A, Beckman K, Erickson S, Fenno S, Hartman K, Rose M, Patel B, Griffiths G, Bhat N, Murray TA, Boulware DR. Outpatient treatment of Covid-19 with metformin, ivermectin, and fluvoxamine and the development of Long Covid over 10-month follow-up. medRxiv 2022:2022.12.21.22283753. [PMID: 36597543 PMCID: PMC9810227 DOI: 10.1101/2022.12.21.22283753] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Long Covid is an emerging chronic illness potentially affecting millions, sometimes preventing the ability to work or participate in normal daily activities. COVID-OUT was an investigator-initiated, multi-site, phase 3, randomized, quadruple-blinded placebo-controlled clinical trial (NCT04510194). The design simultaneously assessed three oral medications (metformin, ivermectin, fluvoxamine) using two by three parallel treatment factorial assignment to efficiently share placebo controls and assessed Long Covid outcomes for 10 months to understand whether early outpatient treatment of SARS-CoV-2 with metformin, ivermectin, or fluvoxamine prevents Long Covid. Methods This was a decentralized, remotely delivered trial in the US of 1,125 adults age 30 to 85 with overweight or obesity, fewer than 7 days of symptoms, and enrolled within three days of a documented SARS-CoV-2 infection. Immediate release metformin titrated over 6 days to 1,500mg per day 14 days total; ivermectin 430mcg/kg/day for 3 days; fluvoxamine, 50mg on day one then 50mg twice daily through 14 days. Medical-provider diagnosis of Long Covid, reported by participant by day 300 after randomization was a pre-specified secondary outcome; the primary outcome of the trial was severe Covid by day 14. Result The median age was 45 years (IQR 37 to 54), 56% female of whom 7% were pregnant. Two percent identified as Native American; 3.7% as Asian; 7.4% as Black/African American; 82.8% as white; and 12.7% as Hispanic/Latino. The median BMI was 29.8 kg/m2 (IQR 27 to 34); 51% had a BMI >30kg/m2. Overall, 8.4% reported having received a diagnosis of Long Covid from a medical provider: 6.3% in the metformin group and 10.6% in the metformin control; 8.0% in the ivermectin group and 8.1% in the ivermectin control; and 10.1% in the fluvoxamine group and 7.5% in the fluvoxamine control. The Hazard Ratio (HR) for Long Covid in the metformin group versus control was 0.58 (95% CI 0.38 to 0.88); 0.99 (95% CI 0.592 to 1.643) in the ivermectin group; and 1.36 in the fluvoxamine group (95% CI 0.785 to 2.385). Conclusions There was a 42% relative decrease in the incidence of Long Covid in the metformin group compared to its blinded control in a secondary outcome of this randomized phase 3 trial.
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Affiliation(s)
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, ND
| | - David Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL
| | - Jacinda Nicklas
- General Internal Medicine, University of Colorado, Denver, CO
| | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN
| | - Hrishikesh Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - Jennifer Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Pullen
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | - Nichole Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Kenny Beckman
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Spencer Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Katrina Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Michael Rose
- General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Neeta Bhat
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
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15
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Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila) 2022; 60:1205-1213. [DOI: 10.1080/15563650.2022.2131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Jon B. Cole
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samantha C. Lee
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Nathan M. Kunzler
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Brian E. Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Travis D. Olives
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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16
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Boulware DR, Murray TA, Proper JL, Tignanelli CJ, Buse JB, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Siegel LK, Klatt NR, Odde DJ, Karger AB, Ingraham NE, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Lindberg S, Fricton R, Lee S, Zaman A, Saveraid HG, Tordsen WJ, Pullen MF, Sherwood NE, Huling JD, Bramante CT. Impact of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vaccination and Booster on Coronavirus Disease 2019 (COVID-19) Symptom Severity Over Time in the COVID-OUT Trial. Clin Infect Dis 2022; 76:e1-e9. [PMID: 36124697 PMCID: PMC9494422 DOI: 10.1093/cid/ciac772] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/15/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination has decreasing protection from acquiring any infection with emergence of new variants; however, vaccination continues to protect against progression to severe coronavirus disease 2019 (COVID-19). The impact of vaccination status on symptoms over time is less clear. METHODS Within a randomized trial on early outpatient COVID-19 therapy testing metformin, ivermectin, and/or fluvoxamine, participants recorded symptoms daily for 14 days. Participants were given a paper symptom diary allowing them to circle the severity of 14 symptoms as none (0), mild (1), moderate (2), or severe (3). This is a secondary analysis of clinical trial data on symptom severity over time using generalized estimating equations comparing those unvaccinated, SARS-CoV-2 vaccinated with primary vaccine series only, or vaccine-boosted. RESULTS The parent clinical trial prospectively enrolled 1323 participants, of whom 1062 (80%) prospectively recorded some daily symptom data. Of these, 480 (45%) were unvaccinated, 530 (50%) were vaccinated with primary series only, and 52 (5%) vaccine-boosted. Overall symptom severity was least for the vaccine-boosted group and most severe for unvaccinated at baseline and over the 14 days (P < .001). Individual symptoms were least severe in the vaccine-boosted group including cough, chills, fever, nausea, fatigue, myalgia, headache, and diarrhea, as well as smell and taste abnormalities. Results were consistent over Delta and Omicron variant time periods. CONCLUSIONS SARS-CoV-2 vaccine-boosted participants had the least severe symptoms during COVID-19, which abated the quickest over time. Clinical Trial Registration. NCT04510194.
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Affiliation(s)
- David R Boulware
- Alternative Corresponding Author: David R Boulware MD, MPH, CTropMed, FIDSA Professor of Medicine Infectious Disease & International Medicine Department of Medicine
- University of Minnesota Microbiology Research Facility (MRF) 4-103, 689 SE 23rd Ave, Minneapolis, MN 55455 USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - John B Buse
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jacinda M Nicklas
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | - Michael A Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Medicine, Olive View - University of California, Los Angeles, CA, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas E Ingraham
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Via Rao
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Aubrey A Hagen
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nandini Avula
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Neha V Reddy
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Spencer M Erickson
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Regina Fricton
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Samuel Lee
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adnin Zaman
- Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Hanna G Saveraid
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Walker J Tordsen
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Matthew F Pullen
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn T Bramante
- Corresponding Author: Carolyn Bramante, MD MPH Division of General Internal Medicine and Pediatrics University of Minnesota 717 Delaware St SE, MMC 1932 Minneapolis, MN 55414, USA
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17
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Gnanenthiran SR, Borghi C, Burger D, Caramelli B, Charchar F, Chirinos JA, Cohen JB, Cremer A, Di Tanna GL, Duvignaud A, Freilich D, Gommans DHF, Gracia-Ramos AE, Murray TA, Pelorosso F, Poulter NR, Puskarich MA, Rizas KD, Rothlin R, Schlaich MP, Schreinlecher M, Steckelings UM, Sharma A, Stergiou GS, Tignanelli CJ, Tomaszewski M, Unger T, van Kimmenade RRJ, Wainford RD, Williams B, Rodgers A, Schutte AE. Renin-Angiotensin System Inhibitors in Patients With COVID-19: A Meta-Analysis of Randomized Controlled Trials Led by the International Society of Hypertension. J Am Heart Assoc 2022; 11:e026143. [PMID: 36000426 PMCID: PMC9496439 DOI: 10.1161/jaha.122.026143] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Published randomized controlled trials are underpowered for binary clinical end points to assess the safety and efficacy of renin‐angiotensin system inhibitors (RASi) in adults with COVID‐19. We therefore performed a meta‐analysis to assess the safety and efficacy of RASi in adults with COVID‐19. Methods and Results MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Controlled Trial Register were searched for randomized controlled trials that randomly assigned patients with COVID‐19 to RASi continuation/commencement versus no RASi therapy. The primary outcome was all‐cause mortality at ≤30 days. A total of 14 randomized controlled trials met the inclusion criteria and enrolled 1838 participants (aged 59 years, 58% men, mean follow‐up 26 days). Of the trials, 11 contributed data. We found no effect of RASi versus control on all‐cause mortality (7.2% versus 7.5%; relative risk [RR], 0.95; [95% CI, 0.69–1.30]) either overall or in subgroups defined by COVID‐19 severity or trial type. Network meta‐analysis identified no difference between angiotensin‐converting enzyme inhibitors versus angiotensin II receptor blockers. RASi users had a nonsignificant reduction in acute myocardial infarction (2.1% versus 3.6%; RR, 0.59; [95% CI, 0.33–1.06]), but increased risk of acute kidney injury (7.0% versus 3.6%; RR, 1.82; [95% CI, 1.05–3.16]), in trials that initiated and continued RASi. There was no increase in need for dialysis or differences in congestive cardiac failure, cerebrovascular events, venous thromboembolism, hospitalization, intensive care admission, inotropes, or mechanical ventilation. Conclusions This meta‐analysis of randomized controlled trials evaluating angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers versus control in patients with COVID‐19 found no difference in all‐cause mortality, a borderline decrease in myocardial infarction, and an increased risk of acute kidney injury with RASi. Our findings provide strong evidence that RASi can be used safely in patients with COVID‐19.
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Affiliation(s)
- Sonali R Gnanenthiran
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Claudio Borghi
- Department of Medical and Surgical Sciences University of Bologna Italy
| | - Dylan Burger
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Ottawa Hospital Research Institute University of Ottawa Canada
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, InCor University of Sao Paulo Brazil
| | - Fadi Charchar
- School of Health and Life Sciences Federation University Australia Ballarat VIC Australia
| | - Julio A Chirinos
- Division of Cardiovascular Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division and Department of Biostatistics, Epidemiology, and Informatics University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Antoine Cremer
- Department of Cardiology and Hypertension, Hypertension Excellence Center Hôpital Saint André, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | - Gian Luca Di Tanna
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Alexandre Duvignaud
- Department of Infectious Diseases and Tropical Medicine, Division of Tropical Medicine and Clinical International Health Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | | | - D H Frank Gommans
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Abraham E Gracia-Ramos
- Departamento de Medicina Interna, Hospital General, Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social Mexico City Mexico.,Departamento de Medicina Interna Hospital Regional de Alta Especialidad de Zumpango Estado de Mexico Mexico
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health University of Minnesota Minneapolis MN
| | - Facundo Pelorosso
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Servicio de Anatomía Patologica, Hospital de Alta Complejidad El Calafate SAMIC Santa Cruz Argentina
| | - Neil R Poulter
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Michael A Puskarich
- Department of Emergency Medicine Hennepin County Medical Center University of Minnesota Minneapolis MN
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I Ludwig Maximilian University Hospital Munich Munich Germany
| | - Rodolfo Rothlin
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Sociedad Argentina de Farmacología Clínica, Asociacion Medica Argentina Buenos Aires Argentina
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, Royal Perth Hospital Unit-Royal Perth Hospital Medical Research Foundation University of Western Australia Perth Australia
| | - Michael Schreinlecher
- Department of Internal Medicine III, Cardiology and Angiology Medical University of Innsbruck Innsbruck Austria
| | | | - Abhinav Sharma
- Division of Cardiology McGill University Health Centre Montreal Quebec Canada
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital National and Kapodistrian University of Athens Athens Greece
| | | | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health University of Manchester Manchester UK.,Manchester Academic Health Science Centre Manchester University National Health Service Foundation Trust Manchester Manchester UK
| | - Thomas Unger
- Cardiovascular Research Institute Maastricht-School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands
| | - Roland R J van Kimmenade
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Richard D Wainford
- Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute Boston University School of Medicine Boston MA
| | - Bryan Williams
- Institute of Cardiovascular Science University College London and National Institute for Health Research University College London Hospitals Biomedical Research Centre London UK
| | - Anthony Rodgers
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Aletta E Schutte
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
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18
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Bramante CT, Huling JD, Tignanelli CJ, Buse JB, Liebovitz DM, Nicklas JM, Cohen K, Puskarich MA, Belani HK, Proper JL, Siegel LK, Klatt NR, Odde DJ, Luke DG, Anderson B, Karger AB, Ingraham NE, Hartman KM, Rao V, Hagen AA, Patel B, Fenno SL, Avula N, Reddy NV, Erickson SM, Lindberg S, Fricton R, Lee S, Zaman A, Saveraid HG, Tordsen WJ, Pullen MF, Biros M, Sherwood NE, Thompson JL, Boulware DR, Murray TA. Randomized Trial of Metformin, Ivermectin, and Fluvoxamine for Covid-19. N Engl J Med 2022; 387:599-610. [PMID: 36070710 PMCID: PMC9945922 DOI: 10.1056/nejmoa2201662] [Citation(s) in RCA: 107] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Early treatment to prevent severe coronavirus disease 2019 (Covid-19) is an important component of the comprehensive response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS In this phase 3, double-blind, randomized, placebo-controlled trial, we used a 2-by-3 factorial design to test the effectiveness of three repurposed drugs - metformin, ivermectin, and fluvoxamine - in preventing serious SARS-CoV-2 infection in nonhospitalized adults who had been enrolled within 3 days after a confirmed diagnosis of infection and less than 7 days after the onset of symptoms. The patients were between the ages of 30 and 85 years, and all had either overweight or obesity. The primary composite end point was hypoxemia (≤93% oxygen saturation on home oximetry), emergency department visit, hospitalization, or death. All analyses used controls who had undergone concurrent randomization and were adjusted for SARS-CoV-2 vaccination and receipt of other trial medications. RESULTS A total of 1431 patients underwent randomization; of these patients, 1323 were included in the primary analysis. The median age of the patients was 46 years; 56% were female (6% of whom were pregnant), and 52% had been vaccinated. The adjusted odds ratio for a primary event was 0.84 (95% confidence interval [CI], 0.66 to 1.09; P = 0.19) with metformin, 1.05 (95% CI, 0.76 to 1.45; P = 0.78) with ivermectin, and 0.94 (95% CI, 0.66 to 1.36; P = 0.75) with fluvoxamine. In prespecified secondary analyses, the adjusted odds ratio for emergency department visit, hospitalization, or death was 0.58 (95% CI, 0.35 to 0.94) with metformin, 1.39 (95% CI, 0.72 to 2.69) with ivermectin, and 1.17 (95% CI, 0.57 to 2.40) with fluvoxamine. The adjusted odds ratio for hospitalization or death was 0.47 (95% CI, 0.20 to 1.11) with metformin, 0.73 (95% CI, 0.19 to 2.77) with ivermectin, and 1.11 (95% CI, 0.33 to 3.76) with fluvoxamine. CONCLUSIONS None of the three medications that were evaluated prevented the occurrence of hypoxemia, an emergency department visit, hospitalization, or death associated with Covid-19. (Funded by the Parsemus Foundation and others; COVID-OUT ClinicalTrials.gov number, NCT04510194.).
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Affiliation(s)
- Carolyn T Bramante
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jared D Huling
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Christopher J Tignanelli
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - John B Buse
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - David M Liebovitz
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jacinda M Nicklas
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Kenneth Cohen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Michael A Puskarich
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Hrishikesh K Belani
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jennifer L Proper
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Lianne K Siegel
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nichole R Klatt
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - David J Odde
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Darlette G Luke
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Blake Anderson
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Amy B Karger
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nicholas E Ingraham
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Katrina M Hartman
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Via Rao
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Aubrey A Hagen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Barkha Patel
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Sarah L Fenno
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nandini Avula
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Neha V Reddy
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Spencer M Erickson
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Sarah Lindberg
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Regina Fricton
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Samuel Lee
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Adnin Zaman
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Hanna G Saveraid
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Walker J Tordsen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Matthew F Pullen
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Michelle Biros
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Nancy E Sherwood
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Jennifer L Thompson
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - David R Boulware
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
| | - Thomas A Murray
- From the Departments of Medicine (C.T.B., N.E.I., K.M.H., A.A.H., B.P., S.L.F., N.A., N.V.R., S.M.E., H.G.S., M.F.P., D.R.B.) and Surgery (C.J.T., N.R.K.), Emergency Medicine (M.A.P., M.B.), and Laboratory Medicine and Pathology (A.B.K.), Medical School, the Divisions of Biostatistics (J.D.H., J.L.P., L.K.S., V.R., S. Lindberg, T.A.M.) and Epidemiology and Community Health (N.E.S.), School of Public Health, and the Department of Biomedical Engineering (D.J.O.), University of Minnesota, the Department of Emergency Medicine, Hennepin County Medical Center (M.A.P., W.J.T., M.B.), and the Investigational Drug Service Pharmacy, University of Minnesota-Fairview (D.G.L.), Minneapolis, and UnitedHealth Group, Optum Labs, Minnetonka (K.C.) - all in Minnesota; the Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill (J.B.B.); the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (D.M.L., R.F., S. Lee); the Department of Medicine, School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora (J.M.N., A.Z.); the Department of Medicine, Olive View-University of California, Los Angeles (H.K.B.); Atlanta Veterans Affairs Medical Center and the Department of Medicine, Emory University School of Medicine - both in Atlanta (B.A.); and the Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville (J.L.T.)
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Lee DH, Driver BE, Prekker ME, Puskarich MA, Plummer D, Mojika EY, Smith JC, DeVries PA, Stang JL, Reardon RF. Bronchoscopy in the emergency department. Am J Emerg Med 2022; 58:114-119. [DOI: 10.1016/j.ajem.2022.05.040] [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] [Received: 02/04/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022] Open
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Puskarich MA, Ingraham NE, Merck LH, Driver BE, Wacker DA, Black LP, Jones AE, Fletcher CV, South AM, Murray TA, Lewandowski C, Farhat J, Benoit JL, Biros MH, Cherabuddi K, Chipman JG, Schacker TW, Guirgis FW, Voelker HT, Koopmeiners JS, Tignanelli CJ. Efficacy of Losartan in Hospitalized Patients With COVID-19-Induced Lung Injury: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e222735. [PMID: 35294537 PMCID: PMC8928006 DOI: 10.1001/jamanetworkopen.2022.2735] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/23/2022] [Indexed: 12/14/2022] Open
Abstract
Importance SARS-CoV-2 viral entry may disrupt angiotensin II (AII) homeostasis, contributing to COVID-19 induced lung injury. AII type 1 receptor blockade mitigates lung injury in preclinical models, although data in humans with COVID-19 remain mixed. Objective To test the efficacy of losartan to reduce lung injury in hospitalized patients with COVID-19. Design, Setting, and Participants This blinded, placebo-controlled randomized clinical trial was conducted in 13 hospitals in the United States from April 2020 to February 2021. Hospitalized patients with COVID-19 and a respiratory sequential organ failure assessment score of at least 1 and not already using a renin-angiotensin-aldosterone system (RAAS) inhibitor were eligible for participation. Data were analyzed from April 19 to August 24, 2021. Interventions Losartan 50 mg orally twice daily vs equivalent placebo for 10 days or until hospital discharge. Main Outcomes and Measures The primary outcome was the imputed arterial partial pressure of oxygen to fraction of inspired oxygen (Pao2:Fio2) ratio at 7 days. Secondary outcomes included ordinal COVID-19 severity; days without supplemental o2, ventilation, or vasopressors; and mortality. Losartan pharmacokinetics and RAAS components (AII, angiotensin-[1-7] and angiotensin-converting enzymes 1 and 2)] were measured in a subgroup of participants. Results A total of 205 participants (mean [SD] age, 55.2 [15.7] years; 123 [60.0%] men) were randomized, with 101 participants assigned to losartan and 104 participants assigned to placebo. Compared with placebo, losartan did not significantly affect Pao2:Fio2 ratio at 7 days (difference, -24.8 [95%, -55.6 to 6.1]; P = .12). Compared with placebo, losartan did not improve any secondary clinical outcomes and led to fewer vasopressor-free days than placebo (median [IQR], 9.4 [9.1-9.8] vasopressor-free days vs 8.7 [8.2-9.3] vasopressor-free days). Conclusions and Relevance This randomized clinical trial found that initiation of orally administered losartan to hospitalized patients with COVID-19 and acute lung injury did not improve Pao2:Fio2 ratio at 7 days. These data may have implications for ongoing clinical trials. Trial Registration ClinicalTrials.gov Identifier: NCT04312009.
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Affiliation(s)
- Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Lisa H. Merck
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | - Brian E. Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - David A. Wacker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis
| | - Lauren Page Black
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | | | - Andrew M. South
- Section of Nephrology, Department of Pediatrics, Wake Forest School of Medicine and Brenner Children's Hospital, Winston Salem, North Carolina
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, North Carolina
- Department of Surgery-Hypertension and Vascular Research, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Thomas A. Murray
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Christopher Lewandowski
- Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, Michigan
| | - Joseph Farhat
- Department of Surgery, North Memorial Medical Center, Minneapolis, Minnesota
| | - Justin L. Benoit
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michelle H. Biros
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Kartik Cherabuddi
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Timothy W. Schacker
- Division of Infectious Disease, Department of Medicine, University of Minnesota, Minneapolis
| | - Faheem W. Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville
| | - Helen T. Voelker
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Joseph S. Koopmeiners
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
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21
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Reardon RF, Chinn E, Plummer D, Laudenbach A, Rowland Fisher A, Smoot W, Lee D, Novik J, Wagner B, Kaczmarczyk C, Moore J, Thompson E, Tschautscher C, Dunphy T, Pahl T, Puskarich MA, Miner JR. Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice. Acad Emerg Med 2022; 29:334-343. [PMID: 34644420 PMCID: PMC9298053 DOI: 10.1111/acem.14399] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/19/2021] [Indexed: 01/15/2023]
Abstract
Introduction Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F‐TEE), so we trained and credentialed all of the physicians in our group. Methods We trained 52 EPs to perform and interpret F‐TEEs using a 4‐h simulator‐based course. We kept a database of all F‐TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics. Results Emergency physicians attempted 557 total F‐TEE examinations (median = 10, interquartile range = 5–15) during the 42‐month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F‐TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%–96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%–95%). Indications for F‐TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication. Conclusion After initiating a mandatory group F‐TEE training and credentialing program, we report the largest series to date of EP‐performed resuscitative F‐TEE. The majority of F‐TEE examinations (75%) were performed by EPs without advanced US training beyond residency.
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Affiliation(s)
- Robert F. Reardon
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Elliott Chinn
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Dave Plummer
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Andrew Laudenbach
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Andie Rowland Fisher
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Will Smoot
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Daniel Lee
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Joseph Novik
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Barrett Wagner
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Chris Kaczmarczyk
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Johanna Moore
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Emily Thompson
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Craig Tschautscher
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Teresa Dunphy
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis Minnesota USA
| | - Thomas Pahl
- Glacial Ridge Health System Glenwood Minnesota USA
| | - Michael A. Puskarich
- Department of Emergency Medicine Hennepin County Medical Center & University of Minnesota Medical School Minneapolis Minnesota USA
| | - James R. Miner
- Department of Emergency Medicine Hennepin County Medical Center & University of Minnesota Medical School Minneapolis Minnesota USA
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Jennaro TS, Viglianti EM, Ingraham NE, Jones AE, Stringer KA, Puskarich MA. Serum Levels of Acylcarnitines and Amino Acids Are Associated with Liberation from Organ Support in Patients with Septic Shock. J Clin Med 2022; 11:jcm11030627. [PMID: 35160078 PMCID: PMC8836990 DOI: 10.3390/jcm11030627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 12/01/2021] [Revised: 01/12/2022] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Sepsis-induced metabolic dysfunction is associated with mortality, but the signatures that differentiate variable clinical outcomes among survivors are unknown. Our aim was to determine the relationship between host metabolism and chronic critical illness (CCI) in patients with septic shock. We analyzed metabolomics data from mechanically ventilated patients with vasopressor-dependent septic shock from the placebo arm of a recently completed clinical trial. Baseline serum metabolites were measured by liquid chromatography-mass spectrometry and 1H-nuclear magnetic resonance. We conducted a time-to-event analysis censored at 28 days. Specifically, we determined the relationship between metabolites and time to extubation and freedom from vasopressors using a competing risk survival model, with death as a competing risk. We also compared metabolite concentrations between CCI patients, defined as intensive care unit level of care ≥ 14 days, and those with rapid recovery. Elevations in two acylcarnitines and four amino acids were related to the freedom from organ support (subdistributional hazard ratio < 1 and false discovery rate < 0.05). Proline, glycine, glutamine, and methionine were also elevated in patients who developed CCI. Our work highlights the need for further testing of metabolomics to identify patients at risk of CCI and to elucidate potential mechanisms that contribute to its etiology.
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Affiliation(s)
- Theodore S. Jennaro
- Department of Clinical Pharmacy and the NMR Metabolomics Laboratory, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA; (T.S.J.); (K.A.S.)
| | - Elizabeth M. Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy and the NMR Metabolomics Laboratory, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA; (T.S.J.); (K.A.S.)
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI 48109, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, School of Medicine, University of Minnesota, Minneapolis, MN 55415, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA
- Correspondence:
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23
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Beiser DG, Jarou ZJ, Kassir AA, Puskarich MA, Vrablik MC, Rosenman ED, McDonald SA, Meltzer AC, Courtney DM, Kabrhel C, Kline JA. Predicting 30-day return hospital admissions in patients with COVID-19 discharged from the emergency department: A national retrospective cohort study. J Am Coll Emerg Physicians Open 2021; 2:e12595. [PMID: 35005705 PMCID: PMC8716570 DOI: 10.1002/emp2.12595] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/09/2021] [Accepted: 10/15/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Identification of patients with coronavirus disease 2019 (COVID-19) at risk for deterioration after discharge from the emergency department (ED) remains a clinical challenge. Our objective was to develop a prediction model that identifies patients with COVID-19 at risk for return and hospital admission within 30 days of ED discharge. METHODS We performed a retrospective cohort study of discharged adult ED patients (n = 7529) with SARS-CoV-2 infection from 116 unique hospitals contributing to the National Registry of Suspected COVID-19 in Emergency Care. The primary outcome was return hospital admission within 30 days. Models were developed using classification and regression tree (CART), gradient boosted machine (GBM), random forest (RF), and least absolute shrinkage and selection (LASSO) approaches. RESULTS Among patients with COVID-19 discharged from the ED on their index encounter, 571 (7.6%) returned for hospital admission within 30 days. The machine-learning (ML) models (GBM, RF, and LASSO) performed similarly. The RF model yielded a test area under the receiver operating characteristic curve of 0.74 (95% confidence interval [CI], 0.71-0.78), with a sensitivity of 0.46 (95% CI, 0.39-0.54) and a specificity of 0.84 (95% CI, 0.82-0.85). Predictive variables, including lowest oxygen saturation, temperature, or history of hypertension, diabetes, hyperlipidemia, or obesity, were common to all ML models. CONCLUSIONS A predictive model identifying adult ED patients with COVID-19 at risk for return for return hospital admission within 30 days is feasible. Ensemble/boot-strapped classification methods (eg, GBM, RF, and LASSO) outperform the single-tree CART method. Future efforts may focus on the application of ML models in the hospital setting to optimize the allocation of follow-up resources.
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Affiliation(s)
- David G. Beiser
- Section of Emergency MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Zachary J. Jarou
- Department of Emergency MedicineSt. Joseph Mercy Ann Arbor HospitalUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Alaa A. Kassir
- Section of Emergency MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Michael A. Puskarich
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Marie C. Vrablik
- Department of Emergency MedicineUniversity of WashingtonSeattleWashingtonUSA
| | | | - Samuel A. McDonald
- Department of Emergency MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Andrew C. Meltzer
- Department of Emergency MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - D. Mark Courtney
- Department of Emergency MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Christopher Kabrhel
- Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Jeffrey A. Kline
- Department of Emergency MedicineIndiana UniversityIndianapolisIndianaUSA
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Verdoorn BP, Evans TK, Hanson GJ, Zhu Y, Langhi Prata LGP, Pignolo RJ, Atkinson EJ, Wissler‐Gerdes EO, Kuchel GA, Mannick JB, Kritchevsky SB, Khosla S, Rizza SA, Walston JD, Musi N, Lipsitz LA, Kiel DP, Yung R, LeBrasseur NK, Singh RJ, McCarthy T, Puskarich MA, Niedernhofer LJ, Robbins PD, Sorenson M, Tchkonia T, Kirkland JL. Fisetin for COVID-19 in skilled nursing facilities: Senolytic trials in the COVID era. J Am Geriatr Soc 2021; 69:3023-3033. [PMID: 34375437 PMCID: PMC8447437 DOI: 10.1111/jgs.17416] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 05/22/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 01/19/2023]
Abstract
The burden of senescent cells (SnCs), which do not divide but are metabolically active and resistant to death by apoptosis, is increased in older adults and those with chronic diseases. These individuals are also at the greatest risk for morbidity and mortality from SARS-CoV-2 infection. SARS-CoV-2 complications include cytokine storm and multiorgan failure mediated by the same factors as often produced by SnCs through their senescence-associated secretory phenotype (SASP). The SASP can be amplified by infection-related pathogen-associated molecular profile factors. Senolytic agents, such as Fisetin, selectively eliminate SnCs and delay, prevent, or alleviate multiple disorders in aged experimental animals and animal models of human chronic diseases, including obesity, diabetes, and respiratory diseases. Senolytics are now in clinical trials for multiple conditions linked to SnCs, including frailty; obesity/diabetes; osteoporosis; and cardiovascular, kidney, and lung diseases, which are also risk factors for SARS-CoV-2 morbidity and mortality. A clinical trial is underway to test if senolytics decrease SARS-CoV-2 progression and morbidity in hospitalized older adults. We describe here a National Institutes of Health-funded, multicenter, placebo-controlled clinical trial of Fisetin for older adult skilled nursing facility (SNF) residents who have been, or become, SARS-CoV-2 rtPCR-positive, including the rationale for targeting fundamental aging mechanisms in such patients. We consider logistic challenges of conducting trials in long-term care settings in the SARS-CoV-2 era, including restricted access, consent procedures, methods for obtaining biospecimens and clinical data, staffing, investigational product administration issues, and potential solutions for these challenges. We propose developing a national network of SNFs engaged in interventional clinical trials.
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Affiliation(s)
- Brandon P. Verdoorn
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
| | - Tamara K. Evans
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
| | - Gregory J. Hanson
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
| | - Yi Zhu
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
| | | | - Robert J. Pignolo
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
| | - Elizabeth J. Atkinson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | | | - George A. Kuchel
- University of Connecticut Center on Aging, UConn HealthFarmingtonConnecticutUSA
| | | | - Stephen B. Kritchevsky
- Sticht Center for Healthy Aging and Alzheimer's PreventionWinston‐SalemNorth CarolinaUSA
| | - Sundeep Khosla
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Endocrinology, Department of MedicineMayo ClinicRochesterMinnesotaUSA
| | - Stacey A. Rizza
- Division of Infectious Diseases, Department of MedicineMayo ClinicRochesterMinnesotaUSA
| | - Jeremy D. Walston
- Department of Medicine, Division of Geriatric Medicine and GerontologyJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Nicolas Musi
- Barshop Institute for Longevity and Aging StudiesUniversity of Texas Health Science Center at San AntonioSan AntonioTexasUSA
| | - Lewis A. Lipsitz
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
- Division of GerontologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeBostonMassachusettsUSA
- Division of GerontologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Raymond Yung
- Geriatrics Center and Institute of GerontologyUniversity of MichiganAnn ArborMichiganUSA
- VA Ann Arbor Geriatrics ResearchEducation and Clinical CenterAnn ArborMichiganUSA
- Department of Internal Medicine Division of Geriatric and Palliative MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Nathan K. LeBrasseur
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Department of Physical Medicine and RehabilitationMayo ClinicRochesterMinnesotaUSA
| | - Ravinder J. Singh
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Teresa McCarthy
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Michael A. Puskarich
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Laura J. Niedernhofer
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Paul D. Robbins
- Institute on the Biology of Aging and Metabolism, Department of Biochemistry, Molecular Biology and BiophysicsUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Tamara Tchkonia
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
| | - James L. Kirkland
- Robert and Arlene Kogod Center on AgingMayo ClinicRochesterMinnesotaUSA
- Division of Geriatrics and GerontologyMayo ClinicRochesterMinnesotaUSA
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Dehon E, Zachrison KS, Peltzer-Jones J, Tabatabai RR, Clair E, Puskarich MA, Ondeyka A, Dixon-Gordon K, Walter LA, Situ-LaCasse EH, Fix ML. Sources of Distress and Coping Strategies Among Emergency Physicians During COVID-19. West J Emerg Med 2021; 22:1240-1252. [PMID: 34787546 PMCID: PMC8597705 DOI: 10.5811/westjem.2021.9.53406] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/10/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic has been shown to increase levels of psychological distress among healthcare workers. Little is known, however, about specific positive and negative individual and organizational factors that affect the mental health of emergency physicians (EP) during COVID-19. Our objective was to assess these factors in a broad geographic sample of EPs in the United States. Methods We conducted an electronic, prospective, cross-sectional national survey of EPs from October 6–December 29, 2020. Measures assessed negative mental health outcomes (depression, anxiety, post-traumatic stress, and insomnia), positive work-related outcomes, and strategies used to cope with COVID-19. After preliminary analyses and internal reliability testing, we performed four separate three-stage hierarchical multiple regression analyses to examine individual and organizational predictive factors for psychological distress. Results Response rate was 50%, with 259 EPs completing the survey from 11 different sites. Overall, 85% of respondents reported negative psychological effects due to COVID-19. Participants reported feeling more stressed (31%), lonelier (26%), more anxious (25%), more irritable (24%) and sadder (17.5%). Prevalence of mental health conditions was 17% for depression, 13% for anxiety, 7.5% for post-traumatic stress disorder (PTSD), and 18% for insomnia. Regular exercise decreased from 69% to 56%, while daily alcohol use increased from 8% to 15%. Coping strategies of behavioral disengagement, self-blame, and venting were significant predictors of psychological distress, while humor and positive reframing were negatively associated with psychological distress. Conclusion Emergency physicians have experienced high levels of psychological distress during the COVID-19 pandemic. Those using avoidant coping strategies were most likely to experience depression, anxiety, insomnia, and PTSD, while humor and positive reframing were effective coping strategies.
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Affiliation(s)
- Erin Dehon
- University of Mississippi Medical Center, Department of Emergency Medicine, Jackson, Mississippi
| | - Kori S Zachrison
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | | | - Ramin R Tabatabai
- Keck School of Medicine of USC, Department of Emergency Medicine, Los Angeles, California
| | - Elizabeth Clair
- University of Mississippi Medical Center, Department of Emergency Medicine, Jackson, Mississippi
| | - Michael A Puskarich
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Amy Ondeyka
- Inspira Health Network, Department of Emergency Medicine, Vineland, New Jersey
| | | | - Lauren A Walter
- University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama
| | - Elaine H Situ-LaCasse
- Banner University Medical Center - Tucson, Department of Emergency Medicine, Tucson, Arizona
| | - Megan L Fix
- University of Utah School of Medicine, Department of Emergency Medicine, Salt Lake City, Utah
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Silverman GM, Sahoo HS, Ingraham NE, Lupei M, Puskarich MA, Usher M, Dries J, Finzel RL, Murray E, Sartori J, Simon G, Zhang R, Melton GB, Tignanelli CJ, Pakhomov SVS. NLP Methods for Extraction of Symptoms from Unstructured Data for Use in Prognostic COVID-19 Analytic Models. J ARTIF INTELL RES 2021. [DOI: 10.1613/jair.1.12631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Statistical modeling of outcomes based on a patient's presenting symptoms (symptomatology) can help deliver high quality care and allocate essential resources, which is especially important during the COVID-19 pandemic. Patient symptoms are typically found in unstructured notes, and thus not readily available for clinical decision making. In an attempt to fill this gap, this study compared two methods for symptom extraction from Emergency Department (ED) admission notes. Both methods utilized a lexicon derived by expanding The Center for Disease Control and Prevention's (CDC) Symptoms of Coronavirus list. The first method utilized a word2vec model to expand the lexicon using a dictionary mapping to the Uni ed Medical Language System (UMLS). The second method utilized the expanded lexicon as a rule-based gazetteer and the UMLS. These methods were evaluated against a manually annotated reference (f1-score of 0.87 for UMLS-based ensemble; and 0.85 for rule-based gazetteer with UMLS). Through analyses of associations of extracted symptoms used as features against various outcomes, salient risks among the population of COVID-19 patients, including increased risk of in-hospital mortality (OR 1.85, p-value < 0.001), were identified for patients presenting with dyspnea. Disparities between English and non-English speaking patients were also identified, the most salient being a concerning finding of opposing risk signals between fatigue and in-hospital mortality (non-English: OR 1.95, p-value = 0.02; English: OR 0.63, p-value = 0.01). While use of symptomatology for modeling of outcomes is not unique, unlike previous studies this study showed that models built using symptoms with the outcome of in-hospital mortality were not significantly different from models using data collected during an in-patient encounter (AUC of 0.9 with 95% CI of [0.88, 0.91] using only vital signs; AUC of 0.87 with 95% CI of [0.85, 0.88] using only symptoms). These findings indicate that prognostic models based on symptomatology could aid in extending COVID-19 patient care through telemedicine, replacing the need for in-person options. The methods presented in this study have potential for use in development of symptomatology-based models for other diseases, including for the study of Post-Acute Sequelae of COVID-19 (PASC).
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Puskarich MA, Jennaro TS, Gillies CE, Evans CR, Karnovsky A, McHugh CE, Flott TL, Jones AE, Stringer KA. Pharmacometabolomics identifies candidate predictor metabolites of an L-carnitine treatment mortality benefit in septic shock. Clin Transl Sci 2021; 14:2288-2299. [PMID: 34216108 PMCID: PMC8604225 DOI: 10.1111/cts.13088] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/22/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
Sepsis‐induced metabolic dysfunction contributes to organ failure and death. L‐carnitine has shown promise for septic shock, but a recent phase II study of patients with vasopressor‐dependent septic shock demonstrated a non‐significant reduction in mortality. We undertook a pharmacometabolomics study of these patients (n = 250) to identify metabolic profiles predictive of a 90‐day mortality benefit from L‐carnitine. The independent predictive value of each pretreatment metabolite concentration, adjusted for L‐carnitine dose, on 90‐day mortality was determined by logistic regression. A grid‐search analysis maximizing the Z‐statistic from a binomial proportion test identified specific metabolite threshold levels that discriminated L‐carnitine responsive patients. Threshold concentrations were further assessed by hazard ratio and Kaplan‐Meier estimate. Accounting for L‐carnitine treatment and dose, 11 1H‐NMR metabolites and 12 acylcarnitines were independent predictors of 90‐day mortality. Based on the grid‐search analysis numerous acylcarnitines and valine were identified as candidate metabolites of drug response. Acetylcarnitine emerged as highly viable for the prediction of an L‐carnitine mortality benefit due to its abundance and biological relevance. Using its most statistically significant threshold concentration, patients with pretreatment acetylcarnitine greater than or equal to 35 µM were less likely to die at 90 days if treated with L‐carnitine (18 g) versus placebo (p = 0.01 by log rank test). Metabolomics also identified independent predictors of 90‐day sepsis mortality. Our proof‐of‐concept approach shows how pharmacometabolomics could be useful for tackling the heterogeneity of sepsis and informing clinical trial design. In addition, metabolomics can help understand mechanisms of sepsis heterogeneity and variable drug response, because sepsis induces alterations in numerous metabolite concentrations.
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Affiliation(s)
- Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Theodore S Jennaro
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Gillies
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, Michigan, USA.,Michigan Institute for Data Science, Office of Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles R Evans
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2, ), University of Michigan, Ann Arbor, Michigan, USA.,Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alla Karnovsky
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2, ), University of Michigan, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Cora E McHugh
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas L Flott
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kathleen A Stringer
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Puskarich MA, McHugh C, Flott TL, Karnovsky A, Jones AE, Stringer KA. Serum Levels of Branched Chain Amino Acids Predict Duration of Cardiovascular Organ Failure in Septic Shock. Shock 2021; 56:65-72. [PMID: 33156242 PMCID: PMC8089113 DOI: 10.1097/shk.0000000000001687] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sepsis shifts cardiac metabolic fuel preference and this disruption may have implications for cardiovascular function. A greater understanding of the role of metabolism in the development and persistence of cardiovascular failure in sepsis could serve to identify novel pharmacotherapeutic approaches. METHODS Secondary analysis of prospective quantitative proton nuclear magnetic resonance (1H-NMR) metabolomic data from patients enrolled in a phase II randomized control trial of L-carnitine in septic shock. Participants with a sequential organ failure assessment (SOFA) score of > = 5, lactate > = 2, and requiring vasopressor support for at least 4 h were eligible for enrollment. The independent prognostic value of metabolites to predict survival with shock resolution within 48 h and vasopressor free days were assessed. Concentrations of predictive metabolites were compared between participants with and without shock resolution at 48 h. RESULTS Serum 1H-NMR metabolomics data from 228 patients were analyzed. Eighty-one (36%) patients met the primary outcome; 33 (14%) died prior to 48 h. The branched chain amino acids (BCAA), valine, leucine, and isoleucine were univariate predictors of the primary outcome after adjusting for multiple hypothesis testing, while valine remained significant after controlling for SOFA score. Similar results were observed when analyzed based on vasopressor free days, and persisted after controlling for confounding variables and excluding non-survivors. BCAA concentrations at 48 h significantly discriminated between those with shock resolution versus persistent shock. CONCLUSIONS Among patients with septic shock, BCAA concentrations independently predict time to shock resolution. This study provides hypothesis generating data into the potential contribution of BCAAs to the pathophysiology of cardiovascular failure in sepsis, opening areas for future investigations.
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Affiliation(s)
- Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Ann Arbor, MI
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Cora McHugh
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, Ann Arbor, MI
| | - Thomas L. Flott
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, Ann Arbor, MI
| | - Alla Karnovsky
- Michigan Regional Comprehensive Metabolomics Resource Core ((MRC)), Ann Arbor, MI
- Department of Computational Medicine and Bioinformatics, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kathleen A. Stringer
- The NMR Metabolomics Laboratory and the Department of Clinical Pharmacy, College of Pharmacy, Ann Arbor, MI
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ann Arbor, MI
- Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, MI
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29
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Puskarich MA, Cummins NW, Ingraham NE, Wacker DA, Reilkoff RA, Driver BE, Biros MH, Bellolio F, Chipman JG, Nelson AC, Beckman K, Langlois R, Bold T, Aliota MT, Schacker TW, Voelker HT, Murray TA, Koopmeiners JS, Tignanelli CJ. A multi-center phase II randomized clinical trial of losartan on symptomatic outpatients with COVID-19. EClinicalMedicine 2021; 37:100957. [PMID: 34195577 PMCID: PMC8225661 DOI: 10.1016/j.eclinm.2021.100957] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The SARS-CoV-2 virus enters cells via Angiotensin-converting enzyme 2 (ACE2), disrupting the renin-angiotensin-aldosterone axis, potentially contributing to lung injury. Treatment with angiotensin receptor blockers (ARBs), such as losartan, may mitigate these effects, though induction of ACE2 could increase viral entry, replication, and worsen disease. METHODS This study represents a placebo-controlled blinded randomized clinical trial (RCT) to test the efficacy of losartan on outpatients with COVID-19 across three hospital systems with numerous community sites in Minnesota, U.S. Participants included symptomatic outpatients with COVID-19 not already taking ACE-inhibitors or ARBs, enrolled within 7 days of symptom onset. Patients were randomized to 1:1 losartan (25 mg orally twice daily unless estimated glomerular filtration rate, eGFR, was reduced, when dosing was reduced to once daily) versus placebo for 10 days, and all patients and outcome assesors were blinded. The primary outcome was all-cause hospitalization within 15 days. Secondary outcomes included functional status, dyspnea, temperature, and viral load. (clinicatrials.gov, NCT04311177, closed to new participants). FINDINGS From April to November 2020, 117 participants were randomized 58 to losartan and 59 to placebo, and all were analyzed under intent to treat principles. The primary outcome did not differ significantly between the two arms based on Barnard's test [losartan arm: 3 events (5.2% 95% CI 1.1, 14.4%) versus placebo arm: 1 event (1.7%; 95% CI 0.0, 9.1%)]; proportion difference -3.5% (95% CI -13.2, 4.8%); p = 0.32]. Viral loads were not statistically different between treatment groups at any time point. Adverse events per 10 patient days did not differ signifcantly [0.33 (95% CI 0.22-0.49) for losartan vs. 0.37 (95% CI 0.25-0.55) for placebo]. Due to a lower than expected hospitalization rate and low likelihood of a clinically important treatment effect, the trial was terminated early. INTERPRETATION In this multicenter blinded RCT for outpatients with mild symptomatic COVID-19 disease, losartan did not reduce hospitalizations, though assessment was limited by low event rate. Importantly, viral load was not statistically affected by treatment. This study does not support initiation of losartan for low-risk outpatients.
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Affiliation(s)
- Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Nathan W. Cummins
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David A. Wacker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ronald A. Reilkoff
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Michelle H. Biros
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fernanda Bellolio
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew C. Nelson
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Kenneth Beckman
- University of Minnesota Genomics Center, University of Minnesota, Minneapolis, MN, USA
| | - Ryan Langlois
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, USA
| | - Tyler Bold
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Matthew T. Aliota
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Twin Cities, St. Paul, MN, USA
| | - Timothy W. Schacker
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Helen T. Voelker
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joseph S. Koopmeiners
- Department of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Christopher J. Tignanelli
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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30
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Litell JM, Guirgis F, Driver B, Jones AE, Puskarich MA. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. Acad Emerg Med 2021; 28:745-752. [PMID: 33872430 DOI: 10.1111/acem.14265] [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: 09/28/2020] [Revised: 03/16/2021] [Accepted: 04/01/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Effective sepsis resuscitation depends on useful criteria for prompt identification of eligible patients. These criteria should reliably predict a discharge diagnosis of sepsis, ensuring that interventions are triggered for those who need it while avoiding potentially harmful interventions in those who do not. We sought to determine the proportion of patients meeting sepsis criteria in the emergency department (ED) that was ultimately diagnosed with sepsis and to quantify the subset of nonseptic patients with risk factors for harm from fluid resuscitation. METHODS This retrospective cohort study of adult ED patients at a tertiary academic medical center included vital signs and laboratory results from the first 6 hours, plus administration of intravenous antibiotics, to determine if patients met 2016 Sepsis-3 consensus criteria. If these patients also had hypotension and lactic acidosis, we categorized them as Sepsis-3 plus shock. We used discharge ICD-9 codes to determine if patients were ultimately diagnosed with sepsis. RESULTS Over 8 years, 3,121 ED patients met 2016 Sepsis-3 criteria in the first 6 hours. Of these, only 25% and 48% met explicit and implicit criteria for a discharge diagnosis of sepsis. Of 1,032 patients with Sepsis-3 plus shock, 48% and 62% met explicit and implicit criteria. Overall, 60% to 75% of ED patients meeting Sepsis-3 criteria with or without shock did not receive a sepsis discharge diagnosis. At least one plausible risk factor for harm from large-volume fluid resuscitation was identified among 19% to 36% of patients meeting sepsis criteria in the ED but not ultimately diagnosed with sepsis at discharge. CONCLUSIONS Most patients meeting sepsis criteria in the ED were not diagnosed with sepsis at discharge. Urgent treatment bundles triggered by consensus criteria in the early phase of ED care may be administered to several patients without sepsis, potentially exposing some to interventions of uncertain benefit and possible harm.
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Affiliation(s)
- John M. Litell
- Department of Emergency Medicine Hennepin Healthcare Minneapolis Minnesota USA
- Department of Emergency Medicine University of Minnesota Minneapolis Minnesota USA
| | - Faheem Guirgis
- Department of Emergency Medicine University of Florida Jacksonville Florida USA
| | - Brian Driver
- Department of Emergency Medicine Hennepin Healthcare Minneapolis Minnesota USA
- Department of Emergency Medicine University of Minnesota Minneapolis Minnesota USA
| | - Alan E. Jones
- Department of Emergency Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Michael A. Puskarich
- Department of Emergency Medicine Hennepin Healthcare Minneapolis Minnesota USA
- Department of Emergency Medicine University of Minnesota Minneapolis Minnesota USA
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Sahoo HS, Silverman GM, Ingraham NE, Lupei MI, Puskarich MA, Finzel RL, Sartori J, Zhang R, Knoll BC, Liu S, Liu H, Melton GB, Tignanelli CJ, Pakhomov SVS. A fast, resource efficient, and reliable rule-based system for COVID-19 symptom identification. JAMIA Open 2021; 4:ooab070. [PMID: 34423261 PMCID: PMC8374371 DOI: 10.1093/jamiaopen/ooab070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/16/2021] [Accepted: 08/05/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE With COVID-19, there was a need for a rapidly scalable annotation system that facilitated real-time integration with clinical decision support systems (CDS). Current annotation systems suffer from a high-resource utilization and poor scalability limiting real-world integration with CDS. A potential solution to mitigate these issues is to use the rule-based gazetteer developed at our institution. MATERIALS AND METHODS Performance, resource utilization, and runtime of the rule-based gazetteer were compared with five annotation systems: BioMedICUS, cTAKES, MetaMap, CLAMP, and MedTagger. RESULTS This rule-based gazetteer was the fastest, had a low resource footprint, and similar performance for weighted microaverage and macroaverage measures of precision, recall, and f1-score compared to other annotation systems. DISCUSSION Opportunities to increase its performance include fine-tuning lexical rules for symptom identification. Additionally, it could run on multiple compute nodes for faster runtime. CONCLUSION This rule-based gazetteer overcame key technical limitations facilitating real-time symptomatology identification for COVID-19 and integration of unstructured data elements into our CDS. It is ideal for large-scale deployment across a wide variety of healthcare settings for surveillance of acute COVID-19 symptoms for integration into prognostic modeling. Such a system is currently being leveraged for monitoring of postacute sequelae of COVID-19 (PASC) progression in COVID-19 survivors. This study conducted the first in-depth analysis and developed a rule-based gazetteer for COVID-19 symptom extraction with the following key features: low processor and memory utilization, faster runtime, and similar weighted microaverage and macroaverage measures for precision, recall, and f1-score compared to industry-standard annotation systems.
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Affiliation(s)
- Himanshu S Sahoo
- Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Greg M Silverman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas E Ingraham
- Pulmonary Disease and Critical Care Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Monica I Lupei
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Raymond L Finzel
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
| | - John Sartori
- Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rui Zhang
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Benjamin C Knoll
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sijia Liu
- Department of Health Science Research, Mayo Clinic, Rochester, New York, USA
| | - Hongfang Liu
- Department of Health Science Research, Mayo Clinic, Rochester, New York, USA
| | - Genevieve B Melton
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Serguei V S Pakhomov
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota, USA
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Nandi U, Jones AE, Puskarich MA. Group IIA secretory phospholipase 2 independently predicts mortality and positive blood culture in emergency department sepsis patients. J Am Coll Emerg Physicians Open 2021; 2:e12460. [PMID: 34179883 PMCID: PMC8212558 DOI: 10.1002/emp2.12460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The IIA isoform of phospholipase A2 is an acute phase reactant that increases in sepsis, although data regarding its prognostic value are limited. We hypothesized that group IIA secretory phospholipase A2 (sPLA2-IIA) predicts sepsis mortality and positive cultures and sought to compare its predictive characteristics to lactate and procalcitonin. METHODS sPLA2-IIA and procalcitonin levels were measured at enrollment in emergency department patients with early severe sepsis and compared with lactate levels. The primary outcome was in-hospital mortality. The secondary outcome was any positive culture with a sub-group analysis of only blood-culture positive patients. Optimum cut-point was determined using receiver operating characteristics curves. A multivariable model was developed to test the independent prognostic value of elevated sPLA2-IIA to predict mortality. RESULTS Of the 192 patients in the cohort, 160, 153, and 158 had samples available for analysis of sPLA2-IIA, procalcitonin, and lactate, respectively. A total of 21% of patients met the primary outcome of in-hospital mortality. At a 100 ng/mL threshold for sPLA2-IIA, adjusted odds to predict mortality were 3.78 (95% confidence interval = 1.14-12.56, P = 0.03). sPLA2-IIA and procalcitonin were both elevated in culture-positive patients; however, the difference was not statistically significant. sPLA2-IIA was significantly higher in blood culture-positive patients. CONCLUSION An elevated level of sPLA2-IIA was associated with increased mortality in sepsis patients. sPLA2-IIA levels, unlike procalcitonin, also were significantly higher in blood culture-positive patients.
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Affiliation(s)
- Utsav Nandi
- Department of Emergency MedicineUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Alan E. Jones
- Department of Emergency MedicineUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Michael A. Puskarich
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
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Kline JA, Camargo CA, Courtney DM, Kabrhel C, Nordenholz KE, Aufderheide T, Baugh JJ, Beiser DG, Bennett CL, Bledsoe J, Castillo E, Chisolm-Straker M, Goldberg EM, House H, House S, Jang T, Lim SC, Madsen TE, McCarthy DM, Meltzer A, Moore S, Newgard C, Pagenhardt J, Pettit KL, Pulia MS, Puskarich MA, Southerland LT, Sparks S, Turner-Lawrence D, Vrablik M, Wang A, Weekes AJ, Westafer L, Wilburn J. Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021. PLoS One 2021; 16:e0248438. [PMID: 33690722 PMCID: PMC7946184 DOI: 10.1371/journal.pone.0248438] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 12/11/2022] Open
Abstract
Objectives Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. Methods Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. Results Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). Conclusion Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.
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Affiliation(s)
- Jeffrey A. Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, United States of America
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kristen E. Nordenholz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Thomas Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Joshua J. Baugh
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David G. Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Christopher L. Bennett
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Joseph Bledsoe
- Department of Emergency Medicine, Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Edward Castillo
- Department of Emergency Medicine, University of California, San Diego, California, United States of America
| | - Makini Chisolm-Straker
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York, United States of America
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Hans House
- Department of Emergency Medicine, University of Iowa School of Medicine, Iowa City, Iowa, United States of America
| | - Stacey House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louise, Missouri, United States of America
| | - Timothy Jang
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Stephen C. Lim
- University Medical Center New Orleans, Louisiana State University School of Medicine, New Orleans, Louisiana, United States of America
| | - Troy E. Madsen
- Division of Emergency Medicine, Department Surgery, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Danielle M. McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Andrew Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., DC, United States of America
| | - Stephen Moore
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Justine Pagenhardt
- Department of Emergency Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, United States of America
| | - Katherine L. Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Michael S. Pulia
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Lauren T. Southerland
- Department of Emergency Medicine, Ohio State University Medical Center, Columbus, Ohio, United States of America
| | - Scott Sparks
- Department of Emergency Medicine, Riverside Regional Medical Center, Newport News, Virginia, United States of America
| | - Danielle Turner-Lawrence
- Department of Emergency Medicine, Beaumont Health, Royal Oak, Michigan, United States of America
| | - Marie Vrablik
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Alfred Wang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Anthony J. Weekes
- Department of Emergency Medicine, Carolinas Medical Center at Atrium Health, Charlotte, North Carolina, United States of America
| | - Lauren Westafer
- Department of Emergency Medicine, Baystate Health, Springfield, Massachusetts, United States of America
| | - John Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
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Jaton E, Stang J, Biros M, Staugaitis A, Scherber J, Merkle F, Mohr NM, Streib C, Klein L, Puskarich MA. The Use of Electronic Consent for COVID-19 Clinical Trials: Lessons for Emergency Care Research During a Pandemic and Beyond. Acad Emerg Med 2020; 27:1183-1186. [PMID: 32970895 PMCID: PMC7536977 DOI: 10.1111/acem.14141] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Eric Jaton
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
| | - Jamie Stang
- and the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN USA
| | - Michelle Biros
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
| | - Abbey Staugaitis
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
| | - Julie Scherber
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
| | - Florian Merkle
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
- and the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN USA
| | - Nicholas M. Mohr
- and the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
| | - Christopher Streib
- and the Department of Neurology University of Minnesota Minneapolis MN USA
| | - Lauren Klein
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
- and the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN USA
| | - Michael A. Puskarich
- From the Department of Emergency Medicine University of Minnesota Minneapolis MN USA
- and the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN USA
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Tian Y, Russo RM, Li Y, Karmakar M, Liu B, Puskarich MA, Jones AE, Stringer KA, Standiford TJ, Alam HB. Serum citrullinated histone H3 concentrations differentiate patients with septic verses non-septic shock and correlate with disease severity. Infection 2020; 49:83-93. [PMID: 33000445 PMCID: PMC7527151 DOI: 10.1007/s15010-020-01528-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022]
Abstract
Purpose Microbial infection stimulates neutrophil/macrophage/monocyte extracellular trap formation, which leads to the release of citrullinated histone H3 (CitH3) catalyzed by peptidylarginine deiminase (PAD) 2 and 4. Understanding these molecular mechanisms in the pathogenesis of septic shock will be an important next step for developing novel diagnostic and treatment modalities. We sought to determine the expression of CitH3 in patients with septic shock, and to correlate CitH3 levels with PAD2/PAD4 and clinically relevant outcomes. Methods Levels of CitH3 were measured in serum samples of 160 critically ill patients with septic and non-septic shock, and healthy volunteers. Analyses of clinical and laboratory characteristics of patients were conducted. Results Levels of circulating CitH3 at enrollment were significantly increased in septic shock patients (n = 102) compared to patients hospitalized with non-infectious shock (NIC) (n = 32, p < 0.0001). The area under the curve (95% CI) for distinguishing septic shock from NIC using CitH3 was 0.76 (0.65–0.86). CitH3 was positively correlated with PAD2 and PAD4 concentrations and Sequential Organ Failure Assessment Scores [total score (r = 0.36, p < 0.0001)]. The serum levels of CitH3 at 24 h (p < 0.01) and 48 h (p < 0.05) were significantly higher in the septic patients that did not survive. Conclusion CitH3 is increased in patients with septic shock. Its serum concentrations correlate with disease severity and prognosis, which may yield vital insights into the pathophysiology of sepsis. Electronic supplementary material The online version of this article (10.1007/s15010-020-01528-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuzi Tian
- Department of Surgery, University of Michigan Health System, University of Michigan Medical School, 1500 E Medical Center Dr. SPC 5331, Ann Arbor, MI, 48109-5331, USA.,Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Rachel M Russo
- Department of Surgery, University of Michigan Health System, University of Michigan Medical School, 1500 E Medical Center Dr. SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Yongqing Li
- Department of Surgery, University of Michigan Health System, University of Michigan Medical School, 1500 E Medical Center Dr. SPC 5331, Ann Arbor, MI, 48109-5331, USA.
| | - Monita Karmakar
- Department of Surgery, University of Michigan Health System, University of Michigan Medical School, 1500 E Medical Center Dr. SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Baoling Liu
- Department of Surgery, University of Michigan Health System, University of Michigan Medical School, 1500 E Medical Center Dr. SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.,Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kathleen A Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Theodore J Standiford
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan Health System, University of Michigan Medical School, 1500 E Medical Center Dr. SPC 5331, Ann Arbor, MI, 48109-5331, USA.
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Jennaro TS, Puskarich MA, McCann MR, Gillies CE, Pai MP, Karnovsky A, Evans CR, Jones AE, Stringer KA. Using l-Carnitine as a Pharmacologic Probe of the Interpatient and Metabolic Variability of Sepsis. Pharmacotherapy 2020; 40:913-923. [PMID: 32688453 DOI: 10.1002/phar.2448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this review is to discuss the therapeutic use and differential treatment response to Levo-carnitine (l-carnitine) treatment in septic shock, and to demonstrate common lessons learned that are important to the advancement of precision medicine approaches to sepsis. We propose that significant interpatient variability in the metabolic response to l-carnitine and clinical outcomes can be used to elucidate the mechanistic underpinnings that contribute to sepsis heterogeneity. METHODS A narrative review was conducted that focused on explaining interpatient variability in l-carnitine treatment response. Relevant biological and patient-level characteristics considered include genetic, metabolic, and morphomic phenotypes; potential drug interactions; and pharmacokinetics (PKs). MAIN RESULTS Despite promising results in a phase I study, a recent phase II clinical trial of l-carnitine treatment in septic shock showed a nonsignificant reduction in mortality. However, l-carnitine treatment induces significant interpatient variability in l-carnitine and acylcarnitine concentrations over time. In particular, administration of l-carnitine induces a broad, dynamic range of serum concentrations and measured peak concentrations are associated with mortality. Applied systems pharmacology may explain variability in drug responsiveness by using patient characteristics to identify pretreatment phenotypes most likely to derive benefit from l-carnitine. Moreover, provocation of sepsis metabolism with l-carnitine offers a unique opportunity to identify metabolic response signatures associated with patient outcomes. These approaches can unmask latent metabolic pathways deranged in the sepsis syndrome and offer insight into the pathophysiology, progression, and heterogeneity of the disease. CONCLUSIONS The compiled evidence suggests there are several potential explanations for the variability in carnitine concentrations and clinical response to l-carnitine in septic shock. These serve as important confounders that should be considered in interpretation of l-carnitine clinical studies and broadly holds lessons for future clinical trial design in sepsis. Consideration of these factors is needed if precision medicine in sepsis is to be achieved.
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Affiliation(s)
- Theodore S Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc R McCann
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Gillies
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Institute for Data Science, Office of Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alla Karnovsky
- Department of Computational Medicine and Bioinformatics, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles R Evans
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2), University of Michigan, Ann Arbor, Michigan, USA.,Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E Jones
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kathleen A Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Gillies CE, Jennaro TS, Puskarich MA, Sharma R, Ward KR, Fan X, Jones AE, Stringer KA. A Multilevel Bayesian Approach to Improve Effect Size Estimation in Regression Modeling of Metabolomics Data Utilizing Imputation with Uncertainty. Metabolites 2020; 10:E319. [PMID: 32781624 PMCID: PMC7465156 DOI: 10.3390/metabo10080319] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Received: 06/15/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 01/12/2023] Open
Abstract
To ensure scientific reproducibility of metabolomics data, alternative statistical methods are needed. A paradigm shift away from the p-value toward an embracement of uncertainty and interval estimation of a metabolite's true effect size may lead to improved study design and greater reproducibility. Multilevel Bayesian models are one approach that offer the added opportunity of incorporating imputed value uncertainty when missing data are present. We designed simulations of metabolomics data to compare multilevel Bayesian models to standard logistic regression with corrections for multiple hypothesis testing. Our simulations altered the sample size and the fraction of significant metabolites truly different between two outcome groups. We then introduced missingness to further assess model performance. Across simulations, the multilevel Bayesian approach more accurately estimated the effect size of metabolites that were significantly different between groups. Bayesian models also had greater power and mitigated the false discovery rate. In the presence of increased missing data, Bayesian models were able to accurately impute the true concentration and incorporating the uncertainty of these estimates improved overall prediction. In summary, our simulations demonstrate that a multilevel Bayesian approach accurately quantifies the estimated effect size of metabolite predictors in regression modeling, particularly in the presence of missing data.
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Affiliation(s)
- Christopher E. Gillies
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Institute for Data Science (MIDAS), Office of Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Theodore S. Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Ruchi Sharma
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Kevin R. Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Institute for Data Science (MIDAS), Office of Research, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Xudong Fan
- Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI 48109, USA;
- Michigan Institute for Data Science (MIDAS), Office of Research, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Kathleen A. Stringer
- Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI 48109, USA;
- The NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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Cole JB, Olives TD, Ulici A, Litell JM, Bangh SA, Arens AM, Puskarich MA, Prekker ME. Extracorporeal Membrane Oxygenation for Poisonings Reported to U.S. Poison Centers from 2000 to 2018: An Analysis of the National Poison Data System. Crit Care Med 2020; 48:1111-1119. [PMID: 32697480 DOI: 10.1097/ccm.0000000000004401] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess trends in the use of extracorporeal membrane oxygenation for poisoning in the United States. DESIGN Retrospective cohort study. SETTING The National Poison Data System, the databased owned and managed by the American Association of Poison Control Centers, the organization that supports and accredits all 55 U.S. Poison Centers, 2000-2018. PATIENTS All patients reported to National Poison Data System treated with extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 407 patients met final inclusion criteria (332 adults, 75 children). Median age was 27 years (interquartile range, 15-39 yr); 52.5% were male. Median number of ingested substances was three (interquartile range, 2-4); 51.5% were single-substance exposures. Extracorporeal membrane oxygenation use in poisoned patients in the United States has significantly increased over time (z = 3.18; p = 0.001) in both adults (age > 12 yr) and children (age ≤ 12 yr), increasing by 9-100% per year since 2008. Increase in use occurred more commonly in adults. We found substantial geographical variation in extracorporeal membrane oxygenation use by geospatially mapping the ZIP code associated with the initial call, with large, primarily rural areas of the United States reporting no cases. Overall survival was 70% and did not vary significantly over the study period for children or adults. Patients with metabolic and hematologic poisonings were less likely to survive following extracorporeal membrane oxygenation than those with other poisonings (49% vs 72%; p = 0.004). CONCLUSIONS The use of extracorporeal membrane oxygenation to support critically ill, poisoned patients in the United States is increasing, driven primarily by increased use in patients greater than 12 years old. We observed no trends in survival over time. Mortality was higher when extracorporeal membrane oxygenation was used for metabolic or hematologic poisonings. Large, predominantly rural regions of the United States reported no cases of extracorporeal membrane oxygenation for poisoning. Further research should focus on refining criteria for the use of extracorporeal membrane oxygenation in poisoning.
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Affiliation(s)
- Jon B Cole
- Minnesota Poison Control System, Minneapolis, MN
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Travis D Olives
- Minnesota Poison Control System, Minneapolis, MN
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN
| | | | - John M Litell
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, MN
| | | | - Ann M Arens
- Minnesota Poison Control System, Minneapolis, MN
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
- Department of Critical Care Medicine, Abbott Northwestern Hospital, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN
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Ingraham NE, Barakat AG, Reilkoff R, Bezdicek T, Schacker T, Chipman JG, Tignanelli CJ, Puskarich MA. Understanding the renin-angiotensin-aldosterone-SARS-CoV axis: a comprehensive review. Eur Respir J 2020; 56:13993003.00912-2020. [PMID: 32341103 PMCID: PMC7236830 DOI: 10.1183/13993003.00912-2020] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/18/2020] [Indexed: 02/06/2023]
Abstract
Importance Coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been declared a global pandemic with significant morbidity and mortality since first appearing in Wuhan, China, in late 2019. As many countries are grappling with the onset of their epidemics, pharmacotherapeutics remain lacking. The window of opportunity to mitigate downstream morbidity and mortality is narrow but remains open. The renin–angiotensin–aldosterone system (RAAS) is crucial to the homeostasis of both the cardiovascular and respiratory systems. Importantly, SARS-CoV-2 utilises and interrupts this pathway directly, which could be described as the renin–angiotensin–aldosterone–SARS-CoV (RAAS–SCoV) axis. There exists significant controversy and confusion surrounding how anti-hypertensive agents might function along this pathway. This review explores the current state of knowledge regarding the RAAS–SCoV axis (informed by prior studies of SARS-CoV), how this relates to our currently evolving pandemic, and how these insights might guide our next steps in an evidence-based manner. Observations This review discusses the role of the RAAS–SCoV axis in acute lung injury and the effects, risks and benefits of pharmacological modification of this axis. There may be an opportunity to leverage the different aspects of RAAS inhibitors to mitigate indirect viral-induced lung injury. Concerns have been raised that such modulation might exacerbate the disease. While relevant preclinical, experimental models to date favour a protective effect of RAAS–SCoV axis inhibition on both lung injury and survival, clinical data related to the role of RAAS modulation in the setting of SARS-CoV-2 remain limited. Conclusion Proposed interventions for SARS-CoV-2 predominantly focus on viral microbiology and aim to inhibit viral cellular injury. While these therapies are promising, immediate use may not be feasible, and the time window of their efficacy remains a major unanswered question. An alternative approach is the modulation of the specific downstream pathophysiological effects caused by the virus that lead to morbidity and mortality. We propose a preponderance of evidence that supports clinical equipoise regarding the efficacy of RAAS-based interventions, and the imminent need for a multisite randomised controlled clinical trial to evaluate the inhibition of the RAAS–SCoV axis on acute lung injury in COVID-19. The interplay of SARS-CoV-2 with the renin–angiotensin–aldosterone system probably accounts for much of its unique pathology. Appreciating the degree and mechanism of this interaction highlights potential therapeutic options, including blockade (ARBs).https://bit.ly/3aue4tS
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Affiliation(s)
- Nicholas E Ingraham
- Dept of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN, USA
| | - Abdo G Barakat
- Dept of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Ronald Reilkoff
- Dept of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN, USA
| | - Tamara Bezdicek
- Dept of Pharmacy, Fairview Pharmacy Services, Minneapolis, MN, USA
| | - Timothy Schacker
- Dept of Medicine, University of Minnesota, Division of Medicine and Infectious Disease, Minneapolis, MN, USA
| | - Jeffrey G Chipman
- Dept of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN, USA
| | - Christopher J Tignanelli
- Dept of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Michael A Puskarich
- Dept of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA.,Dept of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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Black LP, Puskarich MA, Henson M, Miller T, Reddy ST, Fernandez R, Guirgis FW. Quantitative and Qualitative Assessments of Cholesterol Association With Bacterial Infection Type in Sepsis and Septic Shock. J Intensive Care Med 2020; 36:808-817. [PMID: 32578468 DOI: 10.1177/0885066620931473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reduced cholesterol levels are associated with increased organ failure and mortality in sepsis. Cholesterol levels may vary by infection type (gram negative vs positive), possibly reflecting differences in cholesterol-mediated bacterial clearance. METHODS This was a secondary analysis of a combined data set of 2 prospective cohort studies of adult patients meeting Sepsis-3 criteria. Infection types were classified as gram negative, gram positive, or culture negative. We investigated quantitative (levels) and qualitative (dysfunctional high-density lipoprotein [HDL]) cholesterol differences. We used multivariable logistic regression to control for disease severity. RESULTS Among 171 patients with sepsis, infections were gram negative in 67, gram positive in 46, and culture negative in 47. Both gram-negative and gram-positive infections occurred in 11 patients. Total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and HDL cholesterol (HDL-C) levels were lower for culture-positive sepsis at enrollment (TC, P < .001; LDL-C, P < .001; HDL-C, P = .011) and persisted after controlling for disease severity. Similarly, cholesterol levels were lower among culture-positive patients at 48 hours (TC, P = .012; LDL-C, P = .029; HDL-C, P = .002). Triglyceride (TG) levels were lower at enrollment (P =.033) but not at 48 hours (P = .212). There were no differences in dysfunctional HDL. Among bacteremic patients, cholesterol levels were lower at enrollment (TC, P = .010; LDL-C, P = .010; HDL-C, P ≤ .001; TG, P = .005) and at 48 hours (LDL-C, P = .027; HDL-C, P < .001; TG, P = .020), except for 48 hour TC (P = .051). In the bacteremia subgroup, enrollment TC and LDL-C were lower for gram-negative versus gram-positive infections (TC, P = .039; LDL-C, P = .023). CONCLUSION Cholesterol levels are significantly lower among patients with culture-positive sepsis and bacteremia.
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Affiliation(s)
- Lauren Page Black
- Department of Emergency Medicine, 137869University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.,Department of Emergency Medicine, 5635University of Minnesota, Minneapolis, MN, USA
| | - Morgan Henson
- Department of Emergency Medicine, 137869University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Taylor Miller
- Department of Emergency Medicine, 137869University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Srinivasa T Reddy
- Department of Medicine, Molecular & Medical Pharmacology, University of California, Los Angeles, CA, USA
| | - Rosemarie Fernandez
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA.,Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Faheem W Guirgis
- Department of Emergency Medicine, 137869University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
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Black LP, Puskarich MA, Smotherman C, Miller T, Fernandez R, Guirgis FW. Time to vasopressor initiation and organ failure progression in early septic shock. J Am Coll Emerg Physicians Open 2020; 1:222-230. [PMID: 33000037 PMCID: PMC7493499 DOI: 10.1002/emp2.12060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Received: 10/30/2019] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Research evaluating the relationship between vasopressor initiation timing and clinical outcomes is limited and conflicting. We investigated the association between time to vasopressors, worsening organ failure, and mortality in patients with septic shock. METHODS This was a retrospective study of patients with septic shock (2013-2016) within 24 hours of emergency department (ED) presentation. The primary outcome was worsening organ failure, defined as an increase in Sequential Organ Failure Assessment (SOFA) score ≥2 at 48 hours compared to baseline, or death within 48 hours. The secondary outcome was 28-day mortality. Time to vasopressor initiation was categorized into 6, 4-hour intervals from time of ED triage. Multiple logistic regression was used to identify predictors of worsening organ failure. RESULTS We analyzed data from 428 patients with septic shock. There were 152 patients with the composite primary outcome (SOFA increase ≥2 or death at 48 hours). Of these, 77 patients died in the first 48 hours and 75 patients had a SOFA increase ≥2. Compared to the patients who received vasopressors in the first 4 hours, those with the longest time to vasopressors (20-24 hours) had increased odds of developing worsening organ failure (odds ratios [OR] = 4.34, 95% confidence intervals [CI] = 1.47-12.79, P = 0.008). For all others, the association between vasopressor timing and worsening organ failure was non-significant. There was no association between time to vasopressor initiation and 28-day mortality. CONCLUSIONS Increased time to vasopressor initiation is an independent predictor of worsening organ failure for patients with vasopressor initiation delays >20 hours.
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Affiliation(s)
- Lauren Page Black
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
| | - Michael A. Puskarich
- Department of Emergency MedicineUniversity of MinnesotaMinneapolisMinnesota
- Hennepin County Medical CenterMinneapolisMinnesota
| | - Carmen Smotherman
- Center for Data SolutionsUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
| | - Taylor Miller
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
| | - Rosemarie Fernandez
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFlorida
- Center for Experiential Learning and SimulationUniversity of Florida College of MedicineGainesvilleFlorida
| | - Faheem W. Guirgis
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
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42
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Kline JA, Lin MP, Hall CL, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Runyon MS, Wang H, Courtney DM. Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging. J Patient Exp 2020; 7:386-394. [PMID: 32821799 PMCID: PMC7410137 DOI: 10.1177/2374373519838529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED). METHODS Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education. RESULTS We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics. CONCLUSION Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle P Lin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cassandra L Hall
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Erin Dehon
- Department of Emergency Medicine, University of Mississippi, Jackson, MS, USA
| | - Damon R Kuehl
- Department of Emergency Medicine, Virginia Tech-Carilion, Roanoke, VA, USA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Hao Wang
- Department of Emergency Medicine, John Peter Smith Hospital, Ft. Worth, TX, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University School of Medicine, Chicago, IL, USA
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43
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Stringer KA, Puskarich MA, Kenes MT, Dickson RP. COVID-19: The Uninvited Guest in the Intensive Care Unit - Implications for Pharmacotherapy. Pharmacotherapy 2020; 40:382-386. [PMID: 32267979 PMCID: PMC7262068 DOI: 10.1002/phar.2394] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Kathleen A Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota.,Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan
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44
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Tignanelli CJ, Ingraham NE, Sparks MA, Reilkoff R, Bezdicek T, Benson B, Schacker T, Chipman JG, Puskarich MA. Antihypertensive drugs and risk of COVID-19? Lancet Respir Med 2020; 8:e30-e31. [PMID: 32222166 PMCID: PMC7194709 DOI: 10.1016/s2213-2600(20)30153-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Christopher J Tignanelli
- Department of Surgery, Division of Acute Care Surgery, University of Minnesota, Minneapolis, MN 55455, USA; Institute for Health Informatics, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Nicholas E Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN 55455, USA
| | - Matthew A Sparks
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC, USA
| | - Ronald Reilkoff
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN 55455, USA
| | - Tamara Bezdicek
- Department of Pharmacy, Fairview Southdale, Minnesota, MN, USA
| | - Bradley Benson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Timothy Schacker
- Department of Medicine, Division of Medicine and Infectious Disease, University of Minnesota, Minneapolis, MN 55455, USA
| | - Jeffrey G Chipman
- Department of Surgery, Division of Acute Care Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN 55455, USA; Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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45
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Sabapathi P, Roberts MB, Fuller BM, Puskarich MA, Jones CW, Kilgannon JH, Braz V, Creel-Bulos C, Scott N, Tester KL, Mazzarelli A, Trzeciak S, Roberts BW. Validation of a 5-item tool to measure patient assessment of clinician compassion in the emergency department. BMC Emerg Med 2019; 19:63. [PMID: 31684885 PMCID: PMC6827199 DOI: 10.1186/s12873-019-0279-5] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/14/2019] [Indexed: 12/30/2022] Open
Abstract
Background To test if the 5-item compassion measure (a tool previously validated in the outpatient setting to measure patient assessment of clinician compassion) is a valid and reliable tool to quantify a distinct construct (i.e. clinical compassion) among patients evaluated in the emergency department (ED). Methods Cross-sectional study conducted in three academic emergency departments in the U.S. between November 2018 and April 2019. We enrolled adult patients who were evaluated in the EDs of the participating institutions and administered the 5-item compassion measure after completion of care in the ED. Validity testing was performed using confirmatory factor analysis. Cronbach’s alpha was used to test reliability. Convergent validity with patient assessment of overall satisfaction questions was tested using Spearman correlation coefficients and we tested if the 5-item compassion measure assessed a construct distinct from overall patient satisfaction using confirmatory factor analysis. Results We analyzed 866 patient responses. Confirmatory factor analysis found all five items loaded well on a single construct and our model was found to have good fit. Reliability was excellent (Cronbach’s alpha = 0.93) among the entire cohort. These results remained consistent on sub-analyses stratified by individual institutions. The 5-item compassion measure had moderate correlation with overall patient satisfaction (r = 0.66) and patient recommendation of the ED to friends and family (r = 0.57), but reflected a patient experience domain (i.e. compassionate care) distinctly different from patient satisfaction. Conclusions The 5-item compassion measure is a valid and reliable tool to measure patient assessment of clinical compassion in the ED.
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Affiliation(s)
- Praveen Sabapathi
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA
| | - Michael B Roberts
- Institutional Research and Outcomes Assessment, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA.,Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Christopher W Jones
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA.,Center for Humanism, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Valerie Braz
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA
| | - Christina Creel-Bulos
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Nathaniel Scott
- Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Kristina L Tester
- Center for Humanism, Cooper Medical School of Rowan University, Camden, NJ, USA.,School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Anthony Mazzarelli
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA.,Center for Humanism, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Stephen Trzeciak
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA.,Center for Humanism, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, New Jersey, 08103, USA. .,Center for Humanism, Cooper Medical School of Rowan University, Camden, NJ, USA.
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46
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Evans CR, Karnovsky A, Puskarich MA, Michailidis G, Jones AE, Stringer KA. Untargeted Metabolomics Differentiates l-Carnitine Treated Septic Shock 1-Year Survivors and Nonsurvivors. J Proteome Res 2019; 18:2004-2011. [PMID: 30895797 DOI: 10.1021/acs.jproteome.8b00774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
l-Carnitine is a candidate therapeutic for the treatment of septic shock, a condition that carries a ≥40% mortality. Responsiveness to l-carnitine may hinge on unique metabolic profiles that are not evident from the clinical phenotype. To define these profiles, we performed an untargeted metabolomic analysis of serum from 21 male sepsis patients enrolled in a placebo-controlled l-carnitine clinical trial. Although treatment with l-carnitine is known to induce changes in the sepsis metabolome, we found a distinct set of metabolites that differentiated 1-year survivors from nonsurvivors. Following feature alignment, we employed a new and innovative data reduction strategy followed by false discovery correction, and identified 63 metabolites that differentiated carnitine-treated 1-year survivors versus nonsurvivors. Following identification by MS/MS and database search, several metabolite markers of vascular inflammation were determined to be prominently elevated in the carnitine-treated nonsurvivor cohort, including fibrinopeptide A, allysine, and histamine. While preliminary, these results corroborate that metabolic profiles may be useful to differentiate l-carnitine treatment responsiveness. Furthermore, these data show that the metabolic signature of l-carnitine-treated nonsurvivors is associated with a severity of illness (e.g., vascular inflammation) that is not routinely clinically detected.
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Affiliation(s)
| | | | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, and Department of Emergency Medicine, School of Medicine , University of Minnesota , Minneapolis , Minnesota 55455 , United States
| | - George Michailidis
- Department of Statistics, College of Literature, Science and Art , University of Michigan and the Informatics Institute University of Florida , Gainesville , Flordia 32611 , United States
| | - Alan E Jones
- Emergency Medicine , University of Mississippi Medical Center , Jackson , Mississippi 39216 , United States
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47
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Puskarich MA, Callaway C, Silbergleit R, Pines JM, Obermeyer Z, Wright DW, Hsia RY, Shah MN, Monte AA, Limkakeng AT, Meisel ZF, Levy PD. Priorities to Overcome Barriers Impacting Data Science Application in Emergency Care Research. Acad Emerg Med 2019; 26:97-105. [PMID: 30019795 DOI: 10.1111/acem.13520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/15/2018] [Accepted: 07/10/2018] [Indexed: 12/01/2022]
Abstract
For a variety of reasons including cheap computing, widespread adoption of electronic medical records, digitalization of imaging and biosignals, and rapid development of novel technologies, the amount of health care data being collected, recorded, and stored is increasing at an exponential rate. Yet despite these advances, methods for the valid, efficient, and ethical utilization of these data remain underdeveloped. Emergency care research, in particular, poses several unique challenges in this rapidly evolving field. A group of content experts was recently convened to identify research priorities related to barriers to the application of data science to emergency care research. These recommendations included: 1) developing methods for cross-platform identification and linkage of patients; 2) creating central, deidentified, open-access databases; 3) improving methodologies for visualization and analysis of intensively sampled data; 4) developing methods to identify and standardize electronic medical record data quality; 5) improving and utilizing natural language processing; 6) developing and utilizing syndrome or complaint-based based taxonomies of disease; 7) developing practical and ethical framework to leverage electronic systems for controlled trials; 8) exploring technologies to help enable clinical trials in the emergency setting; and 9) training emergency care clinicians in data science and data scientists in emergency care medicine. The background, rationale, and conclusions of these recommendations are included in the present article.
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Affiliation(s)
- Michael A. Puskarich
- The Department of Emergency Medicine University of Mississippi Medical Center Jackson MS
| | - Clif Callaway
- The Department of Emergency Medicine University of Pittsburgh Pittsburgh PA
| | - Robert Silbergleit
- The Department of Emergency Medicine University of Michigan Ann Arbor MI
| | - Jesse M. Pines
- The Departments of Emergency Medicine and Health Policy & Management George Washington University Washington DC
| | - Ziad Obermeyer
- Brigham and Women's Hospital Harvard Medical School Boston MA
| | - David W. Wright
- The Departments of Emergency Medicine and Health Policy & Management Emory University Atlanta GA
| | - Renee Y. Hsia
- The Department of Emergency Medicine The Institute of Health Policy Studies University of California San Francisco San Francisco CA
| | - Manish N. Shah
- The Department of Emergency Medicine University of Wisconsin–Madison Madison WI
| | - Andrew A. Monte
- The Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | | | - Zachary F. Meisel
- The Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Phillip D. Levy
- The Department of Emergency Medicine and Integrative Biosciences Center Wayne State University Detroit MI
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48
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McHugh CE, Flott TL, Schooff CR, Smiley Z, Puskarich MA, Myers DD, Younger JG, Jones AE, Stringer KA. Rapid, Reproducible, Quantifiable NMR Metabolomics: Methanol and Methanol: Chloroform Precipitation for Removal of Macromolecules in Serum and Whole Blood. Metabolites 2018; 8:metabo8040093. [PMID: 30558115 PMCID: PMC6316042 DOI: 10.3390/metabo8040093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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] [Received: 10/17/2018] [Revised: 11/12/2018] [Accepted: 12/10/2018] [Indexed: 12/30/2022] Open
Abstract
Background: Though blood is an excellent biofluid for metabolomics, proteins and lipids present in blood can interfere with 1d-1H NMR spectra and disrupt quantification of metabolites. Here, we present effective macromolecule removal strategies for serum and whole blood (WB) samples. Methods: A variety of macromolecule removal strategies were compared in both WB and serum, along with tests of ultrafiltration alone and in combination with precipitation methods. Results: In healthy human serum, methanol:chloroform:water extraction with ultrafiltration was compared to methanol precipitation with and without ultrafiltration. Methods were tested in healthy pooled human serum, and in serum from patients with sepsis. Effects of long-term storage at −80 °C were tested to explore the impact of macromolecule removal strategy on serum from different conditions. In WB a variety of extraction strategies were tested in two types of WB (from pigs and baboons) to examine the impact of macromolecule removal strategies on different samples. Conclusions: In healthy human serum methanol precipitation of serum with ultrafiltration was superior, but was similar in recovery and variance to methanol:chloroform:water extraction with ultrafiltration in pooled serum from patients with sepsis. In WB, high quality, quantifiable spectra were obtained with the use of a methanol: chloroform precipitation.
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Affiliation(s)
- Cora E McHugh
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Thomas L Flott
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Casey R Schooff
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Zyad Smiley
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Michael A Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Daniel D Myers
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
| | | | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi, Jackson, MS 39216, USA.
| | - Kathleen A Stringer
- NMR Metabolomics Laboratory, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.
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49
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Jones AE, Puskarich MA, Shapiro NI, Guirgis FW, Runyon M, Adams JY, Sherwin R, Arnold R, Roberts BW, Kurz MC, Wang HE, Kline JA, Courtney DM, Trzeciak S, Sterling SA, Nandi U, Patki D, Viele K. Effect of Levocarnitine vs Placebo as an Adjunctive Treatment for Septic Shock: The Rapid Administration of Carnitine in Sepsis (RACE) Randomized Clinical Trial. JAMA Netw Open 2018; 1:e186076. [PMID: 30646314 PMCID: PMC6324339 DOI: 10.1001/jamanetworkopen.2018.6076] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Sepsis induces profound metabolic derangements, while exogenous levocarnitine mitigates metabolic dysfunction by enhancing glucose and lactate oxidation and increasing fatty acid shuttling. Previous trials in sepsis suggest beneficial effects of levocarnitine on patient-centered outcomes. OBJECTIVES To test the hypothesis that levocarnitine reduces cumulative organ failure in patients with septic shock at 48 hours and, if present, to estimate the probability that the most efficacious dose will decrease 28-day mortality in a pivotal phase 3 clinical trial. DESIGN, SETTING, AND PARTICIPANTS Multicenter adaptive, randomized, blinded, dose-finding, phase 2 clinical trial (Rapid Administration of Carnitine in Sepsis [RACE]). The setting was 16 urban US medical centers. Participants were patients aged 18 years or older admitted from March 5, 2013, to February 5, 2018, with septic shock and moderate organ dysfunction. INTERVENTIONS Within 24 hours of identification, patients were assigned to 1 of the following 4 treatments: low (6 g), medium (12 g), or high (18 g) doses of levocarnitine or an equivalent volume of saline placebo administered as a 12-hour infusion. MAIN OUTCOMES AND MEASURES The primary outcome required, first, a greater than 90% posterior probability that the most promising levocarnitine dose decreases the Sequential Organ Failure Assessment (SOFA) score at 48 hours and, second (given having met the first condition), at least a 30% predictive probability of success in reducing 28-day mortality in a subsequent traditional superiority trial to test efficacy. RESULTS Of the 250 enrolled participants (mean [SD] age, 61.7 [14.8] years; 56.8% male), 35, 34, and 106 patients were adaptively randomized to the low, medium, and high levocarnitine doses, respectively, while 75 patients were randomized to placebo. In the intent-to-treat analysis, the fitted mean (SD) changes in the SOFA score for the low, medium, and high levocarnitine groups were -1.27 (0.49), -1.66 (0.38), and -1.97 (0.32), respectively, vs -1.63 (0.35) in the placebo group. The posterior probability that the 18-g dose is superior to placebo was 0.78, which did not meet the a priori threshold of 0.90. Mortality at 28 days was 45.9% (34 of 74) in the placebo group compared with 43.3% (45 of 104) for the most promising levocarnitine dose (18 g). Similar findings were noted in the per-protocol analysis. CONCLUSIONS AND RELEVANCE In this dose-finding, phase 2 adaptive randomized trial, the most efficacious dose of levocarnitine (18 g) did not meaningfully reduce cumulative organ failure at 48 hours. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01665092.
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Affiliation(s)
- Alan E. Jones
- Department of Emergency Medicine, The University of Mississippi Medical Center, Jackson
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Faheem W. Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine–Jacksonville
| | - Michael Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Jason Y. Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis
| | - Robert Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan
| | - Ryan Arnold
- Department of Emergency Medicine, Christiana Care Health System, Wilmington, Delaware
| | - Brian W. Roberts
- Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Michael C. Kurz
- Department of Emergency Medicine, The University of Alabama School of Medicine at Birmingham
| | - Henry E. Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - D. Mark Courtney
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois
| | - Stephen Trzeciak
- Department of Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Sarah A. Sterling
- Department of Emergency Medicine, The University of Mississippi Medical Center, Jackson
| | - Utsav Nandi
- Department of Emergency Medicine, The University of Mississippi Medical Center, Jackson
| | - Deepti Patki
- Department of Emergency Medicine, The University of Mississippi Medical Center, Jackson
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Hope Kilgannon J, Hunter BR, Puskarich MA, Shea L, Fuller BM, Jones C, Donnino M, Kline JA, Jones AE, Shapiro NI, Abella BS, Trzeciak S, Roberts BW. Partial pressure of arterial carbon dioxide after resuscitation from cardiac arrest and neurological outcome: A prospective multi-center protocol-directed cohort study. Resuscitation 2018; 135:212-220. [PMID: 30452939 DOI: 10.1016/j.resuscitation.2018.11.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/21/2018] [Accepted: 11/13/2018] [Indexed: 12/23/2022]
Abstract
AIMS Partial pressure of arterial carbon dioxide (PaCO2) is a regulator of cerebral blood flow after brain injury. We sought to test the association between PaCO2 after resuscitation from cardiac arrest and neurological outcome. METHODS A prospective protocol-directed cohort study across six hospitals. INCLUSION CRITERIA age ≥18, non-traumatic cardiac arrest, mechanically ventilated after return of spontaneous circulation (ROSC), and receipt of targeted temperature management. Per protocol, PaCO2 was measured by arterial blood gas analyses at one and six hours after ROSC. We determined the mean PaCO2 over this initial six hours after ROSC. The primary outcome was good neurological function at hospital discharge, defined a priori as a modified Rankin Scale ≤3. Multivariable Poisson regression analysis was used to test the association between PaCO2 and neurological outcome. RESULTS Of the 280 patients included, the median (interquartile range) PaCO2 was 44 (37-52) mmHg and 30% had good neurological function. We found mean PaCO2 had a quadratic (inverted "U" shaped) association with good neurological outcome, with a mean PaCO2 of 68 mmHg having the highest predictive probability of good neurological outcome, and worse neurological outcome at higher and lower PaCO2. Presence of metabolic acidosis attenuated the association between PaCO2 and good neurological outcome, with a PaCO2 of 51 mmHg having the highest predictive probability of good neurological outcome among patients with metabolic acidosis. CONCLUSION PaCO2 has a "U" shaped association with neurological outcome, with mild to moderate hypercapnia having the highest probability of good neurological outcome.
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Affiliation(s)
- J Hope Kilgannon
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Benton R Hunter
- The Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Michael A Puskarich
- The Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Lisa Shea
- The Department of Medicine, Division of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher Jones
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Michael Donnino
- The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jeffrey A Kline
- The Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Alan E Jones
- The Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Nathan I Shapiro
- The Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Benjamin S Abella
- The Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Stephen Trzeciak
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States; The Department of Medicine, Division of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Brian W Roberts
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States.
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