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Jenkins AS, Isha S, Hanson AJ, Kunze KL, Johnson PW, Sura L, Cornelius PJ, Hightower J, Heise KJ, Davis O, Satashia PH, Hasan MM, Esterov D, Worsowicz GM, Sanghavi DK. Rehabilitation in the intensive care unit: How amount of physical and occupational therapy affects patients' function and hospital length of stay. PM R 2024; 16:219-225. [PMID: 38037517 DOI: 10.1002/pmrj.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/04/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Patients in the intensive care unit (ICU) often experience extended periods of immobility. Following hospital discharge, many face impaired mobility and never return to their baseline function. Although the benefits of physical and occupational rehabilitation are well established in non-ICU patients, a paucity of work describes effective practices to alleviate ICU-related declines in mobility. OBJECTIVE To assess how rehabilitation with physical and occupational therapy (PT-OT) during ICU stays affects patients' mobility, self-care, and length of hospital stay. DESIGN Retrospective cohort study. SETTING Inpatient ICU. PARTICIPANTS A total of 6628 adult patients who received physical rehabilitation across multiple sites (Arizona, Florida, Minnesota, and Wisconsin) of a single institution between January 2018 and December 2021. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Descriptive statistics, linear regression models, and gradient boosting machine methods were used to determine the relationship between the amount of PT-OT received and outcomes of hospital length of stay (LOS), Activity Measure for Post-Acute Care Daily Activity and Basic Mobility scores. RESULTS The 6628 patients who met inclusion criteria received an average (median) of 23 (range: 1-89) minutes of PT-OT per day. Regression analyses showed each additional 10 minutes of PT-OT per day was associated with a 1.0% (95% confidence interval [CI]: 0.41-1.66, p < .001) higher final Basic Mobility score, a 1.8% (95% CI: 1.30%-2.34%, p < .001) higher final Daily Activity score, and a 1.2-day (95% CI: -1.28 to -1.09, p < .001) lower hospital LOS. One-dimensional partial dependence plots revealed an exponential decrease in predicted LOS as minutes of PT-OT received increased. CONCLUSION Higher rehabilitation minutes provided to patients in the ICU may reduce the LOS and improve patients' functional outcomes at discharge. The benefits of rehabilitation increased with increasing amounts of time of therapy received.
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Affiliation(s)
- Anna S Jenkins
- Mayo Clinic Alix School of Medicine, Jacksonville, Florida, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Abby J Hanson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Katie L Kunze
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Patrick W Johnson
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Lydia Sura
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, USA
| | - Patrick J Cornelius
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna Hightower
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, USA
| | - Katherine J Heise
- Department of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Olivia Davis
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Dmitry Esterov
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory M Worsowicz
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, Florida, USA
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Sinclair De Frías J, Isha S, Olivero L, Raavi L, Narra SA, Paghdar S, Jonna S, Satashia P, Hannon R, Blasavage J, White L, Olanipekun T, Bansal P, Kiley S, Leoni JC, Nativí J, Lyle M, Thomas M, Sareyyupoglu B, Pham S, Smith M, Moreno Franco P, Patel P, Sanghavi D. Association between Impella device support and elevated rates of gout flares: a retrospective propensity-matched study. BMC Rheumatol 2024; 8:9. [PMID: 38424614 PMCID: PMC10902952 DOI: 10.1186/s41927-024-00380-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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/09/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Impella is an advanced ventricular assist device frequently used as a bridge to heart transplantation. The association of Impella with increased rates of gout flares has not been studied. Our primary aim is to determine the rates of gout flares in patients on Impella support. METHODOLOGY A retrospective study was conducted between January 2017 and September 2022 involving all patients who underwent heart transplantation. The cohort was divided into two groups based on Impella support for statistical analysis. In patients receiving Impella support, outcome measures were compared based on the development of gout flares. 1:1 nearest neighbor propensity match, as well as inverse propensity of treatment weighted analyses, were performed to explore the causal relationship between impella use and gout flare in our study population. RESULTS Our analysis included 213 patients, among which 42 (19.71%) patients were supported by Impella. Impella and non-Impella groups had similar age, race, and BMI, but more males were in the Impella group. Gout and chronic kidney disease were more prevalent in Impella-supported patients, while coronary artery disease was less common. The prevalence of gout flare was significantly higher in Impella patients (30.9% vs. 5.3%). 42 Impella-supported patients were matched with 42 patients from the non-impella group upon performing a 1:1 propensity matching. Impella-supported patients were noted to have a significantly higher risk of gout flare (30.9% vs. 7.1%, SMD = 0.636), despite no significant difference in pre-existing gout history and use of anti-gout medications. Impella use was associated with a significantly increased risk of gout flare in unadjusted (OR 8.07), propensity-matched (OR 5.83), and the inverse propensity of treatment-weighted analysis (OR 4.21). CONCLUSION Our study is the first to identify the potential association between Impella support and increased rates of gout flares in hospitalized patients. Future studies are required to confirm this association and further elucidate the biological pathways. It is imperative to consider introducing appropriate measures to prevent and promptly manage gout flares in Impella-supported patients.
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Affiliation(s)
- Jorge Sinclair De Frías
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Lorenzo Olivero
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Lekhya Raavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Sai Abhishek Narra
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Smit Paghdar
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Rachel Hannon
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Jessica Blasavage
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
- Associate Clinical Consultant, Abiomed, Jacksonville, FL, USA
| | - Layton White
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Titilope Olanipekun
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pankaj Bansal
- Department of Rheumatology, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Juan Carlos Leoni
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Jose Nativí
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Melissa Lyle
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Basar Sareyyupoglu
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Si Pham
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Parag Patel
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA.
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Isha S, Balasubramanian P, Sanghavi DK. Authors response: "Association of plasma volume status with outcomes in hospitalized Covid-19 ARDS patients: A retrospective multicenter observational study". J Crit Care 2024; 79:154459. [PMID: 37923617 DOI: 10.1016/j.jcrc.2023.154459] [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: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Shahin Isha
- Department of Critical Care, Mayo Clinic in Florida; 4500 San Pablo Rd, FL-32224, USA
| | | | - Devang K Sanghavi
- Department of Critical Care, Mayo Clinic in Florida; 4500 San Pablo Rd, FL-32224, USA.
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Satashia P, White A, Isha S, Hanson A, Jenkins A, Blasavage J, Matos N, Tomlinson A, Zhang S, Quinones Q, Waldron N, Bhattacharyya A, Kiley S, Guru P, Chaudhury S, Shapiro A, Moreno Franco P, Sanghavi DK. Adding an extension piece to the end of the purge side arm of the Impella device can prevent the incidence of the cassette breaking and decrease the Impella device failure rate: Impact of practice change on patient outcome. Perfusion 2023:2676591231220305. [PMID: 38060246 DOI: 10.1177/02676591231220305] [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] [Indexed: 12/08/2023]
Abstract
Background: Impella 5.5® with Smart Assist is a minimally invasive Left Ventricular Assist Devices (LVAD) approved by the Food and Drug Administration (FDA) for treating ongoing cardiogenic shock for up to 14 days. The Impella® intends to reduce ventricular workload and provide the circulatory support necessary for myocardial recovery.Research Question: Compared to standard practice, does adding an extension piece to the purge tube side arm of the Impella® Device decrease the incidence of device failure and positively impact the health outcome of adult patients receiving Impella® support?Study Design and Methods: A retrospective chart review of ICU patients was done at a tertiary care center from August 2018 to August 2022 to assess the differences in patient outcomes related to Impella® Device utilization before and after the implementation of the extension piece to the purge tube sidearm. Among patients reviewed, a total of 20 were included in our review, with seven not having the purge tube side arm extension added, while 13 patients had the extension.Results: The two study groups had no significant difference in patient health outcomes. Additionally, there were no instances of device failure requiring explanation without the extension tubing. However, there were no cases of the purge cassette cracking with the addition of the extension tubing.Conclusion: The addition of extension tubing to the purge cassette of the Impella® Device did not impact patient health outcomes or the incidence of device failure. There was a complete reduction in the incidence of the purge cassette cracking, which could reduce the potential for infection or device failure over a long period of mechanical support. There is a need for long-term prospective studies to confirm the results.
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Affiliation(s)
- Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Andrew White
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Abby Hanson
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Anna Jenkins
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Jessica Blasavage
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Nikki Matos
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Amanda Tomlinson
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Stephanie Zhang
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Quintin Quinones
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Nathan Waldron
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | | | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Sanjay Chaudhury
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Anna Shapiro
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, FL, USA
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Kindred M, Isha S, Hanson A, Satashia P, Thompson A, Mielke C, Sanghavi D. Letter to the Editor: Improvement in Palliative Care Utilization and Provider Confidence With Respiratory Distress Observation Scale: A Single-Center Experience. J Palliat Med 2023; 26:1602-1603. [PMID: 38060318 DOI: 10.1089/jpm.2023.0498] [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: 12/18/2023] Open
Affiliation(s)
- Mary Kindred
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Abby Hanson
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Ashley Thompson
- Department of Nursing, University of Florida, Gainesville, Florida, USA
| | - Cathy Mielke
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
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Balasubramanian P, Isha S, Hanson AJ, Jenkins A, Satashia P, Balavenkataraman A, Huespe IA, Bansal V, Caples SM, Khan SA, Jain NK, Kashyap R, Cartin-Ceba R, Nates JL, Reddy DRS, Milian RD, Farres H, Martin AK, Patel PC, Smith MA, Shapiro AB, Bhattacharyya A, Chaudhary S, Kiley SP, Quinones QJ, Patel NM, Guru PK, Moreno Franco P, Sanghavi DK. Association of plasma volume status with outcomes in hospitalized Covid-19 ARDS patients: A retrospective multicenter observational study. J Crit Care 2023; 78:154378. [PMID: 37479551 DOI: 10.1016/j.jcrc.2023.154378] [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: 03/13/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To evaluate the association of estimated plasma volume (ePV) and plasma volume status (PVS) on admission with the outcomes in COVID-19-related acute respiratory distress syndrome (ARDS) patients. MATERIALS AND METHODS We performed a retrospective multi-center study on COVID-19-related ARDS patients who were admitted to the Mayo Clinic Enterprise health system. Plasma volume was calculated using the formulae for ePV and PVS, and these variables were analyzed for correlation with patient outcomes. RESULTS Our analysis included 1298 patients with sequential organ failure assessment (SOFA) respiratory score ≥ 2 (PaO2/FIO2 ≤300 mmHg) and a mortality rate of 25.96%. A Cox proportional multivariate analysis showed PVS but not ePV as an independent correlation with 90-day mortality after adjusting for the covariates (HR: 1.015, 95% CI: 1.005-1.025, p = 0.002 and HR 1.054, 95% CI 0.958-1.159, p = 0.278 respectively). CONCLUSION A lower PVS on admission correlated with a greater chance of survival in COVID-19-related ARDS patients. The role of PVS in guiding fluid management should be investigated in future prospective studies.
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Affiliation(s)
- Prasanth Balasubramanian
- Department of Pulmonary and Critical Care, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Abby J Hanson
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Anna Jenkins
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America; Mayo Clinic Alix School of Medicine, Jacksonville, Florida, United States of America
| | - Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Arvind Balavenkataraman
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Iván A Huespe
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic Rochester, Minnesota, United States of America
| | - Sean M Caples
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Syed Anjum Khan
- Department of Critical Care Medicine, Mayo Clinic Health System in Mankato, Minnesota, United States of America
| | - Nitesh K Jain
- Department of Critical Care Medicine, Mayo Clinic Health System in Mankato, Minnesota, United States of America
| | - Rahul Kashyap
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic Rochester, Minnesota, United States of America
| | - Rodrigo Cartin-Ceba
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, Arizona, United States of America
| | - Joseph L Nates
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Dereddi R S Reddy
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Ricardo Diaz Milian
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Houssam Farres
- Department of Surgery, Division of Vascular Surgery, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Archer K Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Parag C Patel
- Department of Transplantation, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Michael A Smith
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Anna B Shapiro
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Anirban Bhattacharyya
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Sean P Kiley
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Quintin J Quinones
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Neal M Patel
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, United States of America.
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Satashia PH, Franco PM, Rivas AL, Isha S, Hanson A, Narra SA, Singh K, Jenkins A, Bhattacharyya A, Guru P, Chaudhary S, Kiley S, Shapiro A, Martin A, Thomas M, Sareyyupoglu B, Libertin CR, Sanghavi DK. From numbers to medical knowledge: harnessing combinatorial data patterns to predict COVID-19 resource needs and distinguish patient subsets. Front Med (Lausanne) 2023; 10:1240426. [PMID: 38020180 PMCID: PMC10664024 DOI: 10.3389/fmed.2023.1240426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background The COVID-19 pandemic intensified the use of scarce resources, including extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV). The combinatorial features of the immune system may be considered to estimate such needs and facilitate continuous open-ended knowledge discovery. Materials and methods Computer-generated distinct data patterns derived from 283 white blood cell counts collected within five days after hospitalization from 97 COVID-19 patients were used to predict patient's use of hospital resources. Results Alone, data on separate cell types-such as neutrophils-did not identify patients that required MV/ECMO. However, when structured as multicellular indicators, distinct data patterns displayed by such markers separated patients later needing or not needing MV/ECMO. Patients that eventually required MV/ECMO also revealed increased percentages of neutrophils and decreased percentages of lymphocytes on admission. Discussion/conclusion Future use of limited hospital resources may be predicted when combinations of available blood leukocyte-related data are analyzed. New methods could also identify, upon admission, a subset of COVID-19 patients that reveal inflammation. Presented by individuals not previously exposed to MV/ECMO, this inflammation differs from the well-described inflammation induced after exposure to such resources. If shown to be reproducible in other clinical syndromes and populations, it is suggested that the analysis of immunological combinations may inform more and/or uncover novel information even in the absence of pre-established questions.
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Affiliation(s)
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Ariel L. Rivas
- Center for Global Health-Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, United States
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Abby Hanson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Sai Abhishek Narra
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Kawaljeet Singh
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Anna Jenkins
- Mayo Clinic Alix School of Medicine, Jacksonville, FL, United States
| | | | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Anna Shapiro
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Archer Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Claudia R. Libertin
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL, United States
| | - Devang K. Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
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Isha S, Jenkins AS, Hanson AJ, Satashia PH, Narra SA, Mundhra GD, Hasan MM, Donepudi A, Giri A, Johnson PW, Villar D, Santos C, Canabal J, Lowman P, Franco PM, Sanghavi DK. The Effect of Molecular Adsorbent Recirculating System in Patients With Liver Failure: A Case Series of 44 Patients. Transplant Proc 2023; 55:2126-2133. [PMID: 37806867 DOI: 10.1016/j.transproceed.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 06/19/2023] [Accepted: 07/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Liver failure is associated with a high mortality rate, with many patients requiring transplant for definitive treatment. The Molecular Adsorbent Recirculating System (MARS) is a nonbiologic system that provides extracorporeal support. Literature on MARS therapy is mixed: outcomes support MARS therapy for patients with isolated acute liver failure, but data on patients with chronic disease is varied. Several case studies report success using MARS as a bridging treatment for patients awaiting transplant. The purpose of this case series is to present the outcomes of 44 patients who underwent MARS therapy for liver failure, 19 of whom used MARS therapy as a bridging therapy to transplant. METHODS This study retrospectively identified 44 patients who underwent MARS therapy for liver failure at Mayo Clinic, Jacksonville, between January 2014 and April 2021. Variables of interest included changes in laboratory markers of hepatic functioning, number and length of MARS therapy sessions, transplantation status, and mortality. RESULTS Following MARS therapy, there were improvements in mean serum bilirubin, ammonia, urea, creatinine, International Normalized Ratio, alanine aminotransferase, and aspartate aminotransferase levels. Twenty-seven patients (61.36%) survived the hospital stay; 17 (38.63%) died in the hospital. The majority of surviving patients (n = 19; 73.07%) received liver transplant. Six did not require transplant (22.22%). All but 1 patient who received MARS as a bridging treatment to transplant survived the follow-up period (n = 18; 94.74%). CONCLUSIONS Outcomes of these 44 cases suggest that MARS improves liver failure-associated laboratory parameters and may be effective therapy as a bridge to liver transplant.
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Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Anna S Jenkins
- Mayo Clinic Alix School of Medicine, Jacksonville, Florida
| | - Abby J Hanson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Sai Abhishek Narra
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Gunjan D Mundhra
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Ashrita Donepudi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Abishek Giri
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Patrick W Johnson
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Dolores Villar
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Christan Santos
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Juan Canabal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Philip Lowman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida; Department of Transplantation, Mayo Clinic, Jacksonville, Florida
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida.
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Isha S, Sharma R, Hannon RM, Sanghavi DK. A suspected case of Lyme disease causing complete heart block. Oxf Med Case Reports 2023; 2023:omad089. [PMID: 37771693 PMCID: PMC10530306 DOI: 10.1093/omcr/omad089] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/12/2023] [Accepted: 07/21/2023] [Indexed: 09/30/2023] Open
Abstract
Carditis is a rare complication of Lyme disease and usually presents in the early dissemination phase, several weeks after exposure to a tick bite. Conduction abnormalities are the most common manifestation of Lyme carditis. The presentation can vary from atrioventricular conduction delay (first-degree atrioventricular conduction block) to life-threatening situations, such as a complete heart block. Although such manifestations occur late, our case report describes an interesting case where the patient developed a complete heart block in the setting of acute Lyme disease. An elevated IgM with negative IgG Lyme serology titer, an unusual finding, initially led us to face a diagnostic dilemma. Our suspicion of a tick bite was affirmed when we detected a positive titer for Babesia microti, an organism carried by the same tick and a common co-infection with Lyme disease. The patient improved with antibiotic therapy and temporary pacemaker support during the initial few days of admission.
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Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Rohan Sharma
- Department of Neurology and Neuro Critical Care, Mayo Clinic, Jacksonville, Florida, USA
| | - Rachel M Hannon
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Shah SZ, Alvarez FG, Sanghavi DK, Moreno Franco P, Isha S, Marquez CP, Libertin C, Guru PK, Sareyyupoglu B, Pham SM. Coronavirus Disease 2019 Causing Infection of Transplanted Lung Allograft: A Pitfall of Prolonged Shedding of Severe Acute Respiratory Syndrome Coronavirus-2 Pretransplant. Mayo Clin Proc Innov Qual Outcomes 2023; 7:93-98. [PMID: 36644594 PMCID: PMC9829600 DOI: 10.1016/j.mayocpiqo.2023.01.001] [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: 10/20/2022] [Revised: 12/25/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) pandemic has led to considerable morbidity and mortality across the world. Lung transplant is a viable option for a few with COVID-19-related lung disease. Whom and when to transplant has been the major question impacting the transplant community given the novelty of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We describe a pitfall of presumed prolonged shedding of SARS-CoV-2 in a patient with COVID-19 associated acute respiratory distress syndrome leading to COVID-19 pneumonia after lung transplant. This raises concerns that replication-competent SARS-CoV-2 virus can persist for months post-infection and can lead to re-infection of grafts in the future.
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Key Words
- BAL, bronchoalveolar lavage
- BSL-3, Biosafety level-3
- COVID-19, coronavirus disease 2019
- CP, convalescent plasma
- CT, computed tomography
- LT, lung transplant
- NPS, nasopharyngeal swab
- RT-PCR, reverse transcriptase–polymerase chain reaction
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- VV-ECMO, veno-venous extracorporeal membrane oxygenation
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Affiliation(s)
- Sadia Z. Shah
- Department of Transplantation, Mayo Clinic, Jacksonville, FL,Correspondence: Address to Sadia Z. Shah, Department of Transplantation, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224
| | | | | | | | - Shahin Isha
- Department of Critical Care, Mayo Clinic, Jacksonville, FL
| | | | - Claudia Libertin
- Division of Infectious Disease, Department of Medicine, and Mayo Clinic, Jacksonville, FL
| | - Pramod K. Guru
- Department of Critical Care, Mayo Clinic, Jacksonville, FL
| | | | - Si M. Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL
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Isha S, Satashia PH, Yarrarapu SNS, Govero AB, Harrison MF, Baig HZ, Guru P, Bhattacharyya A, Ball CT, Caples SM, Grek AA, Vizzini MR, Khan SA, Heise KJ, Sekiguchi H, Cantrell WL, Smith JD, Chaudhary S, Gnanapandithan K, Thompson KM, Graham CG, Cowdell JC, Murawska Baptista A, Libertin CR, Moreno Franco P, Sanghavi DK. A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis. Front Med (Lausanne) 2023; 10:1071741. [PMID: 37089586 PMCID: PMC10117883 DOI: 10.3389/fmed.2023.1071741] [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: 10/16/2022] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Background The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients. Method We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups. Results Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing. Conclusion In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.
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Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Austin B. Govero
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Michael F. Harrison
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Hassan Z. Baig
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Colleen T. Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, United States
| | - Sean M. Caples
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ami A. Grek
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Michael R. Vizzini
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Syed Anjum Khan
- Department of Critical Care Medicine, Mayo Clinic Health System Mankato, Mankato, MN, United States
| | - Katherine J. Heise
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Hiroshi Sekiguchi
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, United States
| | - Warren L. Cantrell
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jeffrey D. Smith
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Charles G. Graham
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Jed C. Cowdell
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - Claudia R. Libertin
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL, United States
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Devang K. Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: Devang K. Sanghavi,
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Cortes MP, Schultz CS, Isha S, Sinclair JE, Bhakta S, Kunze KL, Johnson PW, Cowart JB, Carter RE, Franco PM, Sanghavi DK, Roy A. The Pitfalls of Mining for QuantiFERON Gold in Severely Ill COVID-19 Patients. Mayo Clin Proc Innov Qual Outcomes 2022; 6:409-419. [PMID: 35818352 PMCID: PMC9259470 DOI: 10.1016/j.mayocpiqo.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022] Open
Abstract
Objective To assess the proportion of indeterminate QFT-Plus results in patients admitted with severe COVID-19 pneumonia and to evaluate the factors associated with indeterminate QFT-Plus results. Study design Retrospective cohort study. Material & Methods Data of COVID-19 admissions at Mayo Clinic Florida were extracted between October 13, 2020 and September 20, 2021, and from a pre-pandemic cohort between October 13, 2018 and September 20, 2019. Secondary analysis of the COVID-19 cohort was performed using gradient boosting modeling to generate variable importance and SHAP plots. Results Our findings demonstrated more indeterminate QFT-Plus test results among hospitalized patients with severe COVID-19 infection compared to non-COVID patients (139 of 495, 28.1%). Factors associated with indeterminate QFT-Plus tests included elevated C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and interleukin-6 (IL 6), as well as low leukocytes, lymphocytes, and platelets. Conclusions Patients with severe COVID-19 had a higher likelihood of indeterminate QFT-Plus results which were associated with elevated inflammatory markers consistent with severe infection. IGRA screening tests are likely confounded by COVID-19 infection itself, limiting the screening ability for LTBI reactivation. Indeterminate QFT-Plus results may also require follow-up QFT-Plus testing, after patient recovery from COVID-19, increasing cost and complexity of medical decision making and management. Additional risk assessments may be needed in this patient population for LTBI screening in severe COVID-19 infected patients.
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Key Words
- AUC, Area under the curve
- CDC, Centers for Disease Control and Prevention
- CKD, Chronic kidney disease
- COVID-19, Coronavirus disease 2019
- CRP, C-reactive protein
- GBM, Gradient boosting machine
- IFN, Interferon
- IFN-γ, Interferon gamma release assay
- IL-6, Interleukin-6
- IRGAs, Interferon-gamma release assays
- LDH, Lactate dehydrogenase
- LTBI, Latent tuberculosis infection
- QFT-Plus, QuantiFERON-TB Gold Plus
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Affiliation(s)
- Melissa P Cortes
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Carrie S Schultz
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Shahin Isha
- Department of Critical Care, Mayo Clinic, Jacksonville, FL, USA
| | | | - Shivang Bhakta
- Department of Critical Care, Mayo Clinic, Jacksonville, FL, USA
| | - Katie L Kunze
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Patrick W Johnson
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Jennifer B Cowart
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Pablo Moreno Franco
- Department of Critical Care, Mayo Clinic, Jacksonville, FL, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA.,Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | | | - Archana Roy
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
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