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Dumas G, Morris IS, Hensman T, Bagshaw SM, Demoule A, Ferreyro BL, Kouatchet A, Lemiale V, Mokart D, Pène F, Mehta S, Azoulay E, Munshi L. Association between arterial oxygen and mortality across critically ill patients with hematologic malignancies: results from an international collaborative network. Intensive Care Med 2024:10.1007/s00134-024-07389-5. [PMID: 38598124 DOI: 10.1007/s00134-024-07389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/09/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Patients with hematological malignancies are at high risk for life-threatening complications. To date, little attention has been paid to the impact of hyperoxemia and excess oxygen use on mortality. The aim of this study was to investigate the association between partial pressure of arterial oxygen (PaO2) and 28-day mortality in critically ill patients with hematologic malignancies. METHODS Data from three international cohorts (Europe, Canada, Oceania) of patients who received respiratory support (noninvasive ventilation, high-flow nasal cannula, invasive mechanical ventilation) were obtained. We used mixed-effect Cox models to investigate the association between day one PaO2 or excess oxygen use (inspired fraction of oxygen ≥ 0.6 with PaO2 > 100 mmHg) on day-28 mortality. RESULTS 11,249 patients were included. On day one, 5716 patients (50.8%) had normoxemia (60 ≤ PaO2 ≤ 100 mmHg), 1454 (12.9%) hypoxemia (PaO2 < 60 mmHg), and 4079 patients (36.3%) hyperoxemia (PaO2 > 100 mmHg). Excess oxygen was used in 2201 patients (20%). Crude day-28 mortality rate was 40.6%. There was a significant association between PaO2 and day-28 mortality with a U-shaped relationship (p < 0.001). Higher PaO2 levels (> 100 mmHg) were associated with day-28 mortality with a dose-effect relationship. Subgroup analyses showed an association between hyperoxemia and mortality in patients admitted with neurological disorders; however, the opposite relationship was seen across those admitted with sepsis and neutropenia. Excess oxygen use was also associated with subsequent day-28 mortality (adjusted hazard ratio (aHR) [95% confidence interval (CI)]: 1.11[1.04-1.19]). This result persisted after propensity score analysis (matched HR associated with excess oxygen:1.31 [1.20-1.1.44]). CONCLUSION In critically-ill patients with hematological malignancies, exposure to hyperoxemia and excess oxygen use were associated with increased mortality, with variable magnitude across subgroups. This might be a modifiable factor to improve mortality.
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Affiliation(s)
- Guillaume Dumas
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
- Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM U1042-HP2, Grenoble, France
| | - Idunn S Morris
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
| | - Tamishta Hensman
- Austin Health, Heidelberg, VIC, Australia
- Guys and St, Thomas' NHS Foundation Trust, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - Alexandre Demoule
- Service de Médecine Intensive Et Réanimation (Département R3S), Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers Teaching Hospital, Angers, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, AP-HP, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Djamel Mokart
- Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, AP-HP, Paris, France
- Institut Cochin, INSERM Unité, 1016/Centre National de la Recherche Scientifique (CNRS) UnitéMixte de Recherche (UMR) 8104/Université Paris Cité, Paris, France
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, AP-HP, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, Canada.
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada.
- 18-206 Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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Munshi L, Dumas G, Rochwerg B, Shoukat F, Detsky M, Fergusson DA, Ferreyro BL, Heffernan P, Herridge M, Magder S, Minden M, Patel R, Qureshi S, Schimmer A, Thyagu S, Wang HT, Mehta S. Long-term survival and functional outcomes of critically ill patients with hematologic malignancies: a Canadian multicenter prospective study. Intensive Care Med 2024; 50:561-572. [PMID: 38466402 DOI: 10.1007/s00134-024-07349-z] [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: 10/16/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE Patients with hematologic malignancy (HM) commonly develop critical illness. Their long-term survival and functional outcomes have not been well described. METHODS We conducted a prospective, observational study of HM patients admitted to seven Canadian intensive care units (ICUs) (2018-2020). We followed survivors at 7 days, 6 months and 12 months following ICU discharge. The primary outcome was 12-month survival. We evaluated functional outcomes at 6 and 12 months using the functional independent measure (FIM) and short form (SF)-36 as well as variables associated with 12-month survival. RESULTS We enrolled 414 patients including 35% women. The median age was 61 (interquartile range, IQR: 52-69), median Sequential Organ Failure Assessment (SOFA) score was 9 (IQR: 6-12), and 22% had moderate-severe frailty (clinical frailty scale [CFS] ≥ 6). 51% had acute leukemia, 38% lymphoma/multiple myeloma, and 40% had received a hematopoietic stem cell transplant (HCT). The most common reasons for ICU admission were acute respiratory failure (50%) and sepsis (40%). Overall, 203 (49%) were alive 7 days post-ICU discharge (ICU survivors). Twelve-month survival of the entire cohort was 21% (43% across ICU survivors). The proportion of survivors with moderate-severe frailty was 42% (at 7 days), 14% (6 months), and 8% (12 months). Median FIM at 7 days was 80 (IQR: 50-109). Physical function, pain, social function, mental health, and emotional well-being were below age- and sex-matched population scores at 6 and 12 months. Frailty, allogeneic HCT, kidney injury, and cardiac complications during ICU were associated with lower 12- month survival. CONCLUSIONS 49% of all HM patients were alive at 7 days post-ICU discharge, and 21% at 12 months. Survival varied based upon hematologic diagnosis and frailty status. Survivors had important functional disability and impairment in emotional, physical, and general well-being.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Guillaume Dumas
- Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM U1042-HP2, Grenoble, France
| | - Bram Rochwerg
- Department of Medicine, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Farah Shoukat
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Michael Detsky
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Paul Heffernan
- Department of Medicine at Queen's University, Kingston General Health Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Margaret Herridge
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Sheldon Magder
- Department of Medicine, Royal Victoria Hospital, The Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
- Critical Care Department, Royal Victoria Hospital, The Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Mark Minden
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Rakesh Patel
- Department of Medicine, Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of Critical Care Medicine, Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Salman Qureshi
- Department of Medicine, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Aaron Schimmer
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Santhosh Thyagu
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Han Ting Wang
- Division of Critical Care MedicineDepartment of Medicine at Hopital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
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Dymore-Brown LA, Ahluwalia A, Dangoisse C, Zaman F, Sereeyotin J, Mehta S, Metaxa V. An Update on Gender Disparity in Critical Care Conferences. Crit Care Explor 2024; 6:e1075. [PMID: 38577272 PMCID: PMC10994516 DOI: 10.1097/cce.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
This commentary's objective was to identify whether female representation at critical care conferences has improved since our previous publication in 2018. We audited the scientific programs from three international (International Symposium on Intensive Care and Emergency Medicine [ISICEM], European Society of Intensive Care Medicine [ESICM], and Society of Critical Care Medicine [SCCM]) and two national (State of the Art [SOA] and Critical Care Canada Forum) critical care conferences from the years 2017 to 2022. We collected data on the number of female faculty members and categorized them into physicians, nurses, allied health professions (AHPs), and other. Across all conferences, there was an increased representation of females as speakers and moderators over the 6 years. However, at each conference, male speakers outnumbered female speakers. Only two conferences achieved gender parity in speakers, SCCM in 2021 (48% female) and 2022 and SOA in 2022 (48% female). These conferences also had the highest representation of female nursing and AHP speakers (25% in SCCM, 2021; 19% in SOA, 2022). While there was a statistically significant increase in female speakers (p < 0.01) in 2022 compared with 2016, there was a persistent gender gap in the representation of men and female physicians. While the proportion of female moderators increased in each conference every year, the increase was statistically only significant for ISICEM, ESICM, and SCCM (p < 0.05). The proportion of female nurses and AHP speakers increased in 2022 compared with 2016 (p < 0.0001) but their overall representation was low with the highest proportion (25%) in the 2022 SCCM conference and the lowest (0.5%) in the 2017 ISICEM conference. This follow-up study demonstrates a narrowing but persisting gender gap in the studied critical care conferences. Thus, a commitment toward minimizing gender inequalities is warranted.
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Affiliation(s)
- Laura-Anne Dymore-Brown
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amrit Ahluwalia
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Carole Dangoisse
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Faryal Zaman
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jariya Sereeyotin
- Department of Anaesthesiology, Division of Critical Care Medicine, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth 2024; 132:491-506. [PMID: 38185564 DOI: 10.1016/j.bja.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.
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Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jasmine Kang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Fayyaz Rizvi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ben Forestell
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Mark Hewitt
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mohamed Eltorki
- Department of Pediatrics, Division of Pediatric Emergency Medicine, McMaster University, Ottawa, ON, Canada
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Maala Bhatt
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Lisa Burry
- Department of Medicine, Sinai Health System; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacy, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Pratik Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Mehta S, Gardner K, Hall J, Rosenfield D, Tse S, Ho K, Grant K, Bradbury-Squires DJ, Lang E, Chartier L. Virtual urgent care is here to stay: driving toward safe, equitable, and sustainable integration within emergency medicine. CAN J EMERG MED 2024:10.1007/s43678-024-00658-8. [PMID: 38334940 DOI: 10.1007/s43678-024-00658-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine. METHODS We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement. RESULTS The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada. CONCLUSION Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada.
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Affiliation(s)
- S Mehta
- Unity Health Toronto, Toronto, ON, Canada
- North York General Hospital, North York, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - K Gardner
- IWK Health, Halifax, NS, Canada.
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
| | - J Hall
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - D Rosenfield
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children (SickKids), Toronto, ON, Canada
| | - S Tse
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, CHEO Research Institute, Ottawa, ON, Canada
| | - K Ho
- Faculty of Medicine, Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - K Grant
- Faculty of Medicine, Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - D J Bradbury-Squires
- Faculty of Medicine, Disciplines of Family Medicine and Emergency Medicine, Memorial University of Newfoundland, Newfoundland Regional Health Centre, Grand Falls-Windsor, NL, Canada
| | - E Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - L Chartier
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
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Abdelmalek FM, Angriman F, Moore J, Liu K, Burry L, Seyyed-Kalantari L, Mehta S, Gichoya J, Celi LA, Tomlinson G, Fralick M, Yarnell CJ. Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States. Ann Am Thorac Soc 2024; 21:287-295. [PMID: 38029405 DOI: 10.1513/annalsats.202305-485oc] [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: 05/29/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.
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Affiliation(s)
| | - Federico Angriman
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Julie Moore
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Kuan Liu
- Institute of Health Policy, Management, and Evaluation
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine
- Leslie Dan Faculty of Pharmacy, and
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Laleh Seyyed-Kalantari
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Judy Gichoya
- Department of Radiology and Biomedical Informatics, Emory University, Atlanta, Georgia
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George Tomlinson
- Institute of Health Policy, Management, and Evaluation
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Michael Fralick
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Christopher J Yarnell
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
- Department of Critical Care Medicine and
- Scarborough Health Network Research Institute, Scarborough Health Network, Toronto, Ontario, Canada
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Saavedra-Mitjans M, Frenette AJ, McCredie VA, Burry L, Arbour C, Mehta S, Charbonney E, Wang HT, Albert M, Bernard F, Williamson D. Physicians' beliefs and perceived importance of traumatic brain injury-associated agitation in critically ill patients: a survey of Canadian intensivists. Can J Anaesth 2024; 71:264-273. [PMID: 38129356 DOI: 10.1007/s12630-023-02666-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Agitation is a common behavioural problem following traumatic brain injury (TBI). Intensive care unit (ICU) physicians' perspectives regarding TBI-associated agitation are unknown. Our objective was to describe physicians' beliefs and perceived importance of TBI-associated agitation in critically ill patients. METHODS Following current standard guidance, we built an electronic, self-administrated, 42-item survey, pretested it for reliability and validity, and distributed it to 219 physicians working in 18 ICU level-1 trauma centres in Canada. We report the results using descriptive statistics. RESULTS The overall response rate was 93/219 (42%), and 76/93 (82%) respondents completed the full survey. Most respondents were men with ten or more years of experience. Respondents believed that pre-existing dementia (90%) and regular recreational drug use (86%) are risk factors for agitation. Concerning management, 91% believed that the use of physical restraints could worsen agitation, 90% believed that having family at the bedside reduces agitation, and 72% believed that alpha-2 adrenergic agonists are efficacious for managing TBI agitation. Variability was observed in beliefs on epidemiology, sex, gender, age, socioeconomic status, and other pharmacologic options. Respondents considered TBI agitation frequent enough to justify the implementation of management protocols (87%), perceived the current level of clinical evidence on TBI agitation management to be insufficient (84%), and expressed concerns about acute and long-term detrimental outcomes and burden to patients, health care professionals, and relatives (85%). CONCLUSION Traumatic brain injury-associated agitation in critically ill patients was perceived as an important issue for most ICU physicians. Physicians agreed on multiple approaches to manage TBI-associated agitation although agreement on epidemiology and risk factors was variable.
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Affiliation(s)
- Mar Saavedra-Mitjans
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada.
| | - Anne Julie Frenette
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Victoria A McCredie
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada
- Krembil Research Institute, Toronto, ON, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Caroline Arbour
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health, Toronto, ON, Canada
| | - Emmanuel Charbonney
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Han Ting Wang
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Francis Bernard
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - David Williamson
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
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8
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Carini FC, Angriman F, Scales DC, Munshi L, Burry LD, Sibai H, Mehta S, Ferreyro BL. Venous thromboembolism in critically ill adult patients with hematologic malignancy: a population-based cohort study. Intensive Care Med 2024; 50:222-233. [PMID: 38170226 DOI: 10.1007/s00134-023-07287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The aim of this study was to describe the incidence of venous thromboembolism (VTE) and major bleeding among hospitalized patients with hematologic malignancy, assessing its association with critical illness and other baseline characteristics. METHODS We conducted a population-based cohort study of hospitalized adults with a new diagnosis of hematologic malignancy in Ontario, Canada, between 2006 and 2017. The primary outcome was VTE (pulmonary embolism or deep venous thrombosis). Secondary outcomes were major bleeding and in-hospital mortality. We compared the incidence of VTE between intensive care unit (ICU) and non-ICU patients and described the association of other baseline characteristics and VTE. RESULTS Among 76,803 eligible patients (mean age 67 years [standard deviation, SD, 15]), 20,524 had at least one ICU admission. The incidence of VTE was 3.7% in ICU patients compared to 1.2% in non-ICU patients (odds ratio [OR] 3.08; 95% confidence interval [CI] 2.77-3.42). The incidence of major bleeding was 7.6% and 2.4% (OR 3.33; 95% CI 3.09-3.58), respectively. The association of critical illness and VTE remained significant after adjusting for potential confounders (OR 2.92; 95% CI 2.62-3.25). We observed a higher incidence of VTE among specific subtypes of hematologic malignancy and patients with prior VTE (OR 6.64; 95% CI 5.42-8.14). Admission more than 1 year after diagnosis of hematologic malignancy (OR 0.64; 95% CI 0.56-0.74) and platelet count ≤ 50 × 109/L at the time of hospitalization (OR 0.63; 95% CI 0.48-0.84) were associated with a lower incidence of VTE. CONCLUSION Among patients with hematologic malignancy, critical illness and certain baseline characteristics were associated with a higher incidence of VTE.
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Affiliation(s)
- Federico C Carini
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University Health Network, Toronto, ON, Canada.
- Department of Medicine, Sinai Health System, Toronto, ON, Canada.
- Mount Sinai Hospital, 600 University Avenue, Suite 5-292, Toronto, ON, M5G 1X5, Canada.
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES (Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Lisa D Burry
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- Department of Pharmacy, Sinai Health System, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Hassan Sibai
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
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Alostaz Z, Rose L, Mehta S, Johnston L, Dale CM. Interprofessional intensive care unit (ICU) team perspectives on physical restraint practices and minimization strategies in an adult ICU: A qualitative study of contextual influences. Nurs Crit Care 2024; 29:90-98. [PMID: 36443064 DOI: 10.1111/nicc.12864] [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: 04/19/2022] [Revised: 10/12/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Guidelines advocate for minimization of physical restraint (PR) use in intensive care units (ICU). Interprofessional team perspectives on PR practices can inform the design and implementation of successful PR minimization interventions. AIM To identify ICU staff perspectives of contextual influences on PR practices and minimization strategies. STUDY DESIGN A qualitative descriptive study in a single ICU in Toronto, Canada. One-on-one semi-structured interviews were conducted with 14 ICU staff. A deductive content analysis of interviews was undertaken using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. RESULTS Five themes were developed: risk-averse culture, leadership, practice monitoring and feedback processes, environmental factors, and facilitation. Participants described a risk-averse culture where prophylactic application of PR for intubated patients was used to prevent unplanned extubation thereby avoiding blame from colleagues. Perceived absence of leadership and interprofessional team involvement situated nurses as the primary decision-maker for restraint application and removal. Insufficient monitoring of restraint practices, lack of access to restraint alternatives, and inability to control environmental contributors to delirium and agitation further increased PR use. Recommendations as to how to minimize restraint use included a nurse facilitator to advance leadership-team collaboration, availability of restraints alternatives, and guidance on situations for applying and removing restraints. CONCLUSIONS This analysis of contextual influences on PR practices and minimization using the i-PARIHS framework revealed potentially modifiable barriers to successful PR minimization, including a lack of leadership involvement, gaps in practice monitoring, and collaborative decision-making processes. A team approach to changing behaviour and culture should be considered for successful implementation and sustainability of PR minimization. RELEVANCE TO PRACTICE The establishment of an interprofessional facilitation team that addresses risk-averse culture and promotes collaboration among ICU stakeholders will be crucial to the success of any approach to restraint minimization.
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Affiliation(s)
- Ziad Alostaz
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sangeeta Mehta
- Medical Surgical Intensive Care Unit, Mount Sinai Hospital, Sinai Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Linda Johnston
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
- Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Canada
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10
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Sharif S, Munshi L, Burry L, Mehta S, Gray S, Chaudhuri D, Duffett M, Siemieniuk RA, Rochwerg B. Ketamine sedation in the intensive care unit: a survey of Canadian intensivists. Can J Anaesth 2024; 71:118-126. [PMID: 37884773 DOI: 10.1007/s12630-023-02608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE We sought to understand the beliefs and practices of Canadian intensivists regarding their use of ketamine as a sedative in critically ill patients and to gauge their interest in a randomized controlled trial (RCT) examining its use in the intensive care unit (ICU). METHODS We designed and validated an electronic self-administered survey examining the use of ketamine as a sedative infusion for ICU patients. We surveyed 400 physician members of the Canadian Critical Care Society (CCCS) via email between February and April 2022 and sent three reminders at two-week intervals. The survey was redistributed in January 2023 to improve the response rate. RESULTS We received 87/400 (22%) completed questionnaires. Most respondents reported they rarely use ketamine as a continuous infusion for sedation or analgesia in the ICU (52/87, 58%). Physicians reported the following conditions would make them more likely to use ketamine: asthma exacerbation (73/87, 82%), tolerance to opioids (68/87, 77%), status epilepticus (44/87, 50%), and severe acute respiratory distress syndrome (33/87, 38%). Concern for side-effects that limited respondents' use of ketamine include adverse psychotropic effects (61/87, 69%) and delirium (47/87, 53%). The majority of respondents agreed there is need for an RCT to evaluate ketamine as a sedative infusion in the ICU (62/87, 71%). CONCLUSION This survey of Canadian intensivists illustrates that use of ketamine as a continuous infusion for sedation is limited, and is at least partly driven by concerns of adverse psychotropic effects. Canadian physicians endorse the need for a trial investigating the safety and efficacy of ketamine as a sedative for critically ill patients.
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Affiliation(s)
- Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Hamilton General Hospital, 237 Barton St East, 2nd Floor McMaster Wing, Room 252, Hamilton, ON, L8L 2X2, Canada.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Sara Gray
- Division of Emergency Medicine, and the Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Network, University of Toronto, Toronto, ON, Canada
| | - Dipayan Chaudhuri
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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11
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Riviello E, Mehta S. Equity in ARDS trials: some encouraging findings, and the significant work ahead. Intensive Care Med 2023; 49:1517-1519. [PMID: 38010382 DOI: 10.1007/s00134-023-07272-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Elisabeth Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health; Interdepartmental Division of Critical Care Medicine Sinai Health, University of Toronto, Toronto, Ontario, Canada
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12
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Koerber D, Khan S, Shamsheri T, Kirubarajan A, Mehta S. Accuracy of Heart Rate Measurement with Wrist-Worn Wearable Devices in Various Skin Tones: a Systematic Review. J Racial Ethn Health Disparities 2023; 10:2676-2684. [PMID: 36376641 PMCID: PMC9662769 DOI: 10.1007/s40615-022-01446-9] [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: 08/05/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wearable consumer technology allows for the collection of a growing amount of personal health data. Through the analysis of reflected LED light on the skin, heart rate measurement and arrhythmia detection can be performed. Given that melanin alters skin light absorption, this study seeks to summarize the accuracy of cardiac data from wrist-worn wearable devices for participants of varying skin tones. METHODS We conducted a systematic review, searching Embase, MEDLINE, CINAHL, and Cochrane for original studies that stratified heart rate and rhythm data for consumer wearable technology according to participant race and/or skin tone. RESULTS A total of 10 studies involving 469 participants met inclusion criteria. The frequency-weighted Fitzpatrick score for skin tone was reported in six studies (n = 293), with a mean participant score of 3.5 (range 1-6). Overall, four of the ten studies reported a significant reduction in accuracy of heart rate measurement with wearable devices in darker-skinned individuals, compared to participants with lighter skin tones. Four studies noted no effect of user skin tone on accuracy. The remaining two studies showed mixed results. CONCLUSIONS Preliminary evidence is inconclusive, but some studies suggest that wearable devices may be less accurate for detecting heart rate in participants with darker skin tones. Higher quality evidence is necessary, with larger sample sizes and more objective stratification of participants by skin tone, in order to characterize potential racial bias in consumer devices.
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Affiliation(s)
- Daniel Koerber
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Shawn Khan
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Tahmina Shamsheri
- Department of Interdisciplinary Studies, McMaster University, Hamilton, Canada
| | - Abirami Kirubarajan
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Sangeeta Mehta
- Faculty of Medicine, University of Toronto, Toronto, Canada.
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada.
- Mount Sinai Hospital, 600 University Ave, Suite 18-216, Toronto, ON, Canada.
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13
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Geng F, Ren Y, Hou H, Dai B, Scott JB, Strickland SL, Mehta S, Li J. Gender equity of authorship in pulmonary medicine over the past decade. Pulmonology 2023; 29:495-504. [PMID: 37210334 DOI: 10.1016/j.pulmoe.2023.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Gender disparity in authorship broadly persists in medical literature, little is known about female authorship within pulmonary medicine. METHODS A bibliometric analysis of publications from 2012 to 2021 in 12 journals with the highest impact in pulmonary medicine was conducted. Only original research and review articles were included. Names of the first and last authors were extracted and their genders were identified using the Gender-API web. Female authorship was described by overall distribution and distribution by country/region/continent and journal. We compared the article citations by gender combinations, evaluated the trend in female authorship, and forecasted when parity for first and last authorship would be reached. We also conducted a systematic review of female authorship in clinical medicine. RESULTS 14,875 articles were included, and the overall percentage of female first authors was higher than last authors (37.0% vs 22.2%, p<0.001). Asia had the lowest percentage of female first (27.6%) and last (15.2%) authors. The percentages of female first and last authors increased slightly over time, except for a rapid increase in the COVID-19 pandemic periods. Parity was predicted in 2046 for the first authors and 2059 for the last authors. Articles with male authors were cited more than articles with female authors. However, male-male collaborations significantly decreased, whereas female-female collaborations significantly increased. CONCLUSIONS Despite the slow improvement in female authorship over the past decade, there is still a substantial gender disparity in female first and last authorship in high-impact medical journals in pulmonary medicine.
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Affiliation(s)
- F Geng
- Department of Pulmonary and Critical Care Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Y Ren
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - H Hou
- Department of Pulmonary and Critical Care Medicine, The First Hospital of China Medical University, Shenyang, China
| | - B Dai
- Department of Pulmonary and Critical Care Medicine, The First Hospital of China Medical University, Shenyang, China
| | - J B Scott
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois, USA
| | - S L Strickland
- American Epilepsy Society, Programs, Chicago, Illinois, USA; Department of Health Sciences, Rush University, Chicago, Illinois, USA
| | - S Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - J Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois, USA.
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Lock D, Vassantachart A, Ragab O, Jennelle R, Han HR, Mehta S, Cheng K, Yang C, Omeh S, Miller K, Stal J, Ballas LK. Radiation Therapy Knowledge and Health Literacy among Culturally Diverse Patients with Prostate Cancer Treated at a Safety-Net Hospital. Int J Radiat Oncol Biol Phys 2023; 117:e409-e410. [PMID: 37785358 DOI: 10.1016/j.ijrobp.2023.06.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Shared decision making is integral to the physician-patient relationship for radiotherapy (RT) patients. It is implicit that patients both comprehend and retain information explained during consultation. However, quality and quantity of patient knowledge following this visit is unknown. The purpose of this study was to evaluate post-consultation RT knowledge and health literacy among a diverse group of patients. MATERIALS/METHODS Participants were patients ≥18 years old who received consultation for definitive or salvage RT to the prostate gland/fossa between April 2021 and January 2023 at an urban safety-net hospital. Following consultation, patients completed the Radiation Oncology Knowledge Assessment Survey (ROKAS), designed to measure patient understanding of proposed RT treatment (e.g., treatment frequency, length, safety) and possible short- and long-term side effects (SE). Additional measures included patients' health literacy, health numeracy (numerical medical concepts), acculturation (assimilation to the dominant culture), and socioeconomic factors. ROKAS was administered in both English and Spanish with Spanish-speaking patients offered medical translation if desired. Bivariate Pearson correlations were conducted to examine the relationships between independent variables and post-consultation RT knowledge. Two-sided t-tests were conducted to examine differences in patients' knowledge by language. RESULTS Overall, 39 ROKAS were completed by 24 English-speaking and 15 Spanish-speaking patients (mean age 64.4 [SD 6.8], range 52-79). The majority (93%) of patients 'agreed' or 'strongly agreed' that they understood all the RT information presented. However, only 70% of the RT questions were answered correctly with 26% of patients answering all RT questions correctly. Similarly, 95% of patients 'agreed' or 'strongly agreed' with knowing the side effects of their proposed treatment, but only 71% and 74% of short- and long-term SE questions, respectively, were answered correctly. Higher health literacy (p = 0.04) and health numeracy (p = 0.001) were significantly correlated with better understanding of short-term SE, but not with RT knowledge or long-term SE. Spanish-speaking patients had significantly lower scores of health literacy (p = 0.001) and understanding of long-term (p = 0.01), but not short-term SE. CONCLUSION There is a significant gap between perceived and measured knowledge of RT treatment and SE in patients who receive consultation for RT to the prostate gland/fossa. Health literacy was significantly associated with improved knowledge of RT and short-term SE. Spanish-speaking patients had poorer understanding of long-term SE than English-speaking patients. Efforts to identify gaps in patient health literacy are needed to target those at risk and ensure that culturally diverse patient populations can engage in shared decision making with their providers.
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Affiliation(s)
- D Lock
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - A Vassantachart
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - O Ragab
- Department of Radiation Oncology, Washington DC VA Medical Center, Washington, DC
| | - R Jennelle
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA
| | - H R Han
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - S Mehta
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - K Cheng
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - C Yang
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - S Omeh
- Department of Radiation Oncology, LAC+USC Medical Center, Los Angeles, CA; Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - K Miller
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - J Stal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - L K Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
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Jiao C, Ling DC, Bian SX, Vassantachart A, Cheng K, Mehta S, Lock D, Feng M, Thomas H, Scholey J, Sheng K, Fan Z, Yang W. Contouring Analysis on Synthetic Contrast-Enhanced MR from GRMM-GAN and Implications on MR-Guide Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:S117. [PMID: 37784304 DOI: 10.1016/j.ijrobp.2023.06.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) MR-guided linear accelerators have been commercialized making MR-only planning and adaptation an appealing alternative circumventing MR-CT registration. However, obtaining daily contrast-enhanced MR images can be prohibitive due to the increased risk of side effects from repeated contrast injections. In this work, we evaluate the quality of contrast-enhanced multi-modal MR image synthesis network GRMM-GAN (gradient regularized multi-modal multi-discrimination sparse-attention fusion generative adversarial network) for MR-guided radiation therapy. MATERIALS/METHODS With IRB approval, we trained the GRMM-GAN based on 165 abdominal MR studies from 65 patients. Each study included T2, T1 pre-contrast (T1pre), and T1 contrast enhanced (T1ce) images. The two pre-contrast MR modalities, T2 and T1pre images were adopted as inputs for GRMM-GAN, and the T1ce image at the portal venous phase was used as an output. Ten MR scans containing 21 liver tumors were selected for contouring analysis. A Turing test was first given to six radiation oncologists, in which 100 real T1ce and synthetic T1ce image slices are randomly given to the radiation oncologists to determine the authenticity of the synthesis. We then invited two radiation oncologists (RadOnc 1 and RadOnc2) to manually contour the 21 liver tumors independently on the real T1ce images. RadOnc2 then performed contouring on the respective synthetic T1ce MRs. DICE coefficient (defined as the intersection over the average of two volumes) and Hausdorff distance (HD, measuring how far two volumes are from each other) were used as analysis metrics. The DICE coefficients were calculated from the two radiation oncologists' contours on the real T1ce MR for each tumor. The DICE coefficients were also calculated from RadOnc 2's contours on real and synthetic MRs. Besides, tumor center shifts were extracted. The tumor center of mass coordinates was extracted from real and synthetic volumes. The difference in the coordinates indicated the shifts in the superior-inferior (SI), right-left (RL), and anterior-posterior (AP) directions between real and synthetic tumor volumes. RESULTS An average of 52.3% test score was achieved from the six radiation oncologists, which is close to random guessing. RadOnc 1 and RadOnc 2, who had participated in the contouring analysis, achieved an average DICE of 0.91±0.02 from tumor volumes drawn on the real T1ce MRs. This result sets the inter-operator uncertainty baseline in the real clinical setting. RadOnc 2 achieved an average DICE (real vs. synth) of 0.90±0.04 and HD of 4.76±1.82 mm. Only sub-millimeter (SI: 0.67 mm, RL: 0.41 mm, AP: 0.39 mm) tumor center shifts were observed in all three directions. CONCLUSION The GRMM-GAN method has the potential for MR-guided liver radiation when contrast agents cannot be administered daily and provide synthetic contrast-enhanced MR for better tumor targeting. The network can produce synthetic MR images with satisfactory contour agreement and geometric integrity.
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Affiliation(s)
- C Jiao
- University of California, San Francisco, San Francisco, CA
| | - D C Ling
- University of Southern California, Los Angeles, CA
| | - S X Bian
- University of Southern California, Los Angeles, CA
| | - A Vassantachart
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - K Cheng
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - S Mehta
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - D Lock
- University of Southern California, Los Angeles, CA
| | - M Feng
- University of California, San Francisco, San Francisco, CA
| | - H Thomas
- University of California, San Francisco, San Francisco, CA
| | - J Scholey
- University of California, San Francisco, San Francisco, CA
| | - K Sheng
- University of California, San Francisco, San Francisco, CA
| | - Z Fan
- University of Southern California, Los Angeles, CA
| | - W Yang
- University of California, San Francisco, San Francisco, CA
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Kennedy WR, Chang YW, Jiang J, Molloy J, Pennington-Krygier C, Harmon J, Hong A, Wanebo J, Braun K, Garcia MA, Barani IJ, Yoo W, Tovmasyan A, Tien AC, Li J, Mehta S, Sanai N. A Combined Phase 0/2 "Trigger" Trial Evaluating Pamiparib or Olaparib with Concurrent Radiotherapy in Patients with Newly-Diagnosed or Recurrent Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:e115. [PMID: 37784657 DOI: 10.1016/j.ijrobp.2023.06.898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) This study evaluates the pharmacokinetic (PK) and pharmacodynamic (PD) profiles and clinical efficacy of PARP1/2 selective inhibitors, pamiparib and olaparib, in newly-diagnosed or recurrent glioblastoma (GBM) patients in combination with radiotherapy (RT). MATERIALS/METHODS In this combined phase 0/2 trial presumed newly-diagnosed (Arm A) or recurrent (Arm B) GBM patients received 4 days of pamiparib (60 mg BID) prior to resection either 2-4 or 8-12 hours following the final dose. Arm C enrolled patients with recurrent GBM to 4 days of olaparib (200 mg BID) prior to resection. Enhancing and nonenhancing tumor tissue, cerebrospinal fluid (CSF) and plasma were collected. Total and unbound drug concentrations were measured using validated LC-MS/MS methods. A PK 'trigger', defined as unbound drug and gt; 5-fold biochemical IC 50 in nonenhancing tumor, determined eligibility for the therapeutic expansion phase 2. PARP inhibition was assessed via ex vivo radiation and quantification of PAR levels compared to non-radiated control. Newly-diagnosed MGMT unmethylated GBMs and recurrent GBMs exceeding the PK threshold were eligible for an expansion phase of pamiparib (Arms A and B) or olaparib (Arm C) with concurrent RT followed by maintenance pamiparib or olaparib. RT was 60 Gy in 30 fractions in newly-diagnosed patients and 40 Gy in 15 fractions in recurrent patients, delivered using volumetric-modulated arc therapy (VMAT). RESULTS A total of 38 patients (Arm A, n = 16; Arm B, n = 16; Arm C, n = 6) were enrolled in the initial phase 0 study. The mean unbound concentrations of pamiparib in nonenhancing tumor region for Arm A and Arm B were 167.3 nM and 109.4 nM respectively, and in Arm C the mean unbound concentration of olaparib was 5.2 nM. All patients in the pamiparib arms (n = 32/32) but only 1 of 6 patients in the olaparib Arm C exceeded the PK threshold. Radiation-induced PAR expression was 2.44-fold in untreated control vs 1.16 in Arm A (p<0.05), 0.85 in Arm B (p<0.01) and 1.11 in Arm C patients, respectively. In Arm A, 11 patients had unmethylated tumors, and of those, 7 patients enrolled in phase 2. In Arm B, 9 of the 16 clinically eligible patients with positive PK results were enrolled in phase 2. At a median follow-up of 8.4 months [range: 1.3-15.7 months], the median progression-free survival (PFS) was 5.4, 6.0, and 3.8 months for Arms A (n = 7), B (n = 9), and C (n = 1), respectively. Grade 3+ toxicities related to pamiparib occurred in 4 patients, with 2 adverse events resulting in treatment discontinuation. No grade 3+ toxicities were documented in the olaparib arm. CONCLUSION Pamiparib achieved pharmacologically-relevant concentrations in nonenhancing GBM tissue and suppressed induction of PAR levels ex vivo post-radiation. The majority of patients with MGMT-unmethylated GBM advanced to the phase 2 portion of the trial, and pamiparib was generally well-tolerated in these patients.
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Affiliation(s)
- W R Kennedy
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - Y W Chang
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - J Jiang
- Wayne State University, Detroit, MI
| | - J Molloy
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | | | - J Harmon
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - A Hong
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - J Wanebo
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - K Braun
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - M A Garcia
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - I J Barani
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - W Yoo
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - A Tovmasyan
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - A C Tien
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - J Li
- Wayne State University, Detroit, MI
| | - S Mehta
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - N Sanai
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
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Kennedy WR, Margaryan T, Molloy J, Knight W, Harmon J, Hong A, Wanebo J, Braun K, Garcia MA, Barani IJ, Yoo W, Tien AC, Tovmasyan A, Mehta S, Sanai N. A Combined Phase 0/2 "Trigger" Trial of Niraparib in Combination with Radiation in Patients with Newly-Diagnosed Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:S86-S87. [PMID: 37784592 DOI: 10.1016/j.ijrobp.2023.06.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Poly ADP-ribose (PAR) polymerase (PARP) mediates DNA damage response. Niraparib is an investigational PARP1/2-selective inhibitor. We conducted a combined phase 0/2 study to evaluate niraparib pharmacokinetics (PK) and pharmacodynamics (PD) in patients with newly-diagnosed glioblastoma (GBM), graduating patients to a phase 2 study evaluating a therapeutic regimen of niraparib with concurrent conventionally-fractionated radiotherapy (RT) in O6-methylguanine methyltransferase (MGMT) unmethylated tumors exceeding a prespecified PK threshold in non-enhancing tumor. MATERIALS/METHODS Patients with presumed newly-diagnosed GBM were enrolled in a phase 0 study receiving 4 days of niraparib (300 or 200 mg QD) prior to planned resection 3-5 or 8-12 hours following the last dose. Tumor tissue (enhancing and non-enhancing regions), cerebrospinal fluid (CSF), and plasma were collected. Total and unbound niraparib concentrations were measured using validated LC-MS/MS methods. PARP inhibition was assessed by quantification of PAR induction after 10 Gy ex vivo irradiation in surgical tissue compared to non-irradiated control tissue. A PK 'trigger' determined eligibility for the therapeutic phase 2 expansion portion of the study. This was defined as unbound [niraparib] > 5-fold biochemical IC50 (i.e., 19 nM) in non-enhancing tumor. Patients with MGMT unmethylated tumors exceeding this PK threshold were eligible for expansion phase dosing of niraparib with concurrent RT followed by a maintenance phase of niraparib. Patients with MGMT methylated tumors were not eligible for the expansion phase and proceeded with temozolomide (TMZ) plus RT followed by maintenance TMZ. RT dose was 60 Gy in 30 fractions using volumetric-modulated arc therapy (VMAT). RESULTS All 29 patients enrolled in the phase 0 portion of the study met the PK threshold. In non-enhancing regions, the mean unbound concentration of niraparib was 258.2 nM. The suppression of PAR levels after ex vivo RT was observed in 79% of the patients (17/22). Sixteen patients had unmethylated tumors, and of those, 11 patients enrolled in phase 2. Five of the 6 initial patients enrolled in phase 2 experienced thrombocytopenia related to niraparib, and 3/5 cases were deemed serious and life-threatening. Consequently, starting dose in both phases was lowered to 200 mg, and no serious AEs were observed thereafter. At a median follow-up of 8.1 months [range: 6.0-12.9 months], 6-month PFS was 64% with 4 patients remaining on treatment and 5 patients ongoing survival follow-up. CONCLUSION Niraparib achieves pharmacologically-relevant concentrations in non-enhancing, newly-diagnosed GBM tissue in excess of any other studied PARP inhibitor. When delivered with concurrent RT, niraparib was well-tolerated, with low rates of grade 3+ toxicity. Initial clinical efficacy data are encouraging.
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Affiliation(s)
- W R Kennedy
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - T Margaryan
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - J Molloy
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - W Knight
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - J Harmon
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - A Hong
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - J Wanebo
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - K Braun
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - M A Garcia
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - I J Barani
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - W Yoo
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - A C Tien
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - A Tovmasyan
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - S Mehta
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
| | - N Sanai
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, AZ
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Soussi S, Mehta S, Lorello GR. Equity, diversity, and inclusion in anaesthesia and critical care medicine: consider the various aspects of diversity. Br J Anaesth 2023; 131:e135-e136. [PMID: 37567809 DOI: 10.1016/j.bja.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/06/2023] [Accepted: 07/15/2023] [Indexed: 08/13/2023] Open
Affiliation(s)
- Sabri Soussi
- Department of Anaesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, ON, Canada; Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Gianni R Lorello
- Department of Anaesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, ON, Canada; Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; The Wilson Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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Liu PY, Xia D, McGonigle K, Carroll AB, Chiango J, Scavello H, Martins R, Mehta S, Krespan E, Lunde E, LeVine D, Fellman CL, Goggs R, Beiting DP, Garden OA. Immune-mediated hematological disease in dogs is associated with alterations of the fecal microbiota: a pilot study. Anim Microbiome 2023; 5:46. [PMID: 37770990 PMCID: PMC10540429 DOI: 10.1186/s42523-023-00268-2] [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: 03/29/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The dog is the most popular companion animal and is a valuable large animal model for several human diseases. Canine immune-mediated hematological diseases, including immune-mediated hemolytic anemia (IMHA) and immune thrombocytopenia (ITP), share many features in common with autoimmune hematological diseases of humans. The gut microbiome has been linked to systemic illness, but few studies have evaluated its association with immune-mediated hematological disease. To address this knowledge gap, 16S rRNA gene sequencing was used to profile the fecal microbiota of dogs with spontaneous IMHA and ITP at presentation and following successful treatment. In total, 21 affected and 13 healthy control dogs were included in the study. RESULTS IMHA/ITP is associated with remodeling of fecal microbiota, marked by decreased relative abundance of the spirochete Treponema spp., increased relative abundance of the pathobionts Clostridium septicum and Escherichia coli, and increased overall microbial diversity. Logistic regression analysis demonstrated that Treponema spp. were associated with decreased risk of IMHA/ITP (odds ratio [OR] 0.24-0.34), while Ruminococcaceae UCG-009 and Christensenellaceae R-7 group were associated with increased risk of disease (OR = 6.84 [95% CI 2-32.74] and 8.36 [95% CI 1.85-71.88] respectively). CONCLUSIONS This study demonstrates an association of immune-mediated hematological diseases in dogs with fecal dysbiosis, and points to specific bacterial genera as biomarkers of disease. Microbes identified as positive or negative risk factors for IMHA/ITP represent an area for future research as potential targets for new diagnostic assays and/or therapeutic applications.
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Affiliation(s)
- P-Y Liu
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, Royal College Street, London, NW1 0TU, UK
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, 804201, Taiwan
| | - D Xia
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, Royal College Street, London, NW1 0TU, UK
| | - K McGonigle
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, 3900 Spruce Street, Philadelphia, PA, 19104, USA
| | - A B Carroll
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, 3900 Spruce Street, Philadelphia, PA, 19104, USA
| | - J Chiango
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, 3900 Spruce Street, Philadelphia, PA, 19104, USA
| | - H Scavello
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, 3900 Spruce Street, Philadelphia, PA, 19104, USA
| | - R Martins
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, 3900 Spruce Street, Philadelphia, PA, 19104, USA
| | - S Mehta
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 380 South University Avenue, Philadelphia, 19104, USA
| | - E Krespan
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 380 South University Avenue, Philadelphia, 19104, USA
| | - E Lunde
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, 1809 South Riverside Drive, Ames, IA, 50011, USA
| | - D LeVine
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, 1809 South Riverside Drive, Ames, IA, 50011, USA
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL, 36849, USA
| | - C L Fellman
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, 01536, USA
| | - R Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, 930 Campus Road, Box 31, Ithaca, NY, 14853, USA
| | - D P Beiting
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 380 South University Avenue, Philadelphia, 19104, USA
| | - O A Garden
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, 3900 Spruce Street, Philadelphia, PA, 19104, USA.
- Dean's Office, School of Veterinary Medicine, Louisiana State University, Skip Bertman Drive, Baton Rouge, LA, 70803, USA.
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Secreto C, Chean D, van de Louw A, Kouatchet A, Bauer P, Cerrano M, Lengliné E, Saillard C, Chow-Chine L, Perner A, Pickkers P, Soares M, Rello J, Pène F, Lemiale V, Darmon M, Fodil S, Martin-Loeches I, Mehta S, Schellongowski P, Azoulay E, Mokart D. Characteristics and outcomes of patients with acute myeloid leukemia admitted to intensive care unit with acute respiratory failure: a post-hoc analysis of a prospective multicenter study. Ann Intensive Care 2023; 13:79. [PMID: 37658994 PMCID: PMC10474995 DOI: 10.1186/s13613-023-01172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) is the leading cause of intensive care unit (ICU) admission in patients with Acute Myeloid Leukemia (AML) and data on prognostic factors affecting short-term outcome are needed. METHODS This is a post-hoc analysis of a multicenter, international prospective cohort study on immunocompromised patients with ARF admitted to ICU. We evaluated hospital mortality and associated risk factors in patients with AML and ARF; secondly, we aimed to define specific subgroups within our study population through a cluster analysis. RESULTS Overall, 201 of 1611 immunocompromised patients with ARF had AML and were included in the analysis. Hospital mortality was 46.8%. Variables independently associated with mortality were ECOG performance status ≥ 2 (OR = 2.79, p = 0.04), cough (OR = 2.94, p = 0.034), use of vasopressors (OR = 2.79, p = 0.044), leukemia-specific pulmonary involvement [namely leukostasis, pulmonary infiltration by blasts or acute lysis pneumopathy (OR = 4.76, p = 0.011)] and liver SOFA score (OR = 1.85, p = 0.014). Focal alveolar chest X-ray pattern was associated with survival (OR = 0.13, p = 0.001). We identified 3 clusters, that we named on the basis of the most frequently clinical, biological and radiological features found in each cluster: a "leukemic cluster", with high-risk AML patients with isolated, milder ARF; a "pulmonary cluster", consisting of symptomatic, highly oxygen-requiring, severe ARF with diffuse radiological findings in heavily immunocompromised patients; a clinical "inflammatory cluster", including patients with multi-organ failures in addition to ARF. When included in the multivariate analysis, cluster 2 and 3 were independently associated with hospital mortality. CONCLUSIONS Among AML patients with ARF, factors associated with a worse outcome are related to patient's background (performance status, leukemic pulmonary involvement), symptoms, radiological findings, the need for vasopressors and the liver SOFA score. We identified three specific ARF syndromes in AML patients, which showed a prognostic significance and could guide clinicians to optimize management strategies.
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Affiliation(s)
- Carolina Secreto
- Division of Haematology, Department of Oncology, A.O.U. Città Della Salute e della Scienza di Torino, Turin, Italy.
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France.
| | - Dara Chean
- Médecine Intensive et Réanimation, APHP, Hôpital Saint Louis, Paris Cité University, Paris, France
| | - Andry van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France
| | - Philippe Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marco Cerrano
- Division of Haematology, Department of Oncology, A.O.U. Città Della Salute e della Scienza di Torino, Turin, Italy
| | - Etienne Lengliné
- Hématologie Adulte, Hôpital Saint-Louis, Université Paris Diderot, Paris, France
| | - Colombe Saillard
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduação Em Clínica Médica, Rio De Janeiro, Brazil
| | - Jordi Rello
- Vall d'Hebron Institute of Research, Barcelona, Spain
- CHU Nîmes, Université de Nîmes-Montpellier, Nîmes, France
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University Paris Descartes, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis and Paris Diderot Sorbonne University, Paris, France
| | - Michael Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis and Paris Diderot Sorbonne University, Paris, France
| | - Sofiane Fodil
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis and Paris Diderot Sorbonne University, Paris, France
| | | | - Sangeeta Mehta
- Sinai Health System and University of Toronto, Toronto, ON, Canada
| | | | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis and Paris Diderot Sorbonne University, Paris, France
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
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Heybati K, Wong EKC, Watt J, Zou H, Chandraraj A, Zhang AW, Norman R, Piggott K, Straus SE, Liu B, Mehta S. Outcomes of critically ill older adults with COVID-19: a multicentre retrospective cohort study. Can J Anaesth 2023; 70:1371-1380. [PMID: 37434068 DOI: 10.1007/s12630-023-02518-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 07/13/2023] Open
Abstract
PURPOSE Older adults with COVID-19 have a high prevalence of complications and mortality during hospitalization. Given the large proportion of older adults requiring admission to an intensive care unit (ICU), we aimed to describe the management and outcomes of older adults with COVID-19 requiring ICU care and identify predictors of hospital mortality. METHODS We included consecutive patients ≥ 65 yr of age who were admitted between 11 March 2020 and 30 June 2021 to one of five Toronto (ON, Canada) ICUs with a primary diagnosis of SARS-CoV-2 infection in a retrospective cohort study. Patient characteristics, ICU treatment, and outcomes were recorded. We used multivariable logistic regression to identify predictors of in-hospital mortality. RESULTS Of the 273 patients, the median [interquartile range] age was 74 [69-80] yr, 104 (38.1%) were female, and 164 (60.1%) required invasive mechanical ventilation. One hundred and forty-two patients (52.0%) survived their hospital stay. Compared with survivors, nonsurvivors were older (74 [70-82] yr vs 73 [68-78] yr; P = 0.03), and a smaller proportion was female (39/131, 29.8% vs 65/142, 45.8%; P = 0.01). Patients had long hospital (19 [11-35] days) and ICU (9 [5-22] days) stays, with no significant differences in ICU length of stay or duration of invasive mechanical ventilation between the two groups. Higher APACHE II score, increasing age, and the need for organ support were independently associated with higher in-hospital mortality while female sex was associated with lower mortality. CONCLUSIONS Older critically ill COVID-19 patients had long ICU and hospital stays, and approximately half died in hospital. Further research is needed to identify individuals who will benefit most from an ICU admission and to evaluate posthospitalization outcomes.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric K C Wong
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer Watt
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanyan Zou
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
| | - Arthana Chandraraj
- Division of Geriatric Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Alissa W Zhang
- Division of Geriatric Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Richard Norman
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
| | - Katrina Piggott
- Division of Geriatric Medicine, Department of Medicine, Sinai Health and University Health Network, Toronto, ON, Canada
| | - Sharon E Straus
- Division of Geriatric Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, 600 University Ave., Suite 18-216, Toronto, ON, M5G 1X5, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Mehta S, Jen T, Hamilton D. Regional analgesia for acute pain relief after open thoracotomy and video-assisted thoracoscopic surgery. BJA Educ 2023; 23:295-303. [PMID: 37465231 PMCID: PMC10350558 DOI: 10.1016/j.bjae.2023.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 07/20/2023] Open
Affiliation(s)
- S. Mehta
- Royal Brompton and Harefield Hospitals, London, UK
| | - T.T.H. Jen
- St Paul's Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - D.L. Hamilton
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- University of Sunderland, Sunderland, UK
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Yeung SHM, Boles R, Munshi L, Moore M, Seedon S, Shah S, Thyagu S, Mehta S. Resuscitation outcomes in patients with cancer: experience in a large urban cancer centre. Can J Anaesth 2023; 70:1234-1243. [PMID: 37344744 DOI: 10.1007/s12630-023-02505-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/02/2022] [Accepted: 12/05/2022] [Indexed: 06/23/2023] Open
Abstract
PURPOSE Hospitalized patients with cancer who experience cardiopulmonary arrest have historically low survival rates. This retrospective cohort study describes outcomes of patients at a large Canadian cancer centre who had a "code medical emergency" activated, and the use of pragmatic criteria to identify patients with poor survival following resuscitation. METHODS We included hospitalized patients with cancer who had a "code blue" activated between January 2007 and December 2018. Our primary outcome was intensive care unit (ICU) mortality. We developed pragmatic criteria to identify patients with "poor prognosis" for survival from cardiopulmonary resuscitation (CPR) based on disease status and candidacy for further cancer treatment. We used descriptive statistics to analyze the outcomes of poor prognosis patients. RESULTS Two hundred and twenty-five patients had a code blue activated. The median age was 61 yr, 52% were male, and 48% had a solid tumour. Overall, 173/225 (77%) patients survived the code blue; 164 were admitted to the ICU, where 49% (81/164) died; 31% survived to hospital discharge; and 16% (n = 27) were alive at one year. One hundred and twenty out of 225 (53%) required chest compressions; spontaneous circulation returned in 61% (73/120), and 12% (14/120) survived to hospital discharge. Patients meeting "poor prognosis" criteria (114, 51%) were more likely to die in the ICU (64% vs 35%; P < 0.001) or in hospital (86% vs 59%; P < 0.001), and more often had goals-of-care discussions prior to the code blue (46% vs 7%; P < 0.001). At one year, only 2% of poor prognosis patients were alive, compared with 24% of patients who did not meet any poor prognosis criteria. CONCLUSION Hospitalized patients with cancer requiring CPR have poor hospital and long-term outcomes. The proposed set of pragmatic criteria may be useful to identify patients unlikely to benefit from CPR and life support, to trigger early goals of care discussions, and to avoid potentially goal-discordant interventions.
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Affiliation(s)
- Sabrina H M Yeung
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ramy Boles
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laveena Munshi
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue Suite 18-216, Toronto, ON, M5G 1X5, Canada
| | - Mobolaji Moore
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue Suite 18-216, Toronto, ON, M5G 1X5, Canada
| | - Sarah Seedon
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue Suite 18-216, Toronto, ON, M5G 1X5, Canada
| | - Sumesh Shah
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue Suite 18-216, Toronto, ON, M5G 1X5, Canada
| | - Santhosh Thyagu
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue Suite 18-216, Toronto, ON, M5G 1X5, Canada.
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24
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Kho ME, Reid J, Molloy AJ, Herridge MS, Seely AJ, Rudkowski JC, Buckingham L, Heels-Ansdell D, Karachi T, Fox-Robichaud A, Ball IM, Burns KEA, Pellizzari JR, Farley C, Berney S, Pastva AM, Rochwerg B, D'Aragon F, Lamontagne F, Duan EH, Tsang JLY, Archambault P, English SW, Muscedere J, Serri K, Tarride JE, Mehta S, Verceles AC, Reeve B, O'Grady H, Kelly L, Strong G, Hurd AH, Thabane L, Cook DJ. Critical Care C ycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients. BMJ Open 2023; 13:e075685. [PMID: 37355270 PMCID: PMC10314658 DOI: 10.1136/bmjopen-2023-075685] [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: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults. METHODS AND ANALYSIS We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups. ETHICS AND DISSEMINATION Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).
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Affiliation(s)
- Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Julie Reid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alexander J Molloy
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
| | - Margaret S Herridge
- University Health Network, Toronto General Research Institute, Toronto, Ontario, Canada
| | - Andrew J Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jill C Rudkowski
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Lisa Buckingham
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Ian M Ball
- Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Karen E A Burns
- Li Sha King Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, Unity Health Toronto, Toronto, Ontario, Canada
| | - Joseph R Pellizzari
- Consultation-Liaison Psychiatry Service, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Farley
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sue Berney
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amy M Pastva
- Departments of Medicine and Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Bram Rochwerg
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke Faculte de medecine et des sciences de la sante, Sherbrooke, Quebec, Canada
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Francois Lamontagne
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
- Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Erick H Duan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care Medicine, Niagara Health System, St Catharines, Ontario, Canada
| | - Patrick Archambault
- Anesthesiology and Intensive Care, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
- Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec, Québec, Canada
| | - Shane W English
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Karim Serri
- Critical Care Division, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Québec, Canada
| | - Jean-Eric Tarride
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for the Assessment of Technology in Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Sinai Health System, Toronto, Ontario, Canada
| | - Avelino C Verceles
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brenda Reeve
- Medicine, Brantford General Hospital, Brantford, Ontario, Canada
| | - Heather O'Grady
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Laurel Kelly
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Geoff Strong
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Abby H Hurd
- Physiotherapy, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Research Institute of St. Joe's, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Medicine, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
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Stephen TL, Korobkova L, Breningstall B, Nguyen K, Mehta S, Pachicano M, Jones KT, Hawes D, Cabeen RP, Bienkowski MS. Machine Learning Classification of Alzheimer's Disease Pathology Reveals Diffuse Amyloid as a Major Predictor of Cognitive Impairment in Human Hippocampal Subregions. bioRxiv 2023:2023.05.31.543117. [PMID: 37333119 PMCID: PMC10274752 DOI: 10.1101/2023.05.31.543117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Analyzing Alzheimer's disease (AD) pathology within anatomical subregions is a significant challenge, often carried out by pathologists using a standardized, semi-quantitative approach. To augment traditional methods, a high-throughput, high-resolution pipeline was created to classify the distribution of AD pathology within hippocampal subregions. USC ADRC post-mortem tissue sections from 51 patients were stained with 4G8 for amyloid, Gallyas for neurofibrillary tangles (NFTs) and Iba1 for microglia. Machine learning (ML) techniques were utilized to identify and classify amyloid pathology (dense, diffuse and APP (amyloid precursor protein)), NFTs, neuritic plaques and microglia. These classifications were overlaid within manually segmented regions (aligned with the Allen Human Brain Atlas) to create detailed pathology maps. Cases were separated into low, intermediate, or high AD stages. Further data extraction enabled quantification of plaque size and pathology density alongside ApoE genotype, sex, and cognitive status. Our findings revealed that the increase in pathology burden across AD stages was driven mainly by diffuse amyloid. The pre and para-subiculum had the highest levels of diffuse amyloid while NFTs were highest in the A36 region in high AD cases. Moreover, different pathology types had distinct trajectories across disease stages. In a subset of AD cases, microglia were elevated in intermediate and high compared to low AD. Microglia also correlated with amyloid pathology in the Dentate Gyrus. The size of dense plaques, which may represent microglial function, was lower in ApoE4 carriers. In addition, individuals with memory impairment had higher levels of both dense and diffuse amyloid. Taken together, our findings integrating ML classification approaches with anatomical segmentation maps provide new insights on the complexity of disease pathology in AD progression. Specifically, we identified diffuse amyloid pathology as being a major driver of AD in our cohort, regions of interest and microglial responses that might advance AD diagnosis and treatment.
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Burns KEA, Heels-Ansdell D, Thabane L, Kahn SR, Lauzier F, Mehta S, Ostermann M, Bhuptani P, Crowther MA, Finfer S, Cook DJ. Sex differences in thromboprophylaxis of the critically ill: a secondary analysis of a randomized trial. Can J Anaesth 2023; 70:1008-1018. [PMID: 37310606 DOI: 10.1007/s12630-023-02457-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a common complication of critical illness. Sex- or gender-based analyses are rarely conducted and their effect on outcomes is unknown. We assessed for an effect modification of thromboprophylaxis (dalteparin or unfractionated heparin [UFH]) by sex on thrombotic (deep venous thrombosis [DVT], pulmonary embolism [PE], VTE) and mortality outcomes in a secondary analysis of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT). METHODS We conducted unadjusted analyses using Cox proportional hazards analysis, stratified by centre and admission diagnostic category, including sex, treatment, and an interaction term. Additionally, we performed adjusted analyses and assessed the credibility of our findings. RESULTS Critically ill female (n = 1,614) and male (n = 2,113) participants experienced similar rates of DVT, proximal DVT, PE, any VTE, ICU death, and hospital death. In unadjusted analyses, we did not find significant differences in treatment effect favouring males (vs females) treated with dalteparin (vs UFH) for proximal leg DVT, any DVT, or any PE, but found a statistically significant effect (moderate certainty) favouring dalteparin in males for any VTE (males: hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.52 to 0.96 vs females: HR, 1.16; 95% CI, 0.81 to 1.68; P = 0.04). This effect remained after adjustment for baseline characteristics (males: HR, 0.70; 95% CI, 0.52 to 0.96 vs females: HR, 1.17; 95% CI, 0.81 to 1.68; P = 0.04) and weight (males: HR, 0.70; 95% CI, 0.52 to 0.96 vs females: HR, 1.20; 95% CI, 0.83 to 1.73; P = 0.03). We did not identify a significant effect modification by sex on mortality. CONCLUSIONS We found an effect modification by sex of thromboprophylaxis on VTE in critically ill patients that requires confirmation. Our findings highlight the need for sex- and gender-based analyses in acute care research.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Francois Lauzier
- Research Center of the CHU de Québec-Université Laval, Population Health and Optimal Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - Pulkit Bhuptani
- Department of Pharmacy, Unity Health Toronto-St. Michael's Hospital, Toronto, ON, Canada
| | - Mark A Crowther
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Simon Finfer
- Clinical Trials Unit, The George Institute, Sydney, NSW, Australia
| | - Deborah J Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Heybati K, Flexman AM, Lorello GR, Mehta S. Outcomes of COVID-19 manuscripts submitted to the Canadian Journal of Anesthesia: a retrospective audit of author gender and person of colour status. Can J Anaesth 2023; 70:988-994. [PMID: 37188835 PMCID: PMC10184964 DOI: 10.1007/s12630-023-02455-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 05/17/2023] Open
Abstract
PURPOSE We aimed to evaluate the representation of women and persons of colour (POC) authors of COVID-19 manuscripts submitted to, accepted in, and rejected from the Journal and to evaluate trends in their representation during the pandemic. METHODS All COVID-19 manuscripts submitted to the Journal between 1 February 2020 and 30 April 2021 were included. Manuscript data were retrieved from Editorial Manager, and gender and POC status were obtained through: 1) e-mail communication with corresponding authors; 2) e-mail queries to other coauthors; 3) NamSor software, and 4) Internet searches. The data were described using percentages and summary statistics. A two-sample test of proportions was used for comparisons and trends were analyzed with linear regression. RESULTS We identified 314 manuscripts (1,555 authors), 95 (461 authors) of which were accepted for publication. Of all authors, 515 (33%) were women, and women were the lead and senior authors of 101 (32%) and 69 (23%) manuscripts, respectively. There were no differences in women's representation as authors between accepted and rejected manuscripts. Overall, 923/1,555 (59%) authors were identified as POC, with a significantly lower proportion of POC authors among accepted vs rejected manuscripts (41%, 188/461 vs 67%, 735/1,094; difference, -26%; 95% CI, -32 to -21; P < 0.001). We did not observe significant trends in the proportion of women and POC authors over the study period. CONCLUSION The proportion of women authors of COVID-19 manuscripts was lower than men's representation. Further research is required to determine the factors that account for the higher proportion of POC authors across rejected manuscripts.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alana M Flexman
- Department of Anesthesia and the Centre for Health Evaluation and Outcomes, St. Paul's Hospital/Providence Health Care, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
| | - Gianni R Lorello
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto Western Hospital, Toronto, ON, Canada
- The Wilson Centre, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Mount Sinai Hospital, 600 University Ave, Suite 18-216, Toronto, ON, M5G 1X5, Canada.
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Flexman AM, Mehta S. Equity, Diversity, and Inclusion in anesthesiology and critical care: a time for reflection, acknowledgement, and change. Can J Anaesth 2023; 70:930-935. [PMID: 37165122 PMCID: PMC10171147 DOI: 10.1007/s12630-023-02446-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 05/12/2023] Open
Affiliation(s)
- Alana M Flexman
- Department of Anesthesia, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Centre for Health Evaluation and Outcomes, St. Paul's Hospital/Providence Health Care, Vancouver, BC, Canada.
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada.
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Sharda S, Butler K, Al Mandhari M, Mehta S. Microaggressions in anesthesiology and critical care: individual and institutional approaches to change. Can J Anaesth 2023; 70:1026-1034. [PMID: 37268799 DOI: 10.1007/s12630-023-02459-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/04/2023] Open
Abstract
Microaggressions are subtle verbal or nonverbal insults that convey derogatory and negative messages to and about people who belong to oppressed groups. Microaggressions reflect structurally and historically perpetuated societal values, which advantage some groups of people by considering them to be inherently more worthy than others, while simultaneously disadvantaging others. While microaggressions may seem innocuous and are often unintentional, they cause tangible harm. Microaggressions are commonly experienced by physicians and learners working in perioperative and critical care contexts and are often not adequately addressed, for a multitude of reasons, including witnesses not knowing how to respond. In this narrative review, we provide examples of microaggressions towards physicians and learners working in anesthesia and critical care, and offer individual and institutional approaches to managing such incidents. Concepts of privilege and power are introduced to ground interpersonal interventions within the larger context of systemic discrimination, and to encourage anesthesia and critical care physicians to contribute to systemic solutions.
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Affiliation(s)
- Saroo Sharda
- Department of Anesthesia, Faculty of Health Sciences, McMaster University, 1280 Main St. W., Hamilton, ON, L8S 4L8, Canada.
| | - Kat Butler
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Maha Al Mandhari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health, Toronto, ON, Canada
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Li Y, Fiest K, Burns KEA, O'Hearn K, Maratta C, Menon K, Rochwerg B, Murthy S, Fowler R, Mehta S. Addressing health care inequities in Canadian critical care through inclusive science: a pilot tool for standardized data collection. Can J Anaesth 2023; 70:963-967. [PMID: 37165123 DOI: 10.1007/s12630-023-02450-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 05/12/2023] Open
Abstract
PURPOSE Sociodemographic risks contributing to health inequities are often inadequately captured and reported in critical care studies. To address the lack of standardized terms and definitions, we sought to develop a practical and convenient resource of questions and response options for collecting sociodemographic variables for critical care research. SOURCE To identify domains and variables that impact health equity, we searched: 1) PubMed for critical care randomized trials (2010 to 2021); 2) high-impact critical care and general medicine journals for special issues relating to equity; and 3) governmental and nongovernmental resources. PRINCIPAL FINDINGS We identified 23 domains associated with health equity, including pronouns, age, sex, gender identity, sexual orientation, race and ethnicity, visible minorities, language, household income, marital/relationship status, education, disabilities, immigrant and refugee status, employment, primary care access, expanded health insurance, internet access, housing security, food security, dependents, religion, and postal code. For each domain we provided standardized questions and response options; for 13/23 domains, we included more than one version of the question and response categories. CONCLUSION We developed a standardized, practical, and convenient demographic data collection tool for critical care research studies. Questions and response options can be adapted by researchers for inclusion in individual study questionnaires or case report forms.
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Affiliation(s)
- Yiyan Li
- Canadian Critical Care Trials Group, University of Toronto, Toronto, ON, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Karen E A Burns
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Christina Maratta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Kusum Menon
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Bram Rochwerg
- Juravinski Hospital, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Rob Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, Sinai Health System, 600 University Ave., Suite 18-216, Toronto, ON, M5G 1X5, Canada.
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Benguerfi S, Dumas G, Soares M, Meert AP, Martin-Loeches I, Pene F, Bauer P, Mehta S, Metaxa V, Burghi G, Kouatchet A, Montini L, Mokart D, Van de Louw A, Azoulay E, Lemiale V. Etiologies and Outcome of Patients with Solid Tumors Admitted to ICU with Acute Respiratory Failure: A Secondary Analysis of the EFRAIM Study. Respir Care 2023; 68:740-748. [PMID: 37072164 DOI: 10.4187/respcare.10604] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Acute respiratory failure (ARF) remains the most frequent reason for ICU admission in patients who are immunocompromised. This study reports etiologies and outcomes of ARF in subjects with solid tumors. METHODS This study was a post hoc analysis of the EFRAIM study, a prospective multinational cohort study that included 1611 subjects who were immunocompromised and with ARF admitted to the ICU. Subjects with solid tumors admitted to the ICU with ARF were included in the analysis. RESULTS Among the subjects from the EFRAIM cohort, 529 subjects with solid tumors (32.8%) were included in the analysis. At ICU admission, the median (interquartile range) Sequential Organ Failure Assessment score was 5 (3-9). The types of solid tumor were mostly lung cancer (n = 111, 21%), breast cancer (n = 52, 9.8%), and digestive cancer (n = 47, 8.9%). A majority, 379 subjects (71.6%) were full code at ICU admission. The ARF was caused by bacterial or viral infection (n = 220, 41.6%), extrapulmonary sepsis (n = 62, 11.7%), or related to cancer or treatment toxicity (n = 83, 15.7%), or fungal infection (n = 23, 4.3%). For 63 subjects (11.9%), the ARF etiology remained unknown after an extensive diagnostic workup. The hospital mortality rate was 45.7% (n = 232/508). Hospital mortality was independently associated with chronic cardiac failure (odds ratio 1.78, 95% CI 1.09-2.92; P = .02), lung cancer (odds ratio 2.50, 95% CI 1.51-4.19; P < .001), day 1 Sequential Organ Failure Assessment score (odds ratio 1.97, 95% CI 1.32-2.96; P < .001). ARF etiologies other than infectious, related to cancer, or treatment toxicity were associated with better outcomes (odds ratio 0.32, 95% CI 0.16-0.61; P < .001). CONCLUSIONS Infectious diseases remained the most frequent cause of ARF in subjects with solid tumors admitted to the ICU. Hospital mortality was related to severity at ICU admission, previous comorbidities, and ARF etiologies related to non-malignant causes or pulmonary embolism. Lung tumor was also independently associated with higher mortality.
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Affiliation(s)
- Soraya Benguerfi
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France.
| | - Guillaume Dumas
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduaçãoem Clínica Médica, Rio De Janeiro, Brazil
| | - Anne-Pascale Meert
- Internal Medicine Service, Soins Intensifs & Urgences Oncologique, Institut Jules Bordet, Brussels, Belgium
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland
| | - Frederic Pene
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and Paris Descartes University, Paris, France
| | - Philippe Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gaston Burghi
- Terapia Intensiva, Hospital Maciel, Montevideo, Uruguay
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France
| | - Luca Montini
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Djamel Mokart
- Multipurpose Resuscitation Service and Department of Anesthesia and Resuscitation, Institut Paoli-Calmettes, Marseille, France
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Elie Azoulay
- Department of Intensive-Resuscitation Medicine, APHP, Hôpital Saint-Louis, Paris Diderot Sorbonne Université, Paris, France
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Guttormson JL, Khan B, Brodsky MB, Chlan LL, Curley MAQ, Gélinas C, Happ MB, Herridge M, Hess D, Hetland B, Hopkins RO, Hosey MM, Hosie A, Lodolo AC, McAndrew NS, Mehta S, Misak C, Pisani MA, van den Boogaard M, Wang S. Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:491-498. [PMID: 37000144 PMCID: PMC10112406 DOI: 10.1513/annalsats.202301-023st] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Mechanically ventilated patients experience many adverse symptoms, such as anxiety, thirst, and dyspnea. However, these common symptoms are not included in practice guideline recommendations for routine assessment of mechanically ventilated patients. An American Thoracic Society-sponsored workshop with researchers and clinicians with expertise in critical care and symptom management was convened for a discussion of symptom assessment in mechanically ventilated patients. Members included nurses, physicians, a respiratory therapist, a speech-language pathologist, a critical care pharmacist, and a former intensive care unit patient. This report summarizes existing evidence and consensus among workshop participants regarding 1) symptoms that should be considered for routine assessment of adult patients receiving mechanical ventilation; 2) key symptom assessment principles; 3) strategies that support symptom assessment in nonvocal patients; and 4) areas for future clinical practice development and research. Systematic patient-centered assessment of multiple symptoms has great potential to minimize patient distress and improve the patient experience. A culture shift is necessary to promote ongoing holistic symptom assessment with valid and reliable instruments. This report represents our workgroup consensus on symptom assessment for mechanically ventilated patients. Future work should address how holistic, patient-centered symptom assessment can be embedded into clinical practice.
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Alostaz Z, Rose L, Mehta S, Johnston L, Dale C. Physical restraint practices in an adult intensive care unit: A prospective observational study. J Clin Nurs 2023; 32:1163-1172. [PMID: 35194883 DOI: 10.1111/jocn.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
AIM AND OBJECTIVES To conduct a diagnostic evaluation of physical restraint practice using the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. BACKGROUND Evidence indicates that physical restraints are associated with adverse physical, emotional and psychological sequelae and do not consistently prevent intensive care unit (ICU) patient-initiated device removal. Nevertheless, physical restraints continue to be used extensively in ICUs both in Canada and internationally. Implementation science frameworks have not been previously used to diagnose, develop and guide the implementation of restraint minimisation interventions. DESIGN A prospective observational study of restrained patients in a 20-bed, academic ICU in Toronto, Canada. METHODS Data collection methods included patient observation, electronic medical record review, and verbal check with the point-of-care nurses. Data were collected pertaining to framework domains of unit culture (restraint application/removal), evaluation capacity (documentation) and leadership (rounds discussion). The reporting of this study followed the STROBE guidelines. RESULTS A total of 102 restrained patients, 67 (66%) male and mean age 58 years (SD 1.92), were observed. All observed devices were wrist restraints. Restraint application and removal time was verified in 83 and 57 of 102 patients respectively. At application, 96.4% were mechanically ventilated and 71% sedated/unarousable. Nurses confirmed 71% were prophylactically restrained; 7.2% received restraint alternatives. Restraint removal occurred after interprofessional team rounds (87%), during daytime (79%) and following extubation (52.6%). Of the 923 discrete patient observation of physical restraint use, 691 (75%) were not documented. Of the 30 daytime interprofessional team rounds reviewed, physical restraint was discussed at 3 (10%). CONCLUSION In this single-centre study, a culture of prophylactic physical restraint was observed. Future facilitation of restraint minimisation warrants theoretically informed implementation strategies including leadership involvement to advance interprofessional collaboration. RELEVANCE TO CLINICAL PRACTICE The findings draw attention to the importance of a preliminary diagnostic study of the context prior to designing, and implementing, a physical restraint minimisation intervention.
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Affiliation(s)
- Ziad Alostaz
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Canada
| | - Linda Johnston
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada
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Al-Dorzi HM, AlQahtani S, Al-Dawood A, Al-Hameed FM, Burns KEA, Mehta S, Jose J, Alsolamy SJ, Abdukahil SAI, Afesh LY, Alshahrani MS, Mandourah Y, Almekhlafi GA, Almaani M, Al Bshabshe A, Finfer S, Arshad Z, Khalid I, Mehta Y, Gaur A, Hawa H, Buscher H, Lababidi H, Al Aithan A, Arabi YM. Association of early mobility with the incidence of deep-vein thrombosis and mortality among critically ill patients: a post hoc analysis of PREVENT trial. Crit Care 2023; 27:83. [PMID: 36869382 PMCID: PMC9985278 DOI: 10.1186/s13054-023-04333-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/24/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND This study assessed the mobility levels among critically ill patients and the association of early mobility with incident proximal lower-limb deep-vein thrombosis and 90-day mortality. METHODS This was a post hoc analysis of the multicenter PREVENT trial, which evaluated adjunctive intermittent pneumatic compression in critically ill patients receiving pharmacologic thromboprophylaxis with an expected ICU stay ≥ 72 h and found no effect on the primary outcome of incident proximal lower-limb deep-vein thrombosis. Mobility levels were documented daily up to day 28 in the ICU using a tool with an 8-point ordinal scale. We categorized patients according to mobility levels within the first 3 ICU days into three groups: early mobility level 4-7 (at least active standing), 1-3 (passive transfer from bed to chair or active sitting), and 0 (passive range of motion). We evaluated the association of early mobility and incident lower-limb deep-vein thrombosis and 90-day mortality by Cox proportional models adjusting for randomization and other co-variables. RESULTS Of 1708 patients, only 85 (5.0%) had early mobility level 4-7 and 356 (20.8%) level 1-3, while 1267 (74.2%) had early mobility level 0. Patients with early mobility levels 4-7 and 1-3 had less illness severity, femoral central venous catheters, and organ support compared to patients with mobility level 0. Incident proximal lower-limb deep-vein thrombosis occurred in 1/85 (1.3%) patients in the early mobility 4-7 group, 7/348 (2.0%) patients in mobility 1-3 group, and 50/1230 (4.1%) patients in mobility 0 group. Compared with early mobility group 0, mobility groups 4-7 and 1-3 were not associated with differences in incident proximal lower-limb deep-vein thrombosis (adjusted hazard ratio [aHR] 1.19, 95% confidence interval [CI] 0.16, 8.90; p = 0.87 and 0.91, 95% CI 0.39, 2.12; p = 0.83, respectively). However, early mobility groups 4-7 and 1-3 had lower 90-day mortality (aHR 0.47, 95% CI 0.22, 1.01; p = 0.052, and 0.43, 95% CI 0.30, 0.62; p < 0.0001, respectively). CONCLUSIONS Only a small proportion of critically ill patients with an expected ICU stay ≥ 72 h were mobilized early. Early mobility was associated with reduced mortality, but not with different incidence of deep-vein thrombosis. This association does not establish causality, and randomized controlled trials are required to assess whether and to what extent this association is modifiable. TRIAL REGISTRATION The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103 (registered on 3 November 2013) and Current controlled trials, ID: ISRCTN44653506 (registered on 30 October 2013).
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Affiliation(s)
- Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Samah AlQahtani
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Al-Dawood
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Fahad M Al-Hameed
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Kingdom of Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Unity Health Toronto - St Michael's Hospital, Toronto, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Sangeeta Mehta
- Department of Medicine, University of Toronto, Toronto, Canada.,Medical Surgical ICU, Sinai Health, Toronto, Canada
| | - Jesna Jose
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Sami J Alsolamy
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Sheryl Ann I Abdukahil
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Lara Y Afesh
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Yasser Mandourah
- Military Medical Services, Ministry of Defense, Riyadh, Kingdom of Saudi Arabia
| | - Ghaleb A Almekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Almaani
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Ali Al Bshabshe
- Department of Critical Care Medicine, King Khalid University, Asir Central Hospital, Abha, Kingdom of Saudi Arabia
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Zia Arshad
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, India
| | - Imran Khalid
- Critical Care Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Kingdom of Saudi Arabia
| | - Yatin Mehta
- Institute of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Atul Gaur
- Intensive Care Department, Gosford Hospital, Gosford, NSW, Australia
| | - Hassan Hawa
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center for Applied Medical Research, St. Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Hani Lababidi
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdulsalam Al Aithan
- Intensive Care Division, Department of Medicine, King Abdulaziz Hospital, Ministry of National Guard Health Affairs, Al Ahsa, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center , Al Ahsa, Kingdom of Saudi Arabia
| | - Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia. .,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.
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Parsons Leigh J, Mizen SJ, Moss SJ, Brundin-Mather R, de Grood C, Dodds A, Honarmand K, Shah S, Mehta S. A qualitative descriptive study of the impact of the COVID-19 pandemic on staff in a Canadian intensive care unit. Can J Anaesth 2023; 70:384-394. [PMID: 36627462 PMCID: PMC9831684 DOI: 10.1007/s12630-022-02377-z] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 07/19/2022] [Accepted: 09/20/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE We sought to explore the lived experiences of a professionally diverse sample of healthcare workers (HCWs) in a single intensive care unit (ICU) serving a large and generalizable Canadian population. We aimed to understand how working during the COVID-19 pandemic affected their professional and personal lives, including their perceptions of institutional support, to inform interventions to ameliorate impacts of the COVID-19 and future pandemics. METHODS In this qualitative descriptive study, 23 ICU HCWs, identified using convenience purposive sampling, took part in individual semistructured interviews between July and November 2020, shortly after the first wave of the pandemic in Ontario. We used inductive thematic analysis to identify major themes. RESULTS We identified five major themes related to the COVID-19 pandemic: 1) communication and informational needs (e.g., challenges communicating policy changes); 2) adjusting to restricted visitation (e.g., spending less time interacting with patients); 3) staffing and workplace supports (e.g., importance of positive team dynamics); 4) permeability of professional and personal lives (e.g., balancing shift work and childcare); and 5) a dynamic COVID-19 landscape (e.g., coping with constant change). The COVID-19 pandemic contributed to HCWs in the ICU experiencing varied negative repercussions on their work environment, including staffing and institutional support, which carried into their personal lives. CONCLUSION Healthcare workers in the ICU perceived that the COVID-19 pandemic had negative repercussions on their work environment, including staffing and institutional support, as well as their professional and personal lives. Understanding both the negative and positive experiences of all ICU HCWs working during the COVID-19 pandemic is critical to future pandemic preparedness. Their perspectives will help to inform the development of mental health and wellbeing interventions to support staff during the COVID-19 pandemic and beyond.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, Second Floor, 2A01, Office 2A08, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Sara J Mizen
- School of Health Administration, Dalhousie University, Halifax, NS, Canada
| | - Stephana Julia Moss
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA, USA
- School of Health Administration, Dalhousie University, Halifax, NS, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Chloe de Grood
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Alexandra Dodds
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Sumesh Shah
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Carmain M, Mehta S, Dalal S, Lundsberg L, St. Martin B, Harmanli O. The effect of an educational video on patient adherence and completeness of intake and voiding diaries: a randomized control trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.12.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Yarnell CJ, Angriman F, Ferreyro BL, Liu K, De Grooth HJ, Burry L, Munshi L, Mehta S, Celi L, Elbers P, Thoral P, Brochard L, Wunsch H, Fowler RA, Sung L, Tomlinson G. Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts. Crit Care 2023; 27:67. [PMID: 36814287 PMCID: PMC9944781 DOI: 10.1186/s13054-023-04307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation. METHODS This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008-2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003-2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation. RESULTS We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8). CONCLUSION Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.
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Affiliation(s)
- Christopher J. Yarnell
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Federico Angriman
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Bruno L. Ferreyro
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Kuan Liu
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Harm Jan De Grooth
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lisa Burry
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.492573.e0000 0004 6477 6457Department of Pharmacy and Medicine, Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON Canada
| | - Laveena Munshi
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Sangeeta Mehta
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.231844.80000 0004 0474 0428Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Leo Celi
- grid.116068.80000 0001 2341 2786Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142 USA ,grid.239395.70000 0000 9011 8547Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215 USA ,grid.38142.3c000000041936754XDepartment of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Paul Elbers
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick Thoral
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laurent Brochard
- grid.415502.7Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hannah Wunsch
- grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert A. Fowler
- grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, Toronto, Canada ,grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.413104.30000 0000 9743 1587Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lillian Sung
- grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.42327.300000 0004 0473 9646Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - George Tomlinson
- grid.231844.80000 0004 0474 0428Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Medical-Surgical ICU, 10th floor, 585 University Avenue, Toronto, ON M5G 1X5 Canada
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Manimaran P, Shah R, Trivedi P, Mehta S. Primary cutaneous neuroendocrine tumor with axillary lymph node metastasis: A clinical masquerade. J Postgrad Med 2023; 69:118-119. [PMID: 36751760 DOI: 10.4103/jpgm.jpgm_254_22] [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: 02/07/2023] Open
Affiliation(s)
- P Manimaran
- Department of Oncopathology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India
| | - R Shah
- Department of Oncopathology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India
| | - P Trivedi
- Department of Oncopathology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India
| | - S Mehta
- Department of Oncopathology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India
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Mehta S, Boyer TL, Akhtar S, He T, Zhang C, Vedadghavami A, Bajpayee AG. Sustained intra-cartilage delivery of interleukin-1 receptor antagonist using cationic peptide and protein-based carriers. Osteoarthritis Cartilage 2023; 31:780-792. [PMID: 36739939 PMCID: PMC10392024 DOI: 10.1016/j.joca.2023.01.573] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/20/2022] [Accepted: 01/17/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Blocking the interleukin-1 (IL-1) catabolic cascade following joint trauma can be achieved using its receptor antagonist, IL-1Ra. However, its clinical translation for osteoarthritis therapy has been unsuccessful due to its rapid joint clearance and lack of targeting and penetration into deep cartilage layers at therapeutic concentrations. Here, we target the high negative charge of cartilage aggrecan-glycosaminoglycans (GAGs) by attaching cationic carriers to IL-1Ra. IL-1Ra was conjugated to the cartilage targeting glycoprotein, Avidin, and a short length optimally charged cationic peptide carrier (CPC+14). It is hypothesized that electro-diffusive transport and binding properties of IL-1Ra-Avidin and IL-1Ra-CPC+14 will create intra-cartilage depots of IL-1Ra, resulting in long-term suppression of IL-1 catabolism with only a single administration. DESIGN IL-1Ra was conjugated to Avidin or CPC+14 using site specific maleimide linkers, and confirmed using gel electrophoresis, high-performance liquid chromatography (HPLC), and mass spectrometry. Intra-cartilage transport and retention of conjugates was compared with native IL-1Ra. Attenuation of IL-1 catabolic signaling with one-time dose of IL-1Ra-CPC+14 and IL-1Ra-Avidin was assessed over 16 days using IL-1α challenged bovine cartilage and compared with unmodified IL-1Ra. RESULTS Positively charged IL-1Ra penetrated through the full-thickness of cartilage, creating a drug depot. A single dose of unmodified IL-1Ra was not sufficient to attenuate IL-1-induced cartilage deterioration over 16 days. However, when delivered using Avidin, and to a greater extent CPC+14, IL-1Ra significantly suppressed cytokine induced GAG loss and nitrite release while improving cell metabolism and viability. CONCLUSION Charge-based cartilage targeting drug delivery systems hold promise as they can enable long-term therapeutic benefit with only a single dose.
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Affiliation(s)
- S Mehta
- Department of Bioengineering, Northeastern University, Boston, MA, USA.
| | - T L Boyer
- Department of Bioengineering, Northeastern University, Boston, MA, USA.
| | - S Akhtar
- Department of Biochemistry, Northeastern University, Boston, MA, USA.
| | - T He
- Department of Bioengineering, Northeastern University, Boston, MA, USA.
| | - C Zhang
- Department of Bioengineering, Northeastern University, Boston, MA, USA.
| | - A Vedadghavami
- Department of Bioengineering, Northeastern University, Boston, MA, USA.
| | - A G Bajpayee
- Department of Bioengineering, Northeastern University, Boston, MA, USA; Department of Mechanical Engineering, Northeastern University, Boston, MA, USA.
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Kundu R, Seeger R, Elfassy MD, Rozenberg D, Ahluwalia N, Detsky ME, Ferreyro BL, Mehta S, Law AD, Minden M, Prica A, Sklar M, Munshi L. The association between nutritional risk index and ICU outcomes across hematologic malignancy patients with acute respiratory failure. Ann Hematol 2023; 102:439-445. [PMID: 36542101 DOI: 10.1007/s00277-022-05064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51-68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9-14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79-99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2-7). Mortality across those at severe malnutrition (NRI < 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04-5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure.
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Affiliation(s)
- Riddhi Kundu
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Rena Seeger
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Michael D Elfassy
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Dmitry Rozenberg
- Division of Respirology, Temerty Faculty of Medicine, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Canada
| | - Nanki Ahluwalia
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Michael E Detsky
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Arjun Datt Law
- Division of Medical Oncology/Hematology, Department of Medicine, Malignant HematologyPrincess Margaret Cancer Center, Toronto, Canada
| | - Mark Minden
- Division of Medical Oncology/Hematology, Department of Medicine, Malignant HematologyPrincess Margaret Cancer Center, Toronto, Canada
| | - Anca Prica
- Division of Medical Oncology/Hematology, Department of Medicine, Malignant HematologyPrincess Margaret Cancer Center, Toronto, Canada
| | - Michael Sklar
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital/University Health Network, University of Toronto, 600 University Avenue, 18-206, Toronto, ON, M5G 1X5, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Yarnell CJ, Johnson A, Dam T, Jonkman A, Liu K, Wunsch H, Brochard L, Celi LA, De Grooth HJ, Elbers P, Mehta S, Munshi L, Fowler RA, Sung L, Tomlinson G. Do Thresholds for Invasive Ventilation in Hypoxemic Respiratory Failure Exist? A Cohort Study. Am J Respir Crit Care Med 2023; 207:271-282. [PMID: 36150166 DOI: 10.1164/rccm.202206-1092oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 02/03/2023] Open
Abstract
Rationale: Invasive ventilation is a significant event for patients with respiratory failure. Physiologic thresholds standardize the use of invasive ventilation in clinical trials, but it is unknown whether thresholds prompt invasive ventilation in clinical practice. Objectives: To measure, in patients with hypoxemic respiratory failure, the probability of invasive ventilation within 3 hours after meeting physiologic thresholds. Methods: We studied patients admitted to intensive care receiving FiO2 of 0.4 or more via nonrebreather mask, noninvasive positive pressure ventilation, or high-flow nasal cannula, using data from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019) and the Amsterdam University Medical Centers Database (AmsterdamUMCdb) (2003-2016). We evaluated 17 thresholds, including the ratio of arterial to inspired oxygen, the ratio of saturation to inspired oxygen ratio, composite scores, and criteria from randomized trials. We report the probability of invasive ventilation within 3 hours of meeting each threshold and its association with covariates using odds ratios (ORs) and 95% credible intervals (CrIs). Measurements and Main Results: We studied 4,726 patients (3,365 from MIMIC, 1,361 from AmsterdamUMCdb). Invasive ventilation occurred in 28% (1,320). In MIMIC, the highest probability of invasive ventilation within 3 hours of meeting a threshold was 20%, after meeting prespecified neurologic or respiratory criteria while on vasopressors, and 19%, after a ratio of arterial to inspired oxygen of <80 mm Hg. In AmsterdamUMCdb, the highest probability was 34%, after vasopressor initiation, and 25%, after a ratio of saturation to inspired oxygen of <90. The probability after meeting the threshold from randomized trials was 9% (MIMIC) and 13% (AmsterdamUMCdb). In MIMIC, a race/ethnicity of Black (OR, 0.75; 95% CrI, 0.57-0.96) or Asian (OR, 0.6; 95% CrI, 0.35-0.95) compared with White was associated with decreased probability of invasive ventilation after meeting a threshold. Conclusions: The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was low and associated with patient race/ethnicity.
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Affiliation(s)
- Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Division of Respirology
| | | | - Tariq Dam
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation, and
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts; and
| | - Harm-Jan De Grooth
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Paul Elbers
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lillian Sung
- Institute of Health Policy, Management and Evaluation, and.,Division of Haematology/Oncology
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
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Burns KEA, Moss M, Lorens E, Jose EKA, Martin CM, Viglianti EM, Fox-Robichaud A, Mathews KS, Akgun K, Jain S, Gershengorn H, Mehta S, Han JE, Martin GS, Liebler JM, Stapleton RD, Trachuk P, Vranas KC, Chua A, Herridge MS, Tsang JLY, Biehl M, Burnham EL, Chen JT, Attia EF, Mohamed A, Harkins MS, Soriano SM, Maddux A, West JC, Badke AR, Bagshaw SM, Binnie A, Carlos WG, Çoruh B, Crothers K, D'Aragon F, Denson JL, Drover JW, Eschun G, Geagea A, Griesdale D, Hadler R, Hancock J, Hasmatali J, Kaul B, Kerlin MP, Kohn R, Kutsogiannis DJ, Matson SM, Morris PE, Paunovic B, Peltan ID, Piquette D, Pirzadeh M, Pulchan K, Schnapp LM, Sessler CN, Smith H, Sy E, Thirugnanam S, McDonald RK, McPherson KA, Kraft M, Spiegel M, Dodek PM. Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. Crit Care Med 2022; 50:1689-1700. [PMID: 36300945 PMCID: PMC9668381 DOI: 10.1097/ccm.0000000000005674] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN Cross-sectional survey using four validated instruments. SETTING Sixty-two sites in Canada and the United States. SUBJECTS Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.
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Affiliation(s)
- Karen E A Burns
- Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marc Moss
- University of Colorado - Anschutz Medical Campus and Children's Hospital of Colorado, Aurora, CO
| | - Edmund Lorens
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Claudio M Martin
- Division of Critical Care, London Health Sciences, London Health Sciences Centre, London, ON, Canada
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Alison Fox-Robichaud
- Division of Critical Care, McMaster University, Department of Medicine, Hamilton, ON, Canada
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kathleen Akgun
- Section of Pulmonary, Critical Care & Sleep Medicine, VA Connecticut Healthcare System, West Haven, CT
| | - Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Hayley Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Sangeeta Mehta
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Sinai Health, Toronto, ON, Canada
| | - Jenny E Han
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Gregory S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Janice M Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Polina Trachuk
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, New York University Langone Health, New York, NY
| | - Kelly C Vranas
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | | | - Margaret S Herridge
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | | | - Michelle Biehl
- Departments of Critical Care Medicine and Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Bronx, NY
| | - Jen-Ting Chen
- Harborview Medical Center, University of Washington, Seattle, WA
| | - Engi F Attia
- Division of Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Amira Mohamed
- Division of Pulmonary, Critical Care and Sleep, Department of Internal Medicine, Montefiore Medical Center, Bronx, NY
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of New Mexico, Albuquerque, NM
| | - Sheryll M Soriano
- OSF Medical Group Pulmonary and Critical Care Division, Order of St Francis (OSF) Healthcare, Peoria, IL
| | - Aline Maddux
- University of Colorado - Anschutz Medical Campus and Children's Hospital of Colorado, Aurora, CO
| | - Julia C West
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andrew R Badke
- Pulmonary and Critical Care, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexandra Binnie
- Department of Critical Care Medicine at William Osler Health System, William Osler Health System, Toronto, ON, Canada
| | - W Graham Carlos
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Puget Sound Health Care, Seattle, WA
| | - Frederick D'Aragon
- Department of Anesthesia, University de Sherbrooke, Sherbrooke, QC, Canada
| | - Joshua Lee Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - John W Drover
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Gregg Eschun
- Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada
| | - Anna Geagea
- Division of Critical Care, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia. Vancouver, BC, Canada
| | - Rachel Hadler
- Department of Anesthesia, University of Iowa Hospital and Clinics, Iowa City, IA
| | | | - Jovan Hasmatali
- Department of Critical Care, Health Sciences Centre, Winnipeg, MB, Canada
| | - Bhavika Kaul
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Meeta Prasad Kerlin
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Rachel Kohn
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D James Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scott M Matson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Bojan Paunovic
- Department of Internal Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ithan D Peltan
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, Intermountain Healthcare, Salt Lake City, UT
| | - Dominique Piquette
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mina Pirzadeh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Krishna Pulchan
- Division of Critical Care Medicine, Horizon Health Network, Fredericton, NB, Canada
| | - Lynn M Schnapp
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Curtis N Sessler
- Department of Medicine, Section of Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | | | - Eric Sy
- Regina General Hospital, Regina, SK, Canada
| | | | | | - Katie A McPherson
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Monica Kraft
- University of Arizona College of Medicine, Tucson, AZ
| | - Michelle Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC
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Vassantachart A, Ballas L, Bian S, Lock D, Jang J, Fossum C, Han H, Mehta S, Cheng K, Miller K, Stal J, Ragab O. Do Patients Understand Radiation Therapy? Radiation Oncology Knowledge Assessment and Health Literacy among Culturally Diverse Breast Cancer Patients at a Safety-Net Hospital. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Mehta S, Liu K, Vassantachart A, Tamrazi B, Lee N, Sianto K, Olch A, Wong K. Incidence and Dosimetric Parameters of Brainstem Toxicity in Pediatric Patients after Photon Irradiation for Posterior Fossa Tumors. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Lock D, Vassantachart A, Mehta S, Cui J, Gallogly A, Jennelle R, Hong D. A Structural Solution for Task Management in a Resident-Directed, Team-Based Radiotherapy Clinic. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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46
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Mehta S, Vieira D, Guillen V, Zerpa D, Quintana A, Sanchez C, Ozair S, Brena-Pastor L, Pinos D, Fleming M, Carrera K, Rossitto F, Martinez F, Gonzalez A, Rodriguez K. Artificial intelligence-guided, single-lead EKG may be a game-changer for symptom-to-balloon time reduction in ST-elevated myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1170] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Over decades, efforts to shave off life-saving minutes from ST-Elevated Myocardial Infarction (STEMI) care centred on reducing door-to-needle and door-to-balloon times. We firmly believe that symptom-to-balloon time should prove a better focus to this end. Challenges come with this goal as it heavily relies on a patient's perception and initiative to seek care, which we deem intelligent and wearable Artificial Intelligence (AI)-driven Single Lead EKG technologies as an attractive solution in modern-day cardiology.
Purpose
To provide an accurate, accessible, and cost-effective AI-driven Single Lead STEMI detection algorithm that can be embedded into wearable devices and employed in a self-administered fashion.
Methods
Database: EKG records from Mexico, Colombia, Argentina, and Brazil from April 2014 to December 2019. Dataset: A total of 11,567 12-lead EKG records of 10[s] length with a sampling frequency of 500 Hz, including the following balanced classes: angiographically confirmed and unconfirmed STEMI, branch blocks, non-specific ST-T abnormalities, normal and abnormal (200+ CPT codes, excluding those mentioned above). Cardiologists manually checked the label of each record to ensure precision. Pre-processing: We discard the first and last 250 samples as they may contain a standardisation pulse. The study applied a digital low pass filter of order 5 with a frequency cut-off of 35 Hz. The mean was subtracted from each Lead. Classification: The determined classes were “STEMI” (Including STEMI in different locations of the myocardium – anterior, inferior, and lateral); and “Not-STEMI” (Combination of randomly sample, branch blocks, non-specific ST-T changes, and abnormal records – 25% of each). Training and Testing: A 1-D Convolutional Neural Network was trained and tested with a dataset proportion of 90/10, respectively. A different model was trained and tested for each Lead, using the central 4,500 samples of the records. The last dense layer outputs a probability for each report of being STEMI or Not-STEMI. Lead V2 showed the best overall results. The model was further tested through the same methodology using the best Lead with a subset of the previous data, excluding the unconfirmed STEMI EKG records (Total 7,230 12-lead EKG records for Confirmed Only STEMI dataset). Performance metrics were reported for each experiment and compared.
Results
Combined STEMI data: Accuracy: 91.2%; Sensitivity: 89.6%; Specificity: 92.9%. Confirmed STEMI Only dataset: Accuracy: 92.4%; Sensitivity: 93.4%; Specificity: 91.4% (Figure 1).
Conclusion
By assiduously improving the quality of the model's input, we continue to assess our algorithm's performance and reliability for future clinical validation as a potential remote monitoring and early STEMI detection device.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Mehta
- Lumen Foundation , Miami , United States of America
| | - D Vieira
- Lumen Foundation , Miami , United States of America
| | - V Guillen
- Lumen Foundation , Miami , United States of America
| | - D Zerpa
- Lumen Foundation , Miami , United States of America
| | - A Quintana
- Lumen Foundation , Miami , United States of America
| | - C Sanchez
- Lumen Foundation , Miami , United States of America
| | - S Ozair
- Lumen Foundation , Miami , United States of America
| | | | - D Pinos
- Lumen Foundation , Miami , United States of America
| | - M Fleming
- Lumen Foundation , Miami , United States of America
| | - K Carrera
- Lumen Foundation , Miami , United States of America
| | - F Rossitto
- Lumen Foundation , Miami , United States of America
| | - F Martinez
- Lumen Foundation , Miami , United States of America
| | - A Gonzalez
- Lumen Foundation , Miami , United States of America
| | - K Rodriguez
- Lumen Foundation , Miami , United States of America
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Bunting KV, Mehta S, Gill SK, Steeds RP, Kotecha D. Digoxin improves systolic cardiac function in patients with AF and HFpEF: the RATE-AF randomised trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.793] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The RAte control Therapy Evaluation in permanent AF trial (RATE-AF; NCT02391337) was the first head-to-head controlled trial of beta-blockers versus digoxin in patients with permanent atrial fibrillation (AF) and symptoms of heart failure. Patients randomised to digoxin had similar physical-related quality of life and heart rate, with significantly improved functional class, reduced N-terminal pro-brain natriuretic peptide (NT-proBNP) and substantially less adverse events. The impact of rate control therapy on measures of cardiac function is not currently understood.
Purpose
To compare the effect of digoxin versus beta-blockers on systolic and diastolic cardiac function according to heart failure sub-type.
Methods
Blinded echocardiograms assessing systolic and diastolic function were performed at baseline and 12 month follow-up, using a robust method to account for rhythm irregularity (average of three index-beats acquired in appropriate cardiac cycles). Outcomes were the change in left-ventricular ejection fraction (LVEF), systolic tissue Doppler velocity (s'), stroke volume, global longitudinal strain (GLS), diastolic tissue Doppler (e'), mitral E wave deceleration time, E/e', pulmonary vein diastolic deceleration time, isovolumic relaxation time and left atrial ejection fraction. Analyses were stratified by baseline LVEF (≥50%, 40–50% and <40%).
Results
160 patients were randomised, of which 145 patients survived to 12-month follow-up with median age 75 years (IQR 69–82) and 44% women. Median baseline heart rate was 96 beats/min (IQR 86–112), blood pressure 135/85 mmHg (IQR 124/77–146/91), NTproBNP 1049 pg/mL (744–1463) and mean NYHA class 2.4 (SD 0.6). In 119 patients with LVEF ≥50% at baseline, diastolic and systolic parameters improved over time with digoxin therapy. There was a significantly greater improvement in systolic function in 63 patients on digoxin compared to 67 with beta-blockers; Figure 1. Patients randomised to digoxin had a higher LVEF at follow-up (adjusted mean difference [AMD] 2.3%, 95% CI 0.3–4.2; p=0.021), higher s' (1.1cm/s, 1.0–1.2; p=0.003) and higher stroke volume (6.5mL, 0.4–12.6; p=0.037) compared to beta-blockers, without any difference in diastolic parameters (Figure 2). In 16 patients with LVEF 40–50% at baseline, s' significantly increased with digoxin compared to beta-blockers (AMD 1.5 cm/s, 1.2–1.7; p=0.001), with no difference for other systolic or diastolic parameters. 10 patients with LVEF <40% at baseline showed no difference between digoxin and beta-blockers for any echocardiographic measures.
Conclusion
Patients randomised to digoxin with permanent AF, heart failure symptoms and preserved LVEF have significantly greater improvement in multiple parameters of systolic function compared to conventional treatment with beta-blockers.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Health Research
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Affiliation(s)
- K V Bunting
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - S Mehta
- University of Birmingham, Birmingham Clinical Trials Unit , Birmingham , United Kingdom
| | - S K Gill
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - R P Steeds
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - D Kotecha
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
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48
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Mehta S, Vieira D, Zerpa D, Guillen V, Gonzalez A, Brena-Pastor L, Siyam T, Stoica S, Ozair S, Pinos D, Martinez F, Fleming M, Carrera K, Rossitto F, Whuking C. Performance metrics of AI-enhanced single lead EKG maintained after entry of organised clustered data. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2786] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Our experience in creating innovative Artificial Intelligence-guided single lead EKG methodologies for ST-Elevation Myocardial Infarction (STEMI) detection within complex EKG records has been previously validated.
Purpose
By expanding the intricate variables of our previously tested algorithm input, we seek to further improve our STEMI detecting tool.
Methods
11,567 12-lead EKG records (10-s length, 500 Hz sample frequency) derived from the Latin America Telemedicine Infarct Network database from April 2014 to December 2019. From these records, we included the following balanced classes: angiographically confirmed and unconfirmed STEMI (divided by wall affected), branch blocks, non-specific ST-T changes, normal, and abnormal (Remaining 200+ CPT codes). Cardiologist annotations ensured precision (Ground truth). Determined classes were “STEMI” and “Not-STEMI”. A 1-D Convolutional Neural Network model was trained and tested for each lead with dataset proportions of 90/10, respectively. The last dense layer outputs a probability for each record being STEMI/Not-STEMI. The analysis also included performance metrics and false-negative reports.
Results
Overall, the most promising Single lead for STEMI detection was V2 (91.2% Accuracy, 89.6% Sensitivity, and 92.9% Specificity). 55% of false negatives were inferior wall STEMI (Table 1).
Conclusion
Appreciable progress of our new methodology compared to our previous experiences in AI-guided Single Lead for STEMI detection, especially for lead V2. By performing a thorough analysis of false-negative reports, we aspire to identify potential areas of STEMI detection weakness which will become the focus of future ventures.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Mehta
- Lumen Foundation , Miami , United States of America
| | - D Vieira
- Lumen Foundation , Miami , United States of America
| | - D Zerpa
- Lumen Foundation , Miami , United States of America
| | - V Guillen
- Lumen Foundation , Miami , United States of America
| | - A Gonzalez
- Lumen Foundation , Miami , United States of America
| | | | - T Siyam
- Lumen Foundation , Miami , United States of America
| | - S Stoica
- Lumen Foundation , Miami , United States of America
| | - S Ozair
- Lumen Foundation , Miami , United States of America
| | - D Pinos
- Lumen Foundation , Miami , United States of America
| | - F Martinez
- Lumen Foundation , Miami , United States of America
| | - M Fleming
- Lumen Foundation , Miami , United States of America
| | - K Carrera
- Lumen Foundation , Miami , United States of America
| | - F Rossitto
- Lumen Foundation , Miami , United States of America
| | - C Whuking
- Lumen Foundation , Miami , United States of America
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Mehta S, Vieira D, Zerpa D, Guillen V, Carrasquel M, Ramadan S, Martinez F, Rossitto F, Carrera K, Fleming M, Pinos D, Brena-Pastor L, Ozair S, Gonzalez A, Barco A. No need for a cardiologist for AMI diagnosis – progress of transforming a behemoth telemedicine program with artificial intelligence. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2251] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The Latin American Telemedicine Infarct Network (LATIN) Telemedicine is a mammoth hub and spoke model that provides an umbrella of AMI protection for 100 million patients. In the program, 826,043 patients had a telemedicine encounter; 7,400 with AMI were diagnosed; 4,332 of them managed with guidelines-based strategies. We have gradually begun implementing a system for using Artificial Intelligence (AI) algorithms embedded into EKGs for rapid and accurate STEMI detection and validated the results with a cardiologist's interpretations.
Purpose
To test whether an AI-driven EKG algorithm can effectively substitute a cardiologist for STEMI telemedicine protocols.
Methods
The AI algorithm construction was in the following fashion. Sample: a selection of 8,511 EKG and 90,592 classified heartbeats. Pre-processing: segmentation of each EKG into individual heartbeats. Training & testing: 90% and 10% of the total dataset, respectively. Classification: 1-D Convolutional Neural Network; the study constructed classes for each heartbeat. The algorithm was next deployed on a consecutive series of LATIN EKG records to diagnose STEMI. We afterwards compared the algorithm's results with eight expert cardiologists' interpretations of the same sample.
Results
This study achieved a concordance of 91% between the AI algorithm and cardiologist interpretation (Figure 1).
Conclusions
The initial results with AI algorithms for STEMI diagnosis are encouraging and may provide the base work for new tools for cardiologists to improve their efficiency. Moreover, implementing this innovative tool may overcome current limitations associated with the telemedical management of this disease.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Mehta
- Lumen Foundation , Miami , United States of America
| | - D Vieira
- Lumen Foundation , Miami , United States of America
| | - D Zerpa
- Lumen Foundation , Miami , United States of America
| | - V Guillen
- Lumen Foundation , Miami , United States of America
| | - M Carrasquel
- Lumen Foundation , Miami , United States of America
| | - S Ramadan
- Lumen Foundation , Miami , United States of America
| | - F Martinez
- Lumen Foundation , Miami , United States of America
| | - F Rossitto
- Lumen Foundation , Miami , United States of America
| | - K Carrera
- Lumen Foundation , Miami , United States of America
| | - M Fleming
- Lumen Foundation , Miami , United States of America
| | - D Pinos
- Lumen Foundation , Miami , United States of America
| | | | - S Ozair
- Lumen Foundation , Miami , United States of America
| | - A Gonzalez
- Lumen Foundation , Miami , United States of America
| | - A Barco
- Lumen Foundation , Miami , United States of America
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50
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Mendieta Badimon G, Mehta S, Baber U, Collier T, Dangas G, Sharma SK, Cohen DJ, Angiolillo D, Briguori C, Escaned J, Gabriel Steg P, Huber K, Michael Gibson C, Pocock S, Mehran R. Effect of aspirin discontinuation according to individualised patient bleeding and ischemic risks after PCI: a TWILIGHT trial sub-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2063] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The TWILIGHT trial demonstrated a reduction in BARC 2, 3 or 5 (BARC-235) bleeding without an increase in ischemic events at 1-year in high-risk PCI patients randomized to placebo or aspirin (ASA) on a background of ticagrelor 3-months after PCI. However, the effect of ASA discontinuation according to baseline risk of bleeding and ischemic events remain unclear.
Purpose
To a) develop separate models to predict the risk of bleeding and ischemic events, and b) to assess treatment effect of ASA discontinuation across the risk strata.
Methods
Using the TWILIGHT patient database (N=7,119), two multivariable models, one for BARC-235 bleeding and one for CV death, nonfatal MI or nonfatal ischemic stroke (ischemic endpoint) were developed, and their predictive capacity was assessed. The effect of randomized treatment on bleeding and ischemic events across different patient risk-group categories as determined by the risk scores was investigated.
Results
At 1-year, 350 (5.4%) patients experienced a BARC-235 bleeding event and 258 (3.6%) experienced an ischemic event. Independent predictors of BARC-235 included haemoglobin levels at index PCI, proton-pump inhibitor non-use at discharge, age, liver disease and active smoking (c-statistic 0.64). Independent predictors of the ischemic outcome included a positive troponin ACS, prior CABG, diabetes, age, peripheral artery disease, prior PCI, a history of congestive heart failure, active smoking, the level of index PCI complexity, and prior MI (c-statistic 0.71). The risk of a BARC-235 almost doubled between patients in lower versus higher bleeding risk categories (4.3% versus 7.9%) and ischemic risk more than tripled between patients in lower versus higher ischemic risk categories (2.0% versus 7.0%) (see Figure 1). There was no evidence of a differential treatment effect for dual antiplatelet therapy versus ticagrelor monotherapy across the different risk categories of bleeding (interaction P=0.54) and ischemic risk (interaction P=0.95) (Table 1).
Conclusion
Individual patient bleeding and ischemic risks after PCI can both be readily characterised with good discrimination. The effect of ASA discontinuation in preventing bleeding in ticagrelor-treated patients was consistent regardless of baseline bleeding risk. There was no evidence for increased ischemic events with ASA discontinuation according to baseline ischemic risk.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZenecaIcahn School of Medicine at Mount Sinai
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Affiliation(s)
| | - S Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences , Hamilton , Canada
| | - U Baber
- The University of Oklahoma Health Sciences Center, Cardiology , Oklahoma City , United States of America
| | - T Collier
- London School of Hygiene and Tropical Medicine, Medical Statistics , London , United Kingdom
| | - G Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai , New York City , United States of America
| | - S K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai , New York City , United States of America
| | - D J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA & St. Francis Hospital, Roslyn, NY 11576 , New York , United States of America
| | - D Angiolillo
- University of Florida College of Medicine, Cardiology , Jacksonville , United States of America
| | - C Briguori
- Mediterranea Cardiocentro , Naples , Italy
| | - J Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid , Madrid , Spain
| | - P Gabriel Steg
- Université de Paris, AP-HP, Hôpital Bichat, French Alliance for Cardiovascular Trials and INSERM , Paris , France
| | - K Huber
- Wilhelminen Hospital, Sigmund Freud University, Medical Faculty, 3rd Department of Medicine, Cardiology and Intensive Care Medicine , Vienna , Austria
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center & Harvard Medical School, Cardiovascular Medicine , Boston , United States of America
| | - S Pocock
- London School of Hygiene and Tropical Medicine, Medical Statistics , London , United Kingdom
| | - R Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai , New York City , United States of America
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