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Radbel J, Meshanni JA, Gardner CR, Le-Hoang O, Cervelli J, Laskin JD, Gow AJ, Laskin DL. Novel method to assess resident alveolar macrophage efferocytosis of apoptotic neutrophils by flow cytometry. Toxicol Appl Pharmacol 2023; 460:116359. [PMID: 36565939 PMCID: PMC9870943 DOI: 10.1016/j.taap.2022.116359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
Macrophage efferocytosis of apoptotic neutrophils (PMNs) plays a key role in the resolution of inflammation. In these studies, we describe a novel flow cytometric method to assess efferocytosis of apoptotic PMNs. Resident alveolar macrophages and PMNs were collected from lungs of mice exposed to inhaled ozone (0.8 ppm, 3 h) followed by lipopolysaccharide (3 mg/kg, i.v.) to induce acute lung injury. PMNs were labeled with PKH26 or DilC18(5)-DS (D12730) cell membrane dye and then incubated with resident alveolar macrophages at a ratio of 5:1. After 90 min, macrophage efferocytosis was analyzed by flow cytometry and confirmed by confocal microscopy. Whereas alveolar macrophages incubated with D12730-labeled PMNs could readily be identified as efferocytotic or non-efferocytotic, this was not possible with PKH26 labeled PMNs due to confounding macrophage autofluorescence. Using D12730 labeled PMNs, subsets of resident alveolar macrophages were identified with varying capacities to perform efferocytosis, which may be linked to the activation state of these cells. Future applications of this method will be useful in assessing the role of efferocytosis in the resolution of inflammation in response to toxicant exposure.
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Affiliation(s)
- Jared Radbel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America.
| | - Jaclynn A Meshanni
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Carol R Gardner
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Oanh Le-Hoang
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Jessica Cervelli
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Jeffrey D Laskin
- Department of Environmental and Occupational Health and Justice, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Andrew J Gow
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Debra L Laskin
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, United States of America
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2
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Datta P, Ukey R, Bruiners N, Honnen W, Carayannopoulos MO, Reichman C, Choudhary A, Onyuka A, Handler D, Guerrini V, Mishra PK, Dewald HK, Lardizabal A, Lederer L, Leiser AL, Hussain S, Jagpal SK, Radbel J, Bhowmick T, Horton DB, Barrett ES, Xie YL, Fitzgerald-Bocarsly P, Weiss SH, Woortman M, Parmar H, Roy J, Dominguez-Bello MG, Blaser MJ, Carson JL, Panettieri RA, Libutti SK, Raymond HF, Pinter A, Gennaro ML. Highly versatile antibody binding assay for the detection of SARS-CoV-2 infection and vaccination. J Immunol Methods 2021; 499:113165. [PMID: 34634317 PMCID: PMC8500840 DOI: 10.1016/j.jim.2021.113165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/08/2021] [Accepted: 10/05/2021] [Indexed: 02/08/2023]
Abstract
Monitoring the burden and spread of infection with the new coronavirus SARS-CoV-2, whether within small communities or in large geographical settings, is of paramount importance for public health purposes. Serology, which detects the host antibody response to the infection, is the most appropriate tool for this task, since virus-derived markers are most reliably detected during the acute phase of infection. Here we show that our ELISA protocol, which is based on antibody binding to the Receptor Binding Domain (RBD) of the S1 subunit of the viral Spike protein expressed as a novel fusion protein, detects antibody responses to SARS-CoV-2 infection and vaccination. We also show that our ELISA is accurate and versatile. It compares favorably with commercial assays widely used in clinical practice to determine exposure to SARS-CoV-2. Moreover, our protocol accommodates use of various blood- and non-blood-derived biospecimens, such as breast milk, as well as dried blood obtained with microsampling cartridges that are appropriate for remote collection. As a result, our RBD-based ELISA protocols are well suited for seroepidemiology and other large-scale studies requiring parsimonious sample collection outside of healthcare settings.
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Affiliation(s)
- Pratik Datta
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Rahul Ukey
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Natalie Bruiners
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - William Honnen
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Mary O Carayannopoulos
- Department of Pathology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Charles Reichman
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Alok Choudhary
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Alberta Onyuka
- Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Deborah Handler
- Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Valentina Guerrini
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Pankaj K Mishra
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Hannah K Dewald
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Alfred Lardizabal
- Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Leeba Lederer
- Bikur Cholim of Lakewood, Lakewood, NJ 08701, United States of America
| | - Aliza L Leiser
- Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ 08903, United States of America
| | - Sabiha Hussain
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Sugeet K Jagpal
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Tanaya Bhowmick
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Daniel B Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America; Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Emily S Barrett
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ 08854, United States of America; Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Yingda L Xie
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Division of Infectious Diseases, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | | | - Stanley H Weiss
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ 08903, United States of America; Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Melissa Woortman
- Department of Biochemistry and Microbiology, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, NJ 08901, United States of America
| | - Heta Parmar
- Division of Infectious Diseases, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America
| | - Jason Roy
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Maria Gloria Dominguez-Bello
- Department of Biochemistry and Microbiology, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, NJ 08901, United States of America
| | - Martin J Blaser
- Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States of America
| | - Reynold A Panettieri
- Rutgers Institute for Translational Medicine & Science, New Brunswick, NJ 08901, United States of America
| | - Steven K Libutti
- Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ 08903, United States of America
| | - Henry F Raymond
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America
| | - Abraham Pinter
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America.
| | - Maria Laura Gennaro
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ 08854, United States of America.
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Douin DJ, Shaefi S, Brenner SK, Gupta S, Park I, Wright FL, Mathews KS, Chan L, Al-Samkari H, Orfanos S, Radbel J, Leaf DE. Tissue Plasminogen Activator in Critically Ill Adults with COVID-19. Ann Am Thorac Soc 2021; 18:1917-1921. [PMID: 33872546 PMCID: PMC8641829 DOI: 10.1513/annalsats.202102-127rl] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- David J. Douin
- University of Colorado School of MedicineAurora, Colorado
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical CenterBoston, Massachusetts
| | | | - Shruti Gupta
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| | - Isabel Park
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| | | | | | - Lili Chan
- Icahn School of Medicine at Mount SinaiNew York, New York
| | | | - Sarah Orfanos
- Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey
| | - David E. Leaf
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
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4
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Che H, Radbel J, Sunderram J, Nosher JL, Patel VM, Hacihaliloglu I. Multi-feature Multi-Scale CNN-Derived COVID-19 Classification from Lung Ultrasound Data. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:2618-2621. [PMID: 34891790 DOI: 10.1109/embc46164.2021.9631069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The global pandemic of the novel coronavirus disease 2019 (COVID-19) has put tremendous pressure on the medical system. Imaging plays a complementary role in the management of patients with COVID-19. Computed tomography (CT) and chest X-ray (CXR) are the two dominant screening tools. However, difficulty in eliminating the risk of disease transmission, radiation exposure and not being cost-effective are some of the challenges for CT and CXR imaging. This fact induces the implementation of lung ultrasound (LUS) for evaluating COVID-19 due to its practical advantages of noninvasiveness, repeatability, and sensitive bedside property. In this paper, we utilize a deep learning model to perform the classification of COVID-19 from LUS data, which could produce objective diagnostic information for clinicians. Specifically, all LUS images are processed to obtain their corresponding local phase filtered images and radial symmetry transformed images before fed into the multi-scale residual convolutional neural network (CNN). Secondly, image combination as the input of the network is used to explore rich and reliable features. Feature fusion strategy at different levels is adopted to investigate the relationship between the depth of feature aggregation and the classification accuracy. Our proposed method is evaluated on the point-of-care US (POCUS) dataset together with the Italian COVID-19 Lung US database (ICLUS-DB) and shows promising performance for COVID-19 prediction.
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5
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Churpek MM, Gupta S, Spicer AB, Hayek SS, Srivastava A, Chan L, Melamed ML, Brenner SK, Radbel J, Madhani-Lovely F, Bhatraju PK, Bansal A, Green A, Goyal N, Shaefi S, Parikh CR, Semler MW, Leaf DE. Machine Learning Prediction of Death in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0515. [PMID: 34476402 PMCID: PMC8378790 DOI: 10.1097/cce.0000000000000515] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Critically ill patients with coronavirus disease 2019 have variable mortality. Risk scores could improve care and be used for prognostic enrichment in trials. We aimed to compare machine learning algorithms and develop a simple tool for predicting 28-day mortality in ICU patients with coronavirus disease 2019. DESIGN This was an observational study of adult patients with coronavirus disease 2019. The primary outcome was 28-day inhospital mortality. Machine learning models and a simple tool were derived using variables from the first 48 hours of ICU admission and validated externally in independent sites and temporally with more recent admissions. Models were compared with a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 using the area under the receiver operating characteristic curve and calibration. SETTING Sixty-eight U.S. ICUs. PATIENTS Adults with coronavirus disease 2019 admitted to 68 ICUs in the United States between March 4, 2020, and June 29, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study included 5,075 patients, 1,846 (36.4%) of whom died by day 28. eXtreme Gradient Boosting had the highest area under the receiver operating characteristic curve in external validation (0.81) and was well-calibrated, while k-nearest neighbors were the lowest performing machine learning algorithm (area under the receiver operating characteristic curve 0.69). Findings were similar with temporal validation. The simple tool, which was created using the most important features from the eXtreme Gradient Boosting model, had a significantly higher area under the receiver operating characteristic curve in external validation (0.78) than the Sequential Organ Failure Assessment score (0.69), National Early Warning Score (0.60), and CURB-65 (0.65; p < 0.05 for all comparisons). Age, number of ICU beds, creatinine, lactate, arterial pH, and Pao2/Fio2 ratio were the most important predictors in the eXtreme Gradient Boosting model. CONCLUSIONS eXtreme Gradient Boosting had the highest discrimination overall, and our simple tool had higher discrimination than a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 on external validation. These models could be used to improve triage decisions and clinical trial enrichment.
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Affiliation(s)
- Matthew M Churpek
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexandra B Spicer
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michal L Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine, Seton Hall, NJ
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Pavan K Bhatraju
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Anip Bansal
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, CO
| | - Adam Green
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ
| | - Nitender Goyal
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chirag R Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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6
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Datta P, Ukey R, Bruiners N, Honnen W, Carayannopoulos MO, Reichman C, Choudhary A, Onyuka A, Handler D, Guerrini V, Mishra PK, Dewald HK, Lardizabal A, Lederer L, Leiser AL, Hussain S, Jagpal SK, Radbel J, Bhowmick T, Horton DB, Barrett ES, Xie YL, Fitzgerald-Bocarsly P, Weiss SH, Woortman M, Parmar H, Roy J, Dominguez-Bello MG, Blaser MJ, Carson JL, Panettieri RA, Libutti SK, Raymond HF, Pinter A, Gennaro ML. Highly versatile antibody binding assay for the detection of SARS-CoV-2 infection. medRxiv 2021. [PMID: 34282427 PMCID: PMC8288160 DOI: 10.1101/2021.07.09.21260266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Monitoring the burden and spread of infection with the new coronavirus SARS-CoV-2, whether within small communities or in large geographical settings, is of paramount importance for public health purposes. Serology, which detects the host antibody response to the infection, is the most appropriate tool for this task, since virus-derived markers are most reliably detected during the acute phase of infection. Here we show that our ELISA protocol, which is based on antibody binding to the Receptor Binding Domain (RBD) of the S1 subunit of the viral Spike protein expressed as a novel fusion protein, detects antibody responses to SARS-CoV-2 infection and COVID-19 vaccination. We also show that our ELISA is accurate and versatile. It compares favorably with commercial assays widely used in clinical practice to determine exposure to SARS-CoV-2. Moreover, our protocol accommodates use of various blood- and non-blood-derived biospecimens, such as breast milk, as well as dried blood obtained with microsampling cartridges that are appropriate for remote collection. As a result, our RBD-based ELISA protocols are well suited for seroepidemiology and other large-scale studies requiring parsimonious sample collection outside of healthcare settings.
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7
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Al-Samkari H, Gupta S, Leaf RK, Wang W, Rosovsky RP, Brenner SK, Hayek SS, Berlin H, Kapoor R, Shaefi S, Melamed ML, Sutherland A, Radbel J, Green A, Garibaldi BT, Srivastava A, Leonberg-Yoo A, Shehata AM, Flythe JE, Rashidi A, Goyal N, Chan L, Mathews KS, Hedayati SS, Dy R, Toth-Manikowski SM, Zhang J, Mallappallil M, Redfern RE, Bansal AD, Short SAP, Vangel MG, Admon AJ, Semler MW, Bauer KA, Hernán MA, Leaf DE. Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19. Ann Intern Med 2021; 174:622-632. [PMID: 33493012 PMCID: PMC7863679 DOI: 10.7326/m20-6739] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. DESIGN In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. SETTING 67 hospitals in the United States. PARTICIPANTS Adults with COVID-19 admitted to a participating ICU. MEASUREMENTS Time to death, censored at hospital discharge, or date of last follow-up. RESULTS Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). LIMITATION Observational design. CONCLUSION Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Shruti Gupta
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
| | - Rebecca Karp Leaf
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Wei Wang
- Brigham and Women's Hospital, Boston, Massachusetts (W.W.)
| | - Rachel P Rosovsky
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Samantha K Brenner
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey (S.K.B.)
| | - Salim S Hayek
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Hanna Berlin
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Rajat Kapoor
- Indiana University School of Medicine, Indianapolis, Indiana (R.K.)
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.S.)
| | - Michal L Melamed
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York (M.L.M.)
| | - Anne Sutherland
- Rutgers New Jersey Medical School, Newark, New Jersey (A.S.)
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.R.)
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey (A.G.)
| | | | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and Northwestern University Feinberg School of Medicine, Chicago, Illinois (A.S.)
| | - Amanda Leonberg-Yoo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.L.)
| | - Alexandre M Shehata
- Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey (A.M.S.)
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, UNC School of Medicine, and Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina (J.E.F.)
| | - Arash Rashidi
- University Hospitals Cleveland Medical Center, Cleveland, Ohio (A.R.)
| | | | - Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - Kusum S Mathews
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - S Susan Hedayati
- University of Texas Southwestern Medical Center, Dallas, Texas (S.S.H.)
| | - Rajany Dy
- University Medical Center of Southern Nevada Hospital, University of Nevada, Las Vegas, Nevada (R.D.)
| | | | - Jingjing Zhang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (J.Z.)
| | - Mary Mallappallil
- Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York (M.M.)
| | - Roberta E Redfern
- ProMedica Research, ProMedica Toledo Hospital, Toledo, Ohio (R.E.R.)
| | - Amar D Bansal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (A.D.B.)
| | - Samuel A P Short
- University of Vermont Larner College of Medicine, Burlington, Vermont (S.A.S.)
| | - Mark G Vangel
- Massachusetts General Hospital Biostatistics Center, Boston, Massachusetts (M.G.V.)
| | | | - Matthew W Semler
- Vanderbilt University Medical Center, Nashville, Tennessee (M.W.S.)
| | - Kenneth A Bauer
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.A.B.)
| | - Miguel A Hernán
- Harvard T.H. Chan School of Public Health and Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts (M.A.H.)
| | - David E Leaf
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
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8
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Khan AR, Misdary C, Yegya-Raman N, Kim S, Narayanan N, Siddiqui S, Salgame P, Radbel J, Groote FD, Michel C, Mehnert J, Hernandez C, Braciale T, Malhotra J, Gentile MA, Jabbour SK. Montelukast in hospitalized patients diagnosed with COVID-19. J Asthma 2021; 59:780-786. [PMID: 33577360 PMCID: PMC7938648 DOI: 10.1080/02770903.2021.1881967] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Several therapeutic agents have been assessed for the treatment of COVID-19, but few approaches have been proven efficacious. Because leukotriene receptor antagonists, such as montelukast have been shown to reduce both cytokine release and lung inflammation in preclinical models of viral influenza and acute respiratory distress syndrome, we hypothesized that therapy with montelukast could be used to treat COVID-19. The objective of this study was to determine if montelukast treatment would reduce the rate of clinical deterioration as measured by the COVID-19 Ordinal Scale. METHODS We performed a retrospective analysis of COVID-19 confirmed hospitalized patients treated with or without montelukast. We used "clinical deterioration" as the primary endpoint, a binary outcome defined as any increase in the Ordinal Scale value from Day 1 to Day 3 of the hospital stay, as these data were uniformly available for all admitted patients before hospital discharge. Rates of clinical deterioration between the montelukast and non-montelukast groups were compared using the Fisher's exact test. Univariate logistic regression was also used to assess the association between montelukast use and clinical deterioration. A total of 92 patients were analyzed, 30 who received montelukast at the discretion of the treating physician and 62 patients who did not receive montelukast. RESULTS Patients receiving montelukast experienced significantly fewer events of clinical deterioration compared with patients not receiving montelukast (10% vs 32%, p = 0.022). Our findings suggest that montelukast associates with a reduction in clinical deterioration for COVID-19 confirmed patients as measured on the COVID-19 Ordinal Scale. CONCLUSIONS Hospitalized COVID-19 patients treated with montelukast had fewer events of clinical deterioration, indicating that this treatment may have clinical activity. While this retrospective study highlights a potential pathway for COVID-19 treatment, this hypothesis requires further study by prospective studies.
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Affiliation(s)
- Ahsan R Khan
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Christian Misdary
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Sinae Kim
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA.,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Navaneeth Narayanan
- Rutgers University Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA.,Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Sheraz Siddiqui
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Padmini Salgame
- The Center for Emerging Pathogens, Department of Medicine, Rutgers University - New Jersey Medical School, Newark, NJ, USA
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | | | - Carl Michel
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Janice Mehnert
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY, USA
| | - Caleb Hernandez
- Department of Emergency Medicine, Coney Island Hospital, Brooklyn, NY, USA.,Certa Dose, Inc, Denver, CO, USA
| | - Thomas Braciale
- Certa Dose, Inc, Denver, CO, USA.,Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jyoti Malhotra
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA.,Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Michael A Gentile
- Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA.,Merck & Co., Inc, Kenilworth, NJ, USA
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA.,Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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9
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Gupta S, Wang W, Hayek SS, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Finkel D, Green A, Mallappallil M, Faugno AJ, Zhang J, Velez JCQ, Shaefi S, Parikh CR, Charytan DM, Athavale AM, Friedman AN, Redfern RE, Short SAP, Correa S, Pokharel KK, Admon AJ, Donnelly JP, Gershengorn HB, Douin DJ, Semler MW, Hernán MA, Leaf DE. Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19. JAMA Intern Med 2021; 181:41-51. [PMID: 33080002 PMCID: PMC7577201 DOI: 10.1001/jamainternmed.2020.6252] [Citation(s) in RCA: 313] [Impact Index Per Article: 104.3] [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: 01/08/2023]
Abstract
IMPORTANCE Therapies that improve survival in critically ill patients with coronavirus disease 2019 (COVID-19) are needed. Tocilizumab, a monoclonal antibody against the interleukin 6 receptor, may counteract the inflammatory cytokine release syndrome in patients with severe COVID-19 illness. OBJECTIVE To test whether tocilizumab decreases mortality in this population. DESIGN, SETTING, AND PARTICIPANTS The data for this study were derived from a multicenter cohort study of 4485 adults with COVID-19 admitted to participating intensive care units (ICUs) at 68 hospitals across the US from March 4 to May 10, 2020. Critically ill adults with COVID-19 were categorized according to whether they received or did not receive tocilizumab in the first 2 days of admission to the ICU. Data were collected retrospectively until June 12, 2020. A Cox regression model with inverse probability weighting was used to adjust for confounding. EXPOSURES Treatment with tocilizumab in the first 2 days of ICU admission. MAIN OUTCOMES AND MEASURES Time to death, compared via hazard ratios (HRs), and 30-day mortality, compared via risk differences. RESULTS Among the 3924 patients included in the analysis (2464 male [62.8%]; median age, 62 [interquartile range {IQR}, 52-71] years), 433 (11.0%) received tocilizumab in the first 2 days of ICU admission. Patients treated with tocilizumab were younger (median age, 58 [IQR, 48-65] vs 63 [IQR, 52-72] years) and had a higher prevalence of hypoxemia on ICU admission (205 of 433 [47.3%] vs 1322 of 3491 [37.9%] with mechanical ventilation and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of <200 mm Hg) than patients not treated with tocilizumab. After applying inverse probability weighting, baseline and severity-of-illness characteristics were well balanced between groups. A total of 1544 patients (39.3%) died, including 125 (28.9%) treated with tocilizumab and 1419 (40.6%) not treated with tocilizumab. In the primary analysis, during a median follow-up of 27 (IQR, 14-37) days, patients treated with tocilizumab had a lower risk of death compared with those not treated with tocilizumab (HR, 0.71; 95% CI, 0.56-0.92). The estimated 30-day mortality was 27.5% (95% CI, 21.2%-33.8%) in the tocilizumab-treated patients and 37.1% (95% CI, 35.5%-38.7%) in the non-tocilizumab-treated patients (risk difference, 9.6%; 95% CI, 3.1%-16.0%). CONCLUSIONS AND RELEVANCE Among critically ill patients with COVID-19 in this cohort study, the risk of in-hospital mortality in this study was lower in patients treated with tocilizumab in the first 2 days of ICU admission compared with patients whose treatment did not include early use of tocilizumab. However, the findings may be susceptible to unmeasured confounding, and further research from randomized clinical trials is needed.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wei Wang
- Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey.,Department of Internal Medicine, Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine Center, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Diana Finkel
- Department of Medicine, Division of Infectious Diseases, New Jersey Medical School, Rutgers University, Newark
| | - Adam Green
- Division of Critical Care, Cooper University Health Care, Camden, New Jersey
| | - Mary Mallappallil
- Division of Nephrology, Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York
| | - Anthony J Faugno
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jingjing Zhang
- Division of Nephrology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Juan Carlos Q Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David M Charytan
- Division of Nephrology, Department of Medicine, NYU (New York University) Langone Medical Center, New York, New York
| | | | - Allon N Friedman
- Department of Medicine, Indiana University School of Medicine/Indiana University Health, Indianapolis
| | | | | | - Simon Correa
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kapil K Pokharel
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miguel A Hernán
- Department of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Harvard-MIT (Massachusetts Institute of Technology) Program in Health Sciences and Technology, Boston, Massachusetts
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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10
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Radbel J, Laskin DL, Laskin JD, Kipen HM. Disease-modifying treatment of chemical threat agent-induced acute lung injury. Ann N Y Acad Sci 2020; 1480:14-29. [PMID: 32726497 DOI: 10.1111/nyas.14438] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/10/2020] [Accepted: 06/21/2020] [Indexed: 02/04/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a highly morbid lung pathology induced by exposure to chemical warfare agents, including vesicants, phosgene, chlorine, and ricin. In this review, we describe the pathology associated with the development of ARDS in humans and experimental models of acute lung injury following animal exposure to these high-priority threat agents. Potential future approaches to disease-modifying treatment used in preclinical animal studies, including antioxidants, anti-inflammatories, biologics, and mesenchymal stem cells, are also described. As respiratory pathologies, including ARDS, are the major cause of morbidity and mortality following exposure to chemical threat agents, understanding mechanisms of disease pathogenesis is key to the development of efficacious therapeutics beyond the primary intervention principle, which remains mechanical ventilation.
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Affiliation(s)
- Jared Radbel
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Debra L Laskin
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
| | - Jeffrey D Laskin
- Department of Environmental and Occupational Health, School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Howard M Kipen
- Department of Environmental and Occupational Health, School of Public Health, Rutgers University, Piscataway, New Jersey
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11
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Gupta S, Hayek SS, Wang W, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Sutherland A, Green A, Shehata AM, Goyal N, Vijayan A, Velez JCQ, Shaefi S, Parikh CR, Arunthamakun J, Athavale AM, Friedman AN, Short SAP, Kibbelaar ZA, Abu Omar S, Admon AJ, Donnelly JP, Gershengorn HB, Hernán MA, Semler MW, Leaf DE. Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US. JAMA Intern Med 2020; 180:1436-1447. [PMID: 32667668 PMCID: PMC7364338 DOI: 10.1001/jamainternmed.2020.3596] [Citation(s) in RCA: 614] [Impact Index Per Article: 153.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
Importance The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19. Objectives To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19. Design, Setting, and Participants This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020. Exposures Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds. Main Outcomes and Measures The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes. Results A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (≥80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (≥40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (Pao2:Fio2<100 vs ≥300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2-4 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs ≥100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies. Conclusions and Relevance This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.
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Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Wei Wang
- Department of Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S. Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L. Melamed
- Montefiore Medical Center, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K. Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J. Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Anne Sutherland
- Division of Pulmonary and Critical Care Medicine, Rutgers New Jersey Medical School, Newark
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey
| | - Alexandre M. Shehata
- Department of Medicine, Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin Arunthamakun
- Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | | | - Allon N. Friedman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | | | - Samah Abu Omar
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - John P. Donnelly
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Miguel A. Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard–Massachusetts Institute of Technology Division of Health Sciences and Technology, Boston, Massachusetts
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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12
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Orfanos S, El Husseini I, Nahass T, Radbel J, Hussain S. Observational study of the use of recombinant tissue-type plasminogen activator in COVID-19 shows a decrease in physiological dead space. ERJ Open Res 2020; 6:00455-2020. [PMID: 33043052 PMCID: PMC7533378 DOI: 10.1183/23120541.00455-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/15/2020] [Indexed: 11/23/2022] Open
Abstract
In December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged as the causative agent for coronavirus disease 2019 (COVID-19), a clinical syndrome with high incidence of acute respiratory distress syndrome (ARDS). Part of the pathophysiology of COVID-19-induced ARDS is explained by increased dead space ventilation from pulmonary microthrombi; this is supported by the existence of alveolar capillary microthrombi found on autopsies [1, 2]. This has prompted the use of therapeutic anticoagulation and thrombolytics [3–5]. Thus far, no clinical trials have been completed to evaluate the use of recombinant tissue-type plasminogen activator (rt-PA) to treat COVID-19. The objective of this study was to determine whether rt-PA administration decreases dead space ventilation in patients with COVID-19. #COVID19-induced ARDS is partly explained by the presence of microthrombi, motivating the use of thrombolytics. This study shows that thrombolytics decrease dead space ventilation in COVID-19 ARDS patients.https://bit.ly/2GdM44a
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Affiliation(s)
- Sarah Orfanos
- Dept of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Both authors contributed equally to this work
| | - Ibrahim El Husseini
- Dept of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Both authors contributed equally to this work
| | - Thomas Nahass
- Dept of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jared Radbel
- Dept of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sabiha Hussain
- Dept of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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13
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Radbel J, Narayanan N, Bhatt PJ. Use of Tocilizumab for COVID-19-Induced Cytokine Release Syndrome: A Cautionary Case Report. Chest 2020; 158:e15-e19. [PMID: 32343968 PMCID: PMC7195070 DOI: 10.1016/j.chest.2020.04.024] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/20/2022] Open
Abstract
Novel coronavirus disease 2019 (COVID-19) emerged in late December 2019 in Wuhan, China. Since then, COVID-19 has become a pandemic affecting more than 4.1 million people worldwide. Patients with COVID-19 have a wide spectrum of manifestations, one being cytokine release syndrome (CRS) and its fatal correlate, secondary hemophagocytic lymphohistiocytosis (sHLH). Anti-cytokine therapy such as tocilizumab, an IL-6 receptor antagonist, is a potential treatment for COVID-19; however, data regarding the efficacy of this anti-IL-6 therapy are currently lacking. We report two cases of patients who received a diagnosis of COVID-19 complicated by CRS and were treated with tocilizumab. Both patients progressed to sHLH despite treatment with tocilizumab, and one developed viral myocarditis, challenging the safety and clinical usefulness of tocilizumab in the treatment of COVID-19-induced CRS. These cases highlight the need for clinical trials to determine optimal patient selection and timing for the use of tocilizumab during this disease process.
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MESH Headings
- Adult
- Aged
- Anti-Infective Agents/administration & dosage
- Anti-Inflammatory Agents/administration & dosage
- Antibodies, Monoclonal, Humanized/administration & dosage
- Azithromycin/administration & dosage
- Betacoronavirus/isolation & purification
- C-Reactive Protein/analysis
- COVID-19
- Clinical Deterioration
- Coronavirus Infections/complications
- Coronavirus Infections/diagnosis
- Coronavirus Infections/physiopathology
- Coronavirus Infections/therapy
- Cytokine Release Syndrome/blood
- Cytokine Release Syndrome/therapy
- Cytokine Release Syndrome/virology
- Fatal Outcome
- Female
- Humans
- Hydroxychloroquine/administration & dosage
- Hypoxia/etiology
- Hypoxia/therapy
- Lymphohistiocytosis, Hemophagocytic/blood
- Lymphohistiocytosis, Hemophagocytic/therapy
- Lymphohistiocytosis, Hemophagocytic/virology
- Male
- Myocarditis/therapy
- Myocarditis/virology
- Pandemics
- Pneumonia, Viral/complications
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/etiology
- Pneumonia, Viral/physiopathology
- Pneumonia, Viral/therapy
- Respiration, Artificial/methods
- SARS-CoV-2
- Shock, Septic/etiology
- Shock, Septic/therapy
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Affiliation(s)
- Jared Radbel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Rutgers-Ernest Mario School of Pharmacy, New Brunswick, NJ
| | - Pinki J Bhatt
- Division of Infectious Disease, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
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14
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Radbel J, Jagpal S, Roy J, Brooks A, Tischfield J, Sheldon M, Bixby C, Witt D, Gennaro ML, Horton DB, Barrett ES, Carson JL, Panettieri RA, Blaser MJ. Detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Is Comparable in Clinical Samples Preserved in Saline or Viral Transport Medium. J Mol Diagn 2020; 22:871-875. [PMID: 32405270 PMCID: PMC7219422 DOI: 10.1016/j.jmoldx.2020.04.209] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/28/2020] [Indexed: 12/22/2022] Open
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic sweeps across the world, the availability of viral transport medium (VTM) has become severely limited, contributing to delays in diagnosis and rationing of diagnostic testing. Given that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA has demonstrated stability, we posited that phosphate-buffered saline (PBS) may be a viable transport medium, as an alternative to VTM, for clinical real-time quantitative PCR (qPCR) testing. The intra-individual reliability and interindividual reliability of SARS-CoV-2 qPCR were assessed in clinical endotracheal secretion samples transported in VTM or PBS to evaluate the stability of the qPCR signal for three viral targets (N gene, ORF1ab, and S gene) when samples were stored in these media at room temperature for up to 18 hours. We report that the use of PBS as a transport medium allows high intra-individual and interindividual reliability, maintains viral stability, and compares with VTM in the detection of the three SARS-CoV-2 genes through 18 hours of storage. This study establishes PBS as a clinically useful medium that can be readily deployed for transporting and short-term preservation of specimens containing SARS-CoV-2. Use of PBS as a transport medium has the potential to increase testing capacity for SARS-CoV-2, aiding more widespread screening and early diagnosis of COVID-19.
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Affiliation(s)
- Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey
| | - Sugeet Jagpal
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jason Roy
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Andrew Brooks
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey; Rutgers University Cell and DNA Repository Infinite Biologics and Human Genetics Institute of New Jersey and Department of Genetics, Rutgers University, Piscataway, New Jersey
| | - Jay Tischfield
- Rutgers University Cell and DNA Repository Infinite Biologics and Human Genetics Institute of New Jersey and Department of Genetics, Rutgers University, Piscataway, New Jersey; Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Michael Sheldon
- Rutgers University Cell and DNA Repository Infinite Biologics and Human Genetics Institute of New Jersey and Department of Genetics, Rutgers University, Piscataway, New Jersey
| | - Christian Bixby
- Rutgers University Cell and DNA Repository Infinite Biologics and Human Genetics Institute of New Jersey and Department of Genetics, Rutgers University, Piscataway, New Jersey
| | - Dana Witt
- Rutgers University Cell and DNA Repository Infinite Biologics and Human Genetics Institute of New Jersey and Department of Genetics, Rutgers University, Piscataway, New Jersey
| | - Maria L Gennaro
- Public Health Research Institute, Department of Medicine, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Daniel B Horton
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey; Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey
| | - Emily S Barrett
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Reynold A Panettieri
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Rutgers Institute for Translational Medicine and Science, New Brunswick, New Jersey
| | - Martin J Blaser
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, New Jersey.
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Yacoub H, Khoury L, El Douaihy Y, Salmane C, Kamal J, Saad M, Nasr P, Radbel J, El-Charabaty E, El-Sayegh S. Acute kidney injury adjusted to volume status in critically ill patients: recognition of delayed diagnosis, restaging, and associated outcomes. Int J Nephrol Renovasc Dis 2016; 9:257-262. [PMID: 27822078 PMCID: PMC5096724 DOI: 10.2147/ijnrd.s113389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Critically ill patients receive a significant amount of fluids leading to a positive fluid balance; this dilutes serum creatinine resulting in an overestimated glomerular filtration rate. The goal of our study is to identify undiagnosed or underestimated acute kidney injury (AKI) in the intensive care unit (ICU). It will also identify the morbidity and mortality associated with an underestimated AKI. We reviewed records of patients admitted to our institution (Staten Island University Hospital) between 2012 and 2013 for more than 2 days. Patients with end stage renal disease were excluded. AKI was defined using the Acute Kidney Injury Network criteria. The following formula was used to identify and restage patients with AKI: adjusted creatinine = serum creatinine × [(hospital admission weight (kg) 0.6 + Σ (daily cumulative fluid balance (L))/hospital admission weight × 0.6]. The primary outcome identified newly diagnosed AKI and those who were restaged. The secondary outcome identified associated morbidities. Seven-hundred and thirty-three out of 1,982 ICU records reviewed, were used. Two-hundred and fifty-seven (mean age 69.8±14.9) had AKI, out of which 15.9% were restaged using the equation. Comparison of mean by Student's t-test showed no difference between patients who were restaged. Similarly, chi-square revealed no differences between both arms, except mean admission weight (lower in patients who were restaged), fluid balance on days 1, 2, and 3 (higher in the restaged arm), and the presence of congestive heart failure (more prevalent in the restaged arm). Of note, the mean cost of stay was US$150,562.82 vs $197,174.63 for same stage vs restaged, respectively, however, without statistical significance (P=0.74). Applying the adjustment equation showed a modest (15.9%) increase in the AKI staging slightly impacting outcomes (mortality, length, and cost of stay) without statistical significance.
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Affiliation(s)
- Harout Yacoub
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Leen Khoury
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Youssef El Douaihy
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Chadi Salmane
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Jeanne Kamal
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Marc Saad
- Division of Renal Medicine, Emory University, Atlanta, GA, USA
| | - Patricia Nasr
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Jared Radbel
- Department of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Elie El-Charabaty
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Suzanne El-Sayegh
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
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16
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Dixit D, Bridgeman MB, Andrews LB, Narayanan N, Radbel J, Parikh A, Sunderram J. Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Diagnosis, Management, and Prevention in Critically Ill Patients. Pharmacotherapy 2015; 35:631-48. [DOI: 10.1002/phar.1599] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Critical Care; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | - Mary Barna Bridgeman
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Internal Medicine; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | - Liza Barbarello Andrews
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Critical Care; Robert Wood Johnson University Hospital Hamilton; Hamilton New Jersey
| | - Navaneeth Narayanan
- Ernest Mario School of Pharmacy; Rutgers, The State University of New Jersey; Piscataway New Jersey
- Infectious Disease; Robert Wood Johnson University Hospital; New Brunswick New Jersey
| | - Jared Radbel
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
| | - Amay Parikh
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
| | - Jag Sunderram
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Rutgers Robert Wood Johnson Medical School; New Brunswick New Jersey
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17
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Radbel J, Mehta K, Shah N, Soni R, Singh J. The Sharp Decline in ARDS Mortality: Analysis of 856,293 National Inpatient Sample Admissions. Chest 2014. [DOI: 10.1378/chest.1992518] [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: 11/01/2022] Open
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18
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Azab B, Radbel J, Singh J, Castellano MR, Fasanya C, Bloom SW. A Case Report of Therapeutic Hypothermia in the Postoperative Cardiac Arrest of a Noncardiac Surgical Patient. Ther Hypothermia Temp Manag 2014. [DOI: 10.1089/ther.2013.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Basem Azab
- Staten Island University Hospital, Staten Island, New York
| | - Jared Radbel
- Staten Island University Hospital, Staten Island, New York
| | | | | | | | - Scott W. Bloom
- Staten Island University Hospital, Staten Island, New York
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19
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Hassan S, Naboush A, Radbel J, Asaad R, Alkaied H, Demissie S, Terjanian T. Telephone-based anticoagulation management in the homebound setting: a retrospective observational study. Int J Gen Med 2013; 6:869-75. [PMID: 24348065 PMCID: PMC3857151 DOI: 10.2147/ijgm.s50057] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Anticoagulation management is currently performed through anticoagulation clinics or self-managed with or without the help of medical services. Homebound patients are a unique population that cannot utilize anticoagulation clinics or self-testing. Telephone-based anticoagulation management could be an alternative to the traditional methods of monitoring warfarin in this subgroup. The objective of this retrospective, observational study is to investigate the feasibility of warfarin management in homebound patients. Methods This study was performed through the use of telephone-based adjustments of warfarin dose based on an international normalized ratio (INR) result. Four hundred forty-eight homebound patients referred to the anticoagulation clinic at Staten Island University Hospital were visited at home by a phlebotomist; a blood sample was drawn for initial laboratory testing. A nurse practitioner then called the patient or designated person to relay the INR result and to direct dosage adjustment. INR results and dosage changes were entered into an electronic medical record and analyzed statistically. Results The mean percentage of INR values in range was 58.39%. The mean time when the INR was in the therapeutic range was 62.75%. The percent of patients who were therapeutically controlled decreased as the number of medications increased. The complication rate was 4% per patient year, with an equal distribution between bleeding and clotting. These values compared favorably to other studies in which monitoring was performed through anticoagulation clinics or self-monitoring. The cost per visit at our anticoagulation clinic was found to be approximately $300 compared with $82 when utilizing our homebound service. Conclusion Telephone-based management of warfarin therapy in the homebound setting is feasible. It can lower the cost of health care expenditures compared to other modalities of anticoagulation management.
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Affiliation(s)
- Samer Hassan
- Division of Internal Medicine; Staten Island University Hospital, Staten Island, NY, USA
| | - Ali Naboush
- Division of Internal Medicine; Staten Island University Hospital, Staten Island, NY, USA
| | - Jared Radbel
- Division of Internal Medicine; Staten Island University Hospital, Staten Island, NY, USA
| | - Razan Asaad
- Division of Internal Medicine; Staten Island University Hospital, Staten Island, NY, USA
| | - Homam Alkaied
- Division of Hematology/Oncology; Staten Island University Hospital, Staten Island, NY, USA
| | - Seleshi Demissie
- Division of Statistics; Staten Island University Hospital, Staten Island, NY, USA
| | - Terenig Terjanian
- Division of Hematology/Oncology; Staten Island University Hospital, Staten Island, NY, USA
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20
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Ahmed S, Radbel J, Elsayegh D, Ahmed A, Daneshvar F, Vatandoust G, Khalil A. An Unusual Case of Cryptococcal Pneumonia in an Immunocompetent Patient. Chest 2013. [DOI: 10.1378/chest.1688108] [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: 11/01/2022] Open
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21
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Azab B, Shah N, Radbel J, Tan P, Bhatt V, Vonfrolio S, Habeshy A, Picon A, Bloom S. Pretreatment neutrophil/lymphocyte ratio is superior to platelet/lymphocyte ratio as a predictor of long-term mortality in breast cancer patients. Med Oncol 2013; 30:432. [PMID: 23283648 DOI: 10.1007/s12032-012-0432-4] [Citation(s) in RCA: 184] [Impact Index Per Article: 16.7] [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: 08/27/2012] [Accepted: 10/22/2012] [Indexed: 12/26/2022]
Abstract
The aim of our study was to assess the predictive value of platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR) in terms of survival in breast cancer patients. This is an observational study of 437 breast cancer patients treated between January 2004 and December 2006. Survival status was obtained from our cancer registry and Social Security Death Index. Survival analysis, stratified by NLR and PLR quartiles, was used to evaluate their prognostic values. Patients in the highest 4th PLR and NLR quartiles had higher 5-year mortality rate (30.4 and 40.3 %) compared to those in the lower three PLR and NLR quartiles (12.1 and 8.2 %), p < 0.0001. Multivariate hazard ratios of 4th PLR and NLR quartiles compared to first PLR and NLR quartiles were 3.68 (1.74-7.77, p = 0.001) and 3.67 (1.52-8.86, p = 0.004). Higher PLR only showed a trend of higher mortality in patients with normal lymphocyte count, whereas NLR continued to be statistically significant predictor of 5-year mortality in all lymphocyte count subsets. Pretreatment NLR is an independent predictor of long-term mortality in breast cancer patients, whereas pretreatment PLR was not superior to absolute lymphocyte count alone in predicting long-term mortality.
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Affiliation(s)
- Basem Azab
- Department of Surgery, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA.
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