Publications by authors named "Ghulam Saydain"

23 Publications

  • Page 1 of 1

Pulmonary hypertension in India: Need for organized approach.

Lung India 2022 Jan-Feb;39(1):3-4

Department of Medicine, Pulmonary Critical Care and Sleep Division, Wayne State University, Detroit, MI, USA.

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http://dx.doi.org/10.4103/lungindia.lungindia_714_21DOI Listing
January 2022

Predictors of Complications Secondary to Infective Endocarditis and Their Associated Outcomes: A Large Cohort Study from the National Emergency Database (2016-2018).

Infect Dis Ther 2021 Nov 24. Epub 2021 Nov 24.

Division of Pulmonary and Critical Medicine, Detroit Medical Center Wayne State University, Detroit, MI, USA.

Introduction: Literature regarding outcomes and predictors of complications secondary to infective endocarditis (IE) is limited. We aimed to study the outcomes and predictors of complications of IE.

Methods: Data from a national emergency department sample, which constitutes 20% sample of hospital-owned emergency departments in the USA, were analyzed for hospital visits for IE. Complications of endocarditis were obtained by using ICD codes. Multivariable generalized linear method was used to evaluate predictors of in-hospital mortality and complications.

Results: Out of 255,838 adult IE patients (mean age 60.3 ± 20.1 years, 48.5% females), 97,803 (38.2%) patients developed one or more major complications. The major complications were cardiovascular system complications [57,900 (22.6%)], neurologic [42,851 (16.7%)] complications, and renal [16,236 (6.4%)] complications. These included cardiogenic shock [3873 (1.5%)], septic shock [25,798 (10.1%)], acute heart failure [35,602 (14%)], systemic thromboembolism (STE) [21,390 (8.36%)], heart block [11,430 (4.47%)], in-hospital dialysis [2880 (1.1%)], and disseminated intravascular coagulation (DIC) [2704 (1.1%)]. Patients with complicated IE had risk of mortality (adjusted RR 1.12, 95% CI 1.11-1.13, p < 0.001). The complications strongly associated with mortality were septic shock (RR 1.29, 95% CI 1.27-1.30, p < 0.001), cardiogenic shock (RR 1.24, 95% CI 1.20-1.29, p < 0.001), DIC (RR 1.4, 95% CI 1.35-1.46, p < 0.001), and STE (RR 1.07, 95% CI 1.05-1.08, p < 0.001). Staphylococci were the predominant causative organisms (30.8%) among the complicated IE subgroups with higher associated mortality (42.8%). The main predictors of complications from IE were congenital heart disease, history of congestive heart failure, high Elixhauser comorbidity profile, staphylococcal infection, and fungal infections. The prevalence of cardiogenic shock increased over the study years from 1.13 to 1.98% (p-trend 0.04).

Conclusion: Complicated IE is not uncommon and is associated with significant mortality. Staphylococcal infections were associated with high mortality rates. There has been an increasing trend of cardiogenic shock among IE patients across the US. Further research is needed to improve the outcomes of complicated endocarditis.
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http://dx.doi.org/10.1007/s40121-021-00563-yDOI Listing
November 2021

ST-Elevation Myocardial Infarction Among Septic Shock and Coronary Interventions: A National Emergency Database Study.

J Intensive Care Med 2021 Nov 23:8850666211061731. Epub 2021 Nov 23.

University of California, Mather, CA, USA.

Objective: To study coronary interventions and mortality among patients with ST-elevated myocardial infarction (STEMI) who were admitted with septic shock.

Methods: Data from the national emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the septic shock related visits from 2016 to 2018. Septic shock was defined by the ICD codes.

Results: Out of 1 375 507 adult septic shock patients, 521 300 had a primary diagnosis of septic shock (mean age 67.41±15.67 years, 51.1% females) in the national emergency database for the years 2016 to 2018. Of these patients, 2768 (0.53%) had STEMI recorded during the hospitalization. Mortality rates for STEMI patients were higher than patients without STEMI (52.3% vs 23.5%). Mortality rates improved with PCI among STEMI patients (43.8% vs 56.2%). Coronary angiography was performed among 16% of patients of which percutaneous coronary intervention (PCI) rates were 7.7% among patients with STEMI septic shock. PCI numerically improved mortality, however, had no significant difference than patients without PCI on multivariate logistic regression and univariate logistic regression post coarsened exact matching of baseline characteristics among STEMI patients. Among the predictors, STEMI was a significant predictor of mortality in septic shock patients (OR 2.87, 95% CI 2.37-3.49; <.001). Age, peripheral vascular disease, were predominant predictors of mortality in STEMI with septic shock subgroup ( <.001). Pneumonia was the predominant underlying infection among STEMI (36.4%) and without STEMI group (29.5%).

Conclusion: STEMI complicating septic shock worsens mortality. PCI and coronary angiography numerically improved mortality, however, had no significant difference from patients without PCI. More research will be needed to improve mortality in such a critically ill subgroup of patients.
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http://dx.doi.org/10.1177/08850666211061731DOI Listing
November 2021

Predictors and outcomes of cardiac arrest in the emergency department and in-patient settings in the United States (2016-2018).

Resuscitation 2021 Nov 19;170:100-106. Epub 2021 Nov 19.

Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA.

Background: Outcomes of cardiac arrest (CA) remain dismal despite therapeutic advances. Literature is limited regarding outcomes of CA in emergency departments (ED).

Objective: To study the possible causes, predictors, and outcomes of CA in ED and in-patient settings throughout the United States (US).

Methods: Data from the US national emergency department sample (NEDS) was analyzed for the episodes of CA for 2016-2018. In-hospital CA was divided into in-patient (IPCA) and in the ED (EDCA). Only patients who had cardiopulmonary resuscitation (CPR) within the hospital were included in the study (out-of-hospital were excluded).

Results: A total of 1,068,847 CA (mean age 63.7 ± 19.4 years, 24%females), of whom 325,062 (30.4%) EDCA and 177,104 (16.6%) IPCA were included in the study. Patients without CPR, 743,785 (69.6%), were excluded. Survival was higher among IPCA 55,821 (31.6%) than the EDCA 32,516 (10%). IPCA encounters had multifactorial associated etiologies including respiratory failure (73%), acidosis (38.7%) sepsis (36.8%) and ST-elevated myocardial infarction (STEMI) (7.3%). Majority of ED arrests (67.1%) had no possible identifiable cause. The predominant known causes include intoxication (7.5%), trauma (6.4%), respiratory failure (5%), and STEMI (2.7%). Cardiovascular interventions had significant survival benefits in IPCA on univariate logistic regression after coarsened exact matching for comorbidities. IPCA had higher intervention rates than EDCA. For all live discharges, a total of 40% of patients were discharged to hospice.

Conclusion: Survival remains dismal among CA patients especially those occurring in the ED. Given that there are considerable variations in the etiology between the two studied cohorts, more research is required to improve the understanding of these factors, which may improve survival outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2021.11.009DOI Listing
November 2021

High-flow nasal cannula therapy in a predominantly African American population with COVID-19 associated acute respiratory failure.

BMJ Open Respir Res 2021 09;8(1)

Division of Pulmonary and Critical Care, Wayne State University School of Medicine, Detroit, Michigan, USA.

Importance: Use of non-invasive respiratory modalities in COVID-19 has the potential to reduce rates of intubation and mortality in severe disease however data regarding the use of high-flow nasal cannula (HFNC) in this population is limited.

Objective: To interrogate clinical and laboratory features of SARS-CoV-2 infection associated with high-flow failure.

Design: We conducted a retrospective cohort study to evaluate characteristics of high-flow therapy use early in the pandemic and interrogate factors associated with respiratory therapy failure.

Setting: Multisite single centre hospital system within the metropolitan Detroit region.

Participants: Patients from within the Detroit Medical Center (n=104, 89% African American) who received HFNC therapy during a COVID-19 admission between March and May of 2020.

Primary Outcome: HFNC failure is defined as death or intubation while on therapy.

Results: Therapy failure occurred in 57% of the patient population, factors significantly associated with failure centred around markers of multiorgan failure including hepatic dysfunction/transaminitis (OR=6.1, 95% CI 1.9 to 19.4, p<0.01), kidney injury (OR=7.0, 95% CI 2.7 to 17.8, p<0.01) and coagulation dysfunction (OR=4.5, 95% CI 1.2 to 17.1, p=0.03). Conversely, comorbidities, admission characteristics, early oxygen requirements and evaluation just prior to HFNC therapy initiation were not significantly associated with success or failure of therapy.

Conclusions: In a population disproportionately affected by COVID-19, we present key indicators of likely HFNC failure and highlight a patient population in which aggressive monitoring and intervention are warranted.
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http://dx.doi.org/10.1136/bmjresp-2021-000875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457999PMC
September 2021

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018).

COPD 2021 10 16;18(5):567-575. Epub 2021 Sep 16.

Division of Pulmonary and Critical Care Medicine, Wayne State University, Detroit, MI, USA.

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%;  < 0.001), VT/VF (0.14% vs 0.06%;  < 0.001), STEMI (0.22% vs 0.11%;  < 0.001) and NSTEMI (0.65% vs 0.2%;  < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%;  < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (-trend 0.004 and 0.0003) and the trend of mortality had improved (-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.
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http://dx.doi.org/10.1080/15412555.2021.1979500DOI Listing
October 2021

Thrombotic superior vena cava syndrome: a national emergency department database study.

J Thromb Thrombolysis 2021 Aug 3. Epub 2021 Aug 3.

Department of Internal Medicine, Detroit Medical Center, Wayne State University, 4201, St Antoine St., Detroit, MI, 48201, USA.

Literature regarding etiology and trends of incidence of major thoracic vein thrombosis in the United States is limited. To study the causes, complications, in-hospital mortality rate, and trend in the incidence of major thoracic vein thrombosis which could have led to superior vena cava syndrome (SVCS) between 2010 and 2018. Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments (ED) and in-patient sample in the United States were analyzed using diagnostic codes. A linear p-trend was used to assess the trends. Of the total 1082 million ED visits, 37,807 (3.5/100,000) (mean age 53.81 ± 18.07 years, 55% females) patients were recorded with major thoracic vein thrombosis in the ED encounters. Among these patients, 4070 (10.6%) patients had one or more cancers associated with thrombosis. Pacemaker/defibrillator-related thrombosis was recorded in 2820 (7.5%) patients, while intravascular catheter-induced thrombosis was recorded in 1755 (4.55%) patients. Half of the patients had associated complication of pulmonary embolism. A total of 59 (0.15%) patients died during these hospital encounters. The yearly trend for the thrombosis for every 100,000 ED encounters in the United States increased from 2.17/100,000 in 2010 to 5.98/100,000 in 2018 (liner p-trend < 0.001). Yearly trend for catheter/lead associated thrombosis was also up-trending (p-trend 0.015). SVCS is an uncommon medical emergency related to malignancy and indwelling venous devices. The increasing trend in SVCS incidence, predominantly catheter/lead induced, and the high rate of associated pulmonary embolism should prompt physicians to remain vigilant for appropriate evaluation.
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http://dx.doi.org/10.1007/s11239-021-02548-7DOI Listing
August 2021

Trends and complications associated with acute new-onset heart failure: a National Readmissions Database-based cohort study.

Heart Fail Rev 2021 Jul 28. Epub 2021 Jul 28.

Division of Cardiology, Promedica Toledo, Toledo, OH, USA.

Literature regarding recent trends and outcomes of acute new-onset heart failure (AHF) with preserved ejection fraction (AHFpEF) and reduced ejection fraction (AHFrEF) is limited. The objective of this study is to study the outcomes of AHFpEF and AHFrEF in the USA. Data from the National Readmissions Database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA, representing more than 95% of the national population, were analyzed for hospitalization visits for acute heart failure. ICD-9 and ICD-10 codes were used to identify AHF. A total of 2,559,102 adult index AHF patients (mean age 70.79 ± 14.58 years, 49.4% females), 1,028,970 (40.2%) AHFpEF and 1,330,999 (52%) AHFrEF, were recorded in the National Readmissions Database for the years 2016-2018. A total of 152,465 (5.96%) acute heart failure, 47,271 (4.6%) AHFpEF and 91,973 (6.91%) AHFrEF, died during hospitalization, and 45,810 (1.9%) were readmitted in 30 days among alive discharges. Higher complication rates which included ventricular arrhythmias, acute coronary, and cerebrovascular events were observed among AHFrEF than AHFpEF. Higher proportion of patients with AHFrEF needed intensive care unit and ventilatory support during the hospitalization. The trend of incidence of AHFrEF, mortality among AHFrEF, and overall mortality worsened while AHFpEF improved over the study years 2012-2018 (p-trend < 0.05). Coronary procedures improved mortality rates among AHFpEF and AHFrEF. AHF is very common and is associated with significant mortality. The incidence of AHFrEF and mortality among AHFrEF had worsened, which calls for urgent intervention. Improved recognition of AHF is needed, and guideline-directed treatment of underlying risk factors including coronary artery disease can improve mortality. Graphic abstract of the analysis presented (created with BioRender.com).
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http://dx.doi.org/10.1007/s10741-021-10152-3DOI Listing
July 2021

Dexmedetomidine Induced Polyuria in the Intensive Care Unit.

Case Rep Crit Care 2021 20;2021:8850116. Epub 2021 Feb 20.

Division of Nephrology, Wayne State University/Detroit Medical Center, 4201 St Antoine, Detroit, MI 48201, USA.

Dexmedetomidine is an 2-adrenergic used as an adjunct therapy for sedation in the intensive care unit. While it is known to cause polyuria exclusively in perioperative conditions, not many cases are known in the intensive care unit, thus making the diagnosis challenging. We present the case of a 61-year-old male who had developed polyuria secondary to central diabetes insipidus after receiving dexmedetomidine intravenous infusion in the medical ICU. Increased awareness of this uncommon side effect of dexmedetomidine will help clinicians recognize and address it early.
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http://dx.doi.org/10.1155/2021/8850116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920733PMC
February 2021

Sinus Bradycardia and QT Interval Prolongation in West Nile Virus Encephalitis: A Case Report.

Cureus 2019 Jan 3;11(1):e3821. Epub 2019 Jan 3.

Internal Medicine, Detroit Medical Center - Wayne State University, Detroit, USA.

Cardiac arrhythmias were reported in cases of West Nile Virus (WNV) encephalitis; however, the underlying pathophysiology remains incompletely understood. We present a 67-year-old male with altered mental status, later diagnosed with WNV encephalitis. Hospital course was complicated by progressive sinus bradycardia and corrected QT (QTc) prolongation. These findings persisted despite the absence of classical causes and resolved only after improvement of the underlying encephalitis. After excluding classical causes, autonomic dysfunction is one of the proposed mechanisms behind cardiac arrhythmias in WNV encephalitis. Resolution of arrhythmias is expected after the improvement of underlying encephalitis and should be taken into consideration before proceeding for pacemaker placement or other cardiac intervention. Furthermore, this case highlights the importance of continuous cardiac monitoring in WNV encephalitis patients.
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http://dx.doi.org/10.7759/cureus.3821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402859PMC
January 2019

Genetic determinants of risk in pulmonary arterial hypertension: international genome-wide association studies and meta-analysis.

Lancet Respir Med 2019 03 5;7(3):227-238. Epub 2018 Dec 5.

Medstar Health, Washington, DC, USA.

Background: Rare genetic variants cause pulmonary arterial hypertension, but the contribution of common genetic variation to disease risk and natural history is poorly characterised. We tested for genome-wide association for pulmonary arterial hypertension in large international cohorts and assessed the contribution of associated regions to outcomes.

Methods: We did two separate genome-wide association studies (GWAS) and a meta-analysis of pulmonary arterial hypertension. These GWAS used data from four international case-control studies across 11 744 individuals with European ancestry (including 2085 patients). One GWAS used genotypes from 5895 whole-genome sequences and the other GWAS used genotyping array data from an additional 5849 individuals. Cross-validation of loci reaching genome-wide significance was sought by meta-analysis. Conditional analysis corrected for the most significant variants at each locus was used to resolve signals for multiple associations. We functionally annotated associated variants and tested associations with duration of survival. All-cause mortality was the primary endpoint in survival analyses.

Findings: A locus near SOX17 (rs10103692, odds ratio 1·80 [95% CI 1·55-2·08], p=5·13 × 10) and a second locus in HLA-DPA1 and HLA-DPB1 (collectively referred to as HLA-DPA1/DPB1 here; rs2856830, 1·56 [1·42-1·71], p=7·65 × 10) within the class II MHC region were associated with pulmonary arterial hypertension. The SOX17 locus had two independent signals associated with pulmonary arterial hypertension (rs13266183, 1·36 [1·25-1·48], p=1·69 × 10; and rs10103692). Functional and epigenomic data indicate that the risk variants near SOX17 alter gene regulation via an enhancer active in endothelial cells. Pulmonary arterial hypertension risk variants determined haplotype-specific enhancer activity, and CRISPR-mediated inhibition of the enhancer reduced SOX17 expression. The HLA-DPA1/DPB1 rs2856830 genotype was strongly associated with survival. Median survival from diagnosis in patients with pulmonary arterial hypertension with the C/C homozygous genotype was double (13·50 years [95% CI 12·07 to >13·50]) that of those with the T/T genotype (6·97 years [6·02-8·05]), despite similar baseline disease severity.

Interpretation: This is the first study to report that common genetic variation at loci in an enhancer near SOX17 and in HLA-DPA1/DPB1 is associated with pulmonary arterial hypertension. Impairment of SOX17 function might be more common in pulmonary arterial hypertension than suggested by rare mutations in SOX17. Further studies are needed to confirm the association between HLA typing or rs2856830 genotyping and survival, and to determine whether HLA typing or rs2856830 genotyping improves risk stratification in clinical practice or trials.

Funding: UK NIHR, BHF, UK MRC, Dinosaur Trust, NIH/NHLBI, ERS, EMBO, Wellcome Trust, EU, AHA, ACClinPharm, Netherlands CVRI, Dutch Heart Foundation, Dutch Federation of UMC, Netherlands OHRD and RNAS, German DFG, German BMBF, APH Paris, INSERM, Université Paris-Sud, and French ANR.
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http://dx.doi.org/10.1016/S2213-2600(18)30409-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391516PMC
March 2019

Ventilator associated tracheobronchitis: A call for more evidence.

Lung India 2017 May-Jun;34(3):223-224

Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Wayne State University-School of Medicine, Harper University Hospital, Detroit Medical Center, Detroit, MI, USA.

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http://dx.doi.org/10.4103/lungindia.lungindia_143_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5427747PMC
May 2017

Prevalence, Predictors, and Outcomes of Pulmonary Hypertension in CKD.

J Am Soc Nephrol 2016 Mar 18;27(3):877-86. Epub 2015 Sep 18.

Department of Nephrology, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio; and.

Pulmonary hypertension (PH) is associated with poor outcomes in the dialysis and general populations, but its effect in CKD is unclear. We evaluated the prevalence and predictors of PH measures and their associations with long-term clinical outcomes in patients with nondialysis-dependent CKD. Chronic Renal Insufficiency Cohort (CRIC) Study participants who had Doppler echocardiography performed were considered for inclusion. PH was defined as the presence of estimated pulmonary artery systolic pressure (PASP) >35 mmHg and/or tricuspid regurgitant velocity (TRV) >2.5 m/s. Associations between PH, PASP, and TRV and cardiovascular events, renal events, and all-cause mortality were examined using Cox proportional hazards models. Of 2959 eligible participants, 21% (n=625) had PH, with higher rates among those with lower levels of kidney function. In the multivariate model, older age, anemia, lower left ventricular ejection fraction, and presence of left ventricular hypertrophy were associated with greater odds of having PH. After adjusting for relevant confounding variables, PH was independently associated with higher risk for death (hazard ratio, 1.38; 95% confidence interval, 1.10 to 1.72) and cardiovascular events (hazard ratio, 1.23; 95% confidence interval, 1.00 to 1.52) but not renal events. Similarly, TRV and PASP were associated with death and cardiovascular events but not renal events. In this study of patients with CKD and preserved left ventricular systolic function, we report a high prevalence of PH. PH and higher TRV and PASP (echocardiographic measures of PH) are associated with adverse outcomes in CKD. Future studies may explain the mechanisms that underlie these findings.
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http://dx.doi.org/10.1681/ASN.2014111111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769189PMC
March 2016

Pulmonary Hypertension an Independent Risk Factor for Death in Intensive Care Unit: Correlation of Hemodynamic Factors with Mortality.

Clin Med Insights Circ Respir Pulm Med 2015 23;9:27-33. Epub 2015 Jun 23.

Division of Pulmonary and Critical care, Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA.

Objective: Critically ill patients with pulmonary hypertension (PH) pose additional challenges due to the existence of right ventricular (RV) dysfunction. The purpose of this study was to assess the impact of hemodynamic factors on the outcome.

Methods: We reviewed the records of patients with a diagnosis of PH admitted to the intensive care unit. In addition to evaluating traditional hemodynamic parameters, we defined severe PH as right atrial pressure >20 mmHg, mean pulmonary artery pressure >55 mmHg, or cardiac index (CI) <2 L/min/m(2). We also defined the RV functional index (RFI) as pulmonary artery systolic pressure (PASP) adjusted for CI as PASP/CI; increasing values reflect RV dysfunction.

Results: Fifty-three patients (mean age 60 years, 72% women, 79% Blacks), were included in the study. Severe PH was present in 68% of patients who had higher Sequential Organ Failure Assessment (SOFA) score (6.8 ± 3.3 vs 3.8 ± 1.6; P = 0.001) and overall in-hospital mortality (36% vs 6%; P = 0.02) compared to nonsevere patients, although Acute Physiology and Chronic Health Evaluation (APACHE) II scores (19.9 ± 7.5 vs 18.5 ± 6.04; P = 0.52) were similar and sepsis was more frequent among nonsevere PH patients (31 vs 64%; P = 0.02). Severe PH (P = 0.04), lower mean arterial pressure (P = 0.04), and CI (P = 0.01); need for invasive ventilation (P = 0.02) and vasopressors (P = 0.03); and higher SOFA (P = 0.001), APACHE II (P = 0.03), pulmonary vascular resistance index (PVRI) (P = 0.01), and RFI (P = 0.004) were associated with increased mortality. In a multivariate model, SOFA [OR = 1.45, 95% confidence interval (C.I.) = 1.09-1.93; P = 0.01], PVRI (OR = 1.12, 95% C.I. = 1.02-1.24; P = 0.02), and increasing RFI (OR = 1.06, 95% C.I. = 1.01-1.11; P = 0.01) were independently associated with mortality.

Conclusion: PH is an independent risk factor for mortality in critically ill patients. Composite factors rather than individual hemodynamic parameters are better predictors of outcome. Monitoring of RV function using composite hemodynamic factors resulting in specific interventions is likely to improve survival and needs to be studied further.
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http://dx.doi.org/10.4137/CCRPM.S22199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479167PMC
June 2015

Ventilator-associated pneumonia in advanced lung disease: A wakeup call.

Authors:
Ghulam Saydain

Lung India 2014 Jan;31(1):1-3

Department of Internal Medicine, Pulmonary Critical Care and Sleep Division, Wayne State University, School of Medicine, Detroit, Michigan, USA E-mail:

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http://dx.doi.org/10.4103/0970-2113.125884DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960802PMC
January 2014

Asymmetric pulmonary artery occlusion pressure opens window to pulmonary venous stenosis.

Am J Respir Crit Care Med 2013 Sep;188(5):621

Indiana University Health Physicians, Indianapolis, USA.

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http://dx.doi.org/10.1164/rccm.201302-0223IMDOI Listing
September 2013

Early recognition and management of pulmonary arterial hypertension: a case for profiling.

Oman Med J 2012 Jan;27(1):1-2

Pulmonary Critical Care & Sleep Division, Wayne State University, School of Medicine, 3990 John R Street, 3 Hudson, Detroit MI 48201.

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http://dx.doi.org/10.5001/omj.2012.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282128PMC
January 2012

Hypotension after medical termination of pregnancy: think outside of the uterus.

J Emerg Med 2012 Jul 9;43(1):50-3. Epub 2012 Feb 9.

Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan, USA.

Background: Under usual circumstances, an ectopic pregnancy would not be generally considered in the initial differential diagnosis of shock after voluntary termination of pregnancy.

Objective: To present a rare case of a young woman with shock after voluntary termination of pregnancy due to undiagnosed ectopic pregnancy with concealed hemorrhage.

Case Report: A 37-year-old woman presented to the Emergency Department (ED) 3 days after termination of pregnancy with clinical features of shock. The patient had some evidence of infection and was initially managed as a case of septic shock secondary to possible complication of recent termination of pregnancy. Subsequent work-up led to suspicion of internal bleeding, and ruptured ectopic pregnancy was confirmed and managed successfully.

Conclusion: Ruptured ectopic pregnancy can present with a wide range of symptoms and under variable circumstances. Recognition of subtle signs of hemorrhage and consideration of the diagnosis of ruptured pregnancy in the ED will lead to early diagnosis and appropriate management.
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http://dx.doi.org/10.1016/j.jemermed.2011.06.140DOI Listing
July 2012

Outcome of patients with injection drug use-associated endocarditis admitted to an intensive care unit.

J Crit Care 2010 Jun 11;25(2):248-53. Epub 2009 Nov 11.

Pulmonary, Critical Care and Sleep Division, Wayne State University, Detroit, MI 48201, USA.

Purpose: The purpose of this study was to study the outcome of patients with injection drug use-associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU).

Material And Methods: A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted.

Results: Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival.

Conclusions: Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.
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http://dx.doi.org/10.1016/j.jcrc.2009.09.007DOI Listing
June 2010

Achieving durable glucose control in the intensive care unit without hypoglycaemia: a new practical IV insulin protocol.

Diabetes Metab Res Rev 2007 Jan;23(1):49-55

Department of Medicine, Huntington Hospital, Huntington, NY 11743, USA.

Background: Hyperglycaemia occurs in a substantial portion of critically ill patients in our intensive care units. Near normalization of elevated blood glucose levels with IV insulin may improve outcome. However, currently published IV insulin protocol are not ideal; most are relatively complex and often result in hypoglycaemia. We designed a protocol that would be practical to use while incorporating the necessary complexities required to achieve good glucose control, coupled with a low incidence hypoglycaemia.

Methods: The essential part of the protocol is a matrix specifying the amount by which an insulin flow rate is to be changed. The intersection of the current and the previous blood glucose values on the matrix locates the appropriate cell containing the required change in insulin flow rate. No additional calculations or tables are required.

Results: The initial glucose level obtained by blood glucose meter (BGM) averaged 253.5 +/- 95.6 mg/dL and fell below 140 within 9.3 h on the protocol. The average BGM on the protocol was 133.5 +/- 43.9 mg/dL. Only 0.09% of all glucose values were <40 mg/dL and insulin had to be held only 2.2% of the time on the protocol. Physician input was not required and nursing accuracy in applying the protocol was greater than 94%. This protocol has been adopted as the default IV insulin protocol for the NorthShore-LIJ Health System and several other medical centers.

Conclusion: A practical IV insulin protocol that has been extensively tested is presented. The protocol has been implemented at multiple institutions indicating its ease of use and excellent results.
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http://dx.doi.org/10.1002/dmrr.673DOI Listing
January 2007

Clinical significance of elevated diffusing capacity.

Chest 2004 Feb;125(2):446-52

Pulmonary and Critical Care Division, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA.

Study Objective: Single-breath diffusing capacity of the lung for carbon monoxide (DLCO) is used as a pulmonary function test (PFT) to assess gas transfer in the lungs. The implications of a low DLCO are well-recognized, but the clinical significance of a high DLCO is not clear. The aim of this study was to identify the clinical correlates of a high DLCO.

Patients And Methods: We identified 245 patients with a high DLCO (ie, > 140% predicted) and a matched group of 245 patients with normal DLCO (ie, 85 to 115% predicted), who were selected from a laboratory database of 45,000 patients tested between January 1997 and December 1999. We compared the demographic features, clinical diagnoses, and PFT data between the two groups.

Settings: Large multispecialty group practice.

Results: The patients in the high DLCO group were heavier (mean [+/- SD] weight, 96.0 +/- 22.9 vs 85.0 +/- 21.3 kg, respectively; p < 0.001), had a higher mean body mass index (32.9 +/- 7.4 vs 29.4 +/- 6.4 kg/m(2), respectively; p < 0.001), larger body surface area (p < 0.001), and larger mean total lung capacity (p = 0.007) and alveolar volume (p < 0.001). The clinical diagnoses of obesity (p < 0.001) and asthma (p < 0.001) were more common among patients with high DLCO values. The majority of patients (62%) with a high DLCO had a diagnosis of obesity, asthma, or both. Polycythemia, hemoptysis, and left-to-right shunt were uncommon.

Conclusion: A high DLCO on a PFT is most frequently associated with large lung volumes, obesity, and asthma. Other conditions are much less common. A clinical condition, which typically reduces DLCO, may deceptively normalize DLCO in such patients.
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http://dx.doi.org/10.1378/chest.125.2.446DOI Listing
February 2004

New therapies: plasmapheresis, intravenous immunoglobulin, and monoclonal antibodies.

Crit Care Clin 2002 Oct;18(4):957-75

Division of Pulmonary and Critical Care, Department of Medicine, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA.

Rheumatologic emergencies may pose a serious threat to life, and the treatment of patients with these illnesses continues to be challenging. In the last decade extensive animal and human research has led to development of new therapies. Considerable progress has been made in the therapy for RA. Newly developed biologic therapies have shown promising results in clinical studies, and two agents have already been approved by the FDA. These drugs are currently available for therapy and are under close postmarketing scrutiny to assess long-term efficacy and safety. Similar therapies are under investigation for SLE. Plasmapheresis, once used for many diseases, is now restricted mostly to conditions for which its use has been shown to be beneficial in randomized, controlled studies. Immunoadsorption is used to target specific disease-producing pathogens for removal during extracorporeal therapy. Evidence is accumulating for the use of IVIGs in several immune-mediated conditions. The outlook for some emergencies continues be grim, however, and various therapies are used based on evidence from anecdotal case reports and case series. The new therapies are relatively safe, but careful monitoring is needed, because there is potential for serious adverse events.
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http://dx.doi.org/10.1016/s0749-0704(02)00028-3DOI Listing
October 2002

Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit.

Am J Respir Crit Care Med 2002 Sep;166(6):839-42

Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.

This retrospective study describes the clinical course of 38 patients with idiopathic pulmonary fibrosis (IPF) admitted to the intensive care unit (ICU). There were 25 males and 13 females who were the mean age of 68.3 +/- 11.5 years. Twenty patients were on corticosteroids at the time of admission to the hospital, and 24 had been on home oxygen therapy. The most common reason for ICU admission was respiratory failure. The Acute Physiology and Chronic Health Evaluation III-predicted ICU and hospital mortality rates were 12% and 26%, whereas the actual ICU and hospital mortality rates were 45% and 61%, respectively. We did not find significant differences in pulmonary function or echocardiogram findings between survivors and nonsurvivors. Mechanical ventilation was used in 19 patients (50%). Sepsis developed in nine patients. Multiple organ failure developed in 14% of the survivors and in 43% of the nonsurvivors (p = 0.14). Ninety-two percent of the hospital survivors died at a median of 2 months after discharge. These findings suggest that patients with IPF admitted to the ICU have poor short- and long-term prognosis. Patients with IPF and their families should be informed about the overall outlook when they make decisions about life support and ICU care.
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http://dx.doi.org/10.1164/rccm.2104038DOI Listing
September 2002
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