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Patel AA, Mahajan A, Benjo A, Jani VB, Annapureddy N, Agarwal SK, Simoes PK, Pakanati KC, Sinha V, Konstantinidis I, Pathak A, Nadkarni GN. A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage. Neurohospitalist 2016; 6:7-10. [PMID: 26753051 DOI: 10.1177/1941874415599577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.
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Affiliation(s)
- Achint A Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Alexandre Benjo
- Division of Cardiology, Oschner Clinic Foundation, New Orleans, LA, USA
| | - Vishal B Jani
- Department of Neurology, Michigan State University, East Lansing, MI, USA
| | - Narender Annapureddy
- Division of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shiv Kumar Agarwal
- Division of Cardiology, University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Priya K Simoes
- Department of Medicine, St. Luke's Roosevelt Medical Center at Mount Sinai, New York, NY, USA
| | | | - Vikash Sinha
- Division of Nephrology, University of Chicago, Chicago, IL, USA
| | | | - Ambarish Pathak
- Department of Public Health, New York Medical College, Valhalla, NY
| | - Girish N Nadkarni
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Nadkarni GN, Konstantinidis I, Patel A, Yacoub R, Kumbala D, Patel RAG, Annapureddy N, Pakanati KC, Simoes PK, Javed F, Benjo AM. Trimetazidine Decreases Risk of Contrast-Induced Nephropathy in Patients With Chronic Kidney Disease. J Cardiovasc Pharmacol Ther 2015; 20:539-46. [DOI: 10.1177/1074248415573320] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 01/13/2015] [Indexed: 11/16/2022]
Abstract
Objectives: We sought to synthesize and analyze the available data from randomized controlled trials (RCTs) for trimetazidine (TMZ) in the prevention of contrast-induced nephropathy (CIN). Background: Contrast-induced nephropathy after coronary angiography is associated with poor outcomes. Trimetazidine is an anti-ischemic drug that might reduce incidence of CIN, but current data are inconclusive. Methods: We searched MEDLINE/PubMed, EMBASE, Scopus, Cochrane Library, Web of Science, and ScienceDirect electronic databases for RCTs comparing intravenous hydration with normal saline (NS) and/or N-acetyl cysteine (NAC) versus TMZ plus NS ± NAC for prevention of CIN. We used RevMan 5.2 for statistical analysis with the fixed effects model. Results: Of the 808 studies, 3 RCTs met criteria with 290 patients in the TMZ plus NS ± NAC group and 292 patients in the NS ± NAC group. The mean age of patients was 59.5 years, and baseline serum creatinine ranged from 1.3 to 2 mg/dL. Trimetazidine significantly reduced the incidence of CIN by 11% (risk difference 0.11; 95% confidence interval, 0.16-0.06; P < .01). There was no significant heterogeneity between the studies (I2 statistic = 0). The number needed to treat to prevent 1 episode of CIN was 9. Conclusions: The addition of TMZ to NS ± NAC significantly decreased the incidence of CIN in patients undergoing coronary angiography. In conclusion, TMZ could be considered as a potential tool for prevention of CIN in patients with renal dysfunction.
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Affiliation(s)
- Girish N. Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ioannis Konstantinidis
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Achint Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rabi Yacoub
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Damodar Kumbala
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rajan A. G. Patel
- Division of Cardiology, Department of Medicine, Ochsner Clinic Foundation, Jefferson, LA, USA
| | - Narender Annapureddy
- Division of Rheumatology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Priya K. Simoes
- Department of Medicine, St. Luke’s Roosevelt Hospital Center at Mount Sinai, New York, NY, USA
| | - Fahad Javed
- Division of Cardiology, Department of Medicine, Ochsner Clinic Foundation, Jefferson, LA, USA
| | - Alexandre M. Benjo
- Division of Cardiology, Department of Medicine, Ochsner Clinic Foundation, Jefferson, LA, USA
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Abstract
Inflammatory bowel disease (IBD) is known for causing disturbed homeostatic balance among the intestinal immune compartment, epithelium and microbiota. Owing to the emergence of IBD as a major cause of morbidity and mortality, great efforts have been put into understanding the sequence of intestinal inflammatory events. Intestinal macrophages and dendritic cells act in a synergistic fashion with intestinal epithelial cells and microbiota to initiate the triad that governs the intestinal immune responses (whether inflammatory or regulatory). In this review, we will discuss the interplay of intestinal epithelial cells, bacteria and the innate immune component. Moreover, whether or not genetic intervention of probiotic bacteria is a valid approach for attenuating/mitigating exaggerated inflammation and IBD will also be discussed.
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Affiliation(s)
- Mohammad W Khan
- The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Mohamadzadeh M, Durmaz E, Zadeh M, Pakanati KC, Gramarossa M, Cohran V, Klaenhammer TR. Targeted expression of anthrax protective antigen by Lactobacillus gasseri as an anthrax vaccine. Future Microbiol 2010; 5:1289-96. [PMID: 20722604 DOI: 10.2217/fmb.10.78] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIM Induction of protective immunity against pathogenic microbes, including Bacillus anthracis, requires efficient vaccines that potentiate antibody avidity and increase T-cell longevity. We recently reported that the delivery of targeted B. anthracis protective antigen (PA) genetically fused to a DC-binding peptide (DCpep) by Lactobacillus acidophilus induced mucosal and systemic immunity against B. anthracis challenge in mice. MATERIALS & METHODS Improvement of this oral vaccine strategy was attempted by use of the high copy and genetically stable q-replicating vector, pTRKH2, for expression of the targeted PA fusion protein in Lactobacillus gasseri, a common human commensal microbe, to vaccinate animals against anthrax Sterne infection. RESULTS Oral application of L. gasseri expressing the PA-DCpep fusion proteins elicited robust PA-neutralizing antibody and T-cell mediated immune responses against anthrax Sterne challenge, resulting in complete animal survival. Collectively, this improved expression vaccine strategy reduced the number of inoculations and length of the boosting period, leading to animal protection via efficacious bacterial adjuvanticity and safe oral delivery of this vaccine to mucosal immune cells, including dendritic cells. CONCLUSION Lactobacillus-based delivery offers tremendous practical advantages. Recombinant antigens such as PA would not require chemical coupling agents, and the recombinant bacteria can be administered orally where upon both mucosal and systemic immune responses are elicited.
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Affiliation(s)
- Mansour Mohamadzadeh
- Northwestern University, Feinberg School of Medicine, 303 E. Chicago Ave, Chicago, IL 60611, USA.
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