Publications by authors named "Patrick G Lyons"

26 Publications

  • Page 1 of 1

Communication Training in Adult and Pediatric Critical Care Medicine. A Systematic Review.

ATS Sch 2020 Jul 14;1(3):316-330. Epub 2020 Jul 14.

Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri.

Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. The 23 publications meeting inclusion criteria fell into the following study classifications: intervention ( = 15), cross-sectional survey ( = 5), and instrument validation ( = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.
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http://dx.doi.org/10.34197/ats-scholar.2019-0017REDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043309PMC
July 2020

Comparison of Sepsis Definitions as Automated Criteria.

Crit Care Med 2021 04;49(4):e433-e443

Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, MO.

Objectives: Assess the impact of heterogeneity among established sepsis criteria (Sepsis-1, Sepsis-3, Centers for Disease Control and Prevention Adult Sepsis Event, and Centers for Medicare and Medicaid severe sepsis core measure 1) through the comparison of corresponding sepsis cohorts.

Design: Retrospective analysis of data extracted from electronic health record.

Setting: Single, tertiary-care center in St. Louis, MO.

Patients: Adult, nonsurgical inpatients admitted between January 1, 2012, and January 6, 2018.

Interventions: None.

Measurements And Main Results: In the electronic health record data, 286,759 encounters met inclusion criteria across the study period. Application of established sepsis criteria yielded cohorts varying in prevalence: Centers for Disease Control and Prevention Adult Sepsis Event (4.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (4.8%), International Classification of Disease code (7.2%), Sepsis-3 (7.5%), and Sepsis-1 (11.3%). Between the two modern established criteria, Sepsis-3 (n = 21,550) and Centers for Disease Control and Prevention Adult Sepsis Event (n = 12,494), the size of the overlap was 7,763. The sepsis cohorts also varied in time from admission to sepsis onset (hr): Sepsis-1 (2.9), Sepsis-3 (4.1), Centers for Disease Control and Prevention Adult Sepsis Event (4.6), and Centers for Medicare and Medicaid severe sepsis core measure 1 (7.6); sepsis discharge International Classification of Disease code rate: Sepsis-1 (37.4%), Sepsis-3 (40.1%), Centers for Medicare and Medicaid severe sepsis core measure 1 (48.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (54.5%); and inhospital mortality rate: Sepsis-1 (13.6%), Sepsis-3 (18.8%), International Classification of Disease code (20.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (22.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (24.1%).

Conclusions: The application of commonly used sepsis definitions on a single population produced sepsis cohorts with low agreement, significantly different baseline demographics, and clinical outcomes.
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http://dx.doi.org/10.1097/CCM.0000000000004875DOI Listing
April 2021

Racial Disparities in Readmissions Following Initial Hospitalization for Sepsis.

Crit Care Med 2021 Mar;49(3):e258-e268

Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO.

Objectives: To assess whether Black race is associated with a higher rate of all-cause readmission compared with White race following community-onset sepsis.

Design: Retrospective cohort study.

Setting: One-thousand three-hundred bed urban academic medical centers.

Patients: Three-thousand three-hundred ninety patients hospitalized with community-onset sepsis between January 1, 2010, and December 31, 2017.

Interventions: Community-onset sepsis was defined as patients admitted through the emergency department with an International Classification of Disease, ninth revision, Clinical Modification code for either severe sepsis (995.92) or septic shock (785.52). Beginning in 2015, we used International Classification of Disease, Tenth Revision, Clinical Modification codes R65.20 (severe sepsis) and R65.21 (septic shock). We excluded those individuals hospitalized at another acute care facility that were transferred to our facility. Race was abstracted electronically, and patients who expired or self-identified as a race other than Black or White race were excluded. Patients who experienced a subsequent hospitalization at our facility were considered to be readmitted.

Measurements And Main Results: Compared with White race, Black race demonstrated a significantly higher rate of all-cause readmission (60.8% vs 71.1%; p < 0.001), including a higher rate of readmission for sepsis (14.0% vs 19.8%; p < 0.001). Black patients also resided in zip codes with a lower median household income and were more likely to use public insurance compared with White race. Similar rates of comorbid diseases and disease burden were observed between the two groups, but vasopressors were less likely to be administered to Black patients. Multivariable analysis showed that Black race was associated with a 50% increased odds (odds ratio, 1.52, 99% CI, 1.25-1.84) in all-cause readmission risk compared with White race.

Conclusions: Black race was associated with a higher rate of all-cause and sepsis readmission, possibly as a result of unaddressed health disparities, compared with White race. Programs addressing healthcare disparities should use readmission as another marker of equity.
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http://dx.doi.org/10.1097/CCM.0000000000004809DOI Listing
March 2021

The Clinical Course of Coronavirus Disease 2019 in a US Hospital System: A Multistate Analysis.

Am J Epidemiol 2021 04;190(4):539-552

There are limited data on longitudinal outcomes for coronavirus disease 2019 (COVID-19) hospitalizations that account for transitions between clinical states over time. Using electronic health record data from a hospital network in the St. Louis, Missouri, region, we performed multistate analyses to examine longitudinal transitions and outcomes among hospitalized adults with laboratory-confirmed COVID-19 with respect to 15 mutually exclusive clinical states. Between March 15 and July 25, 2020, a total of 1,577 patients in the network were hospitalized with COVID-19 (49.9% male; median age, 63 years (interquartile range, 50-75); 58.8% Black). Overall, 34.1% (95% confidence interval (CI): 26.4, 41.8) had an intensive care unit admission and 12.3% (95% CI: 8.5, 16.1) received invasive mechanical ventilation (IMV). The risk of decompensation peaked immediately after admission; discharges peaked around days 3-5, and deaths plateaued between days 7 and 16. At 28 days, 12.6% (95% CI: 9.6, 15.6) of patients had died (4.2% (95% CI: 3.2, 5.2) had received IMV) and 80.8% (95% CI: 75.4, 86.1) had been discharged. Among those receiving IMV, 35.1% (95% CI: 28.2, 42.0) remained intubated after 14 days; after 28 days, 37.6% (95% CI: 30.4, 44.7) had died and only 37.7% (95% CI: 30.6, 44.7) had been discharged. Multistate methods offer granular characterizations of the clinical course of COVID-19 and provide essential information for guiding both clinical decision-making and public health planning.
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http://dx.doi.org/10.1093/aje/kwaa286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799307PMC
April 2021

Patient Safety and Resident Schedules without 24-Hour Shifts.

N Engl J Med 2020 09;383(13):1286-1287

University of California, San Francisco, San Francisco, CA.

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http://dx.doi.org/10.1056/NEJMc2025843DOI Listing
September 2020

Closing the Brief Case: "Not Positive" or "Not Sure"-COVID-19-Negative Results in a Symptomatic Patient.

J Clin Microbiol 2020 07 23;58(8). Epub 2020 Jul 23.

Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA

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http://dx.doi.org/10.1128/JCM.01196-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383537PMC
July 2020

The Brief Case: "Not Positive" or "Not Sure"-COVID-19-Negative Results in a Symptomatic Patient.

J Clin Microbiol 2020 Jul 23;58(8). Epub 2020 Jul 23.

Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA

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http://dx.doi.org/10.1128/JCM.01195-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383542PMC
July 2020

Bloodstream Infections and Delayed Antibiotic Coverage Are Associated With Negative Hospital Outcomes in Hematopoietic Stem Cell Transplant Recipients.

Chest 2020 10 17;158(4):1385-1396. Epub 2020 Jun 17.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO; Siteman Cancer Center, St. Louis, MO; Healthcare Innovation Lab, BJC HealthCare, St. Louis, MO. Electronic address:

Background: Bloodstream infections (BSIs) are common after hematopoietic stem cell transplantation (HSCT) and are associated with increased long-term morbidity and mortality. However, short-term outcomes related to BSI in this population remain unknown. More specifically, it is unclear whether choices related to empiric antimicrobials for potentially infected patients are associated with patient outcomes.

Research Question: Are potential delays in appropriate antibiotics associated with hospital outcomes among HSCT recipients with BSI?

Study Design And Methods: We conducted a retrospective cohort study at a large comprehensive inpatient academic cancer center between January 2014 and June 2017. We identified all admissions for HSCT and prior recipients of HSCT. We defined potential delay in appropriate antibiotics as > 24 h between positive blood culture results and the initial dose of an antimicrobial with activity against the pathogen.

Results: We evaluated 2,751 hospital admissions from 1,086 patients. Of these admissions, 395 (14.4%) involved one or more BSIs. Of these 395 hospitalizations, 44 (11.1%) involved potential delays in appropriate antibiotics. The incidence of mortality was higher in BSI hospitalizations than in those without BSI (23% vs 4.5%; P < .001). In multivariable analysis, BSI was an independent predictor of mortality (OR, 8.14; 95% CI, 5.06-13.1; P < .001). Mortality was higher for admissions with potentially delayed appropriate antibiotics than for those with appropriate antibiotics (48% vs 20%; P < .001). Potential delay in antibiotics was also an independent predictor of mortality in multivariable analysis (OR, 13.8; 95% CI, 5.27-35.9; P < .001).

Interpretation: BSIs were common and independently associated with increased morbidity and mortality. Delays in administration of appropriate antimicrobials were identified as an important factor in hospital morbidity and mortality. These findings may have important implications for our current practice of empiric antibiotic treatment in HSCT patients.
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http://dx.doi.org/10.1016/j.chest.2020.06.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545481PMC
October 2020

Accuracy of Clinicians' Ability to Predict the Need for Intensive Care Unit Readmission.

Ann Am Thorac Soc 2020 07;17(7):847-853

Department of Medicine, University of Wisconsin, Madison, Wisconsin.

Determining when an intensive care unit (ICU) patient is ready for discharge to the ward is a complex daily challenge for any ICU care team. Patients who experience unplanned readmissions to the ICU have increased mortality, length of stay, and cost compared with those not readmitted during their hospital stay. The accuracy of clinician prediction for ICU readmission is unknown. To determine the accuracy of ICU physicians and nurses for predicting ICU readmissions We conducted a prospective study in the medical ICU of an academic hospital from October 2015 to September 2017. After daily rounding for patients being transferred to the ward, ICU clinicians (nurses, residents, fellows, and attendings) were asked to report the likelihood of readmission within 48 hours (using a 1-10 scale, with 10 being "extremely likely"). The accuracy of the clinician prediction score (1-10) was assessed for all clinicians and by clinician type using sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic curve for predicting the primary outcome, which was ICU readmission within 48 hours of ICU discharge. A total of 2,833 surveys was collected for 938 ICU-to-ward transfers, of which 40 (4%) were readmitted to the ICU within 48 hours of transfer. The median clinician likelihood of readmission score was 3 (interquartile range, 2-4). When physician and nurse likelihood scores were combined, the median clinician likelihood score had an AUC of 0.70 (95% confidence interval [CI], 0.62-0.78) for predicting ICU readmission within 48 hours. Nurses were significantly more accurate than interns at predicting 48-hour ICU readmission (AUC, 0.73 [95% CI, 0.64-0.82] vs. AUC, 0.60 [95% CI, 0.49-0.71];  = 0.03). All other pairwise comparisons were not significantly different for predicting ICU readmission within 48 hours ( > 0.05 for all comparisons). We found that all clinicians surveyed in our ICU, regardless of the level of experience or clinician type, had only fair accuracy for predicting ICU readmission. Further research is needed to determine if clinical decision support tools would provide prognostic value above and beyond clinical judgment for determining who is ready for ICU discharge.
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http://dx.doi.org/10.1513/AnnalsATS.201911-828OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328179PMC
July 2020

The authors reply.

Crit Care Med 2020 02;48(2):e152-e153

Department of Medicine, Washington University School of Medicine, St. Louis, MO Department of Medicine, University of Chicago, Chicago, IL.

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http://dx.doi.org/10.1097/CCM.0000000000004117DOI Listing
February 2020

Characteristics of Rapid Response Calls in the United States: An Analysis of the First 402,023 Adult Cases From the Get With the Guidelines Resuscitation-Medical Emergency Team Registry.

Crit Care Med 2019 10;47(10):1283-1289

Department of Medicine, University of Chicago, Chicago, IL.

Objectives: To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation-Medical Emergency Team cohort between 2005 and 2015.

Design: Retrospective multicenter cohort study.

Setting: Three hundred sixty U.S. hospitals.

Patients: Consecutive adult patients experiencing rapid response team activation.

Interventions: Rapid response team activation.

Measurements And Main Results: The cohort included 402,023 rapid response team activations from 347,401 unique healthcare encounters. Respiratory triggers (38.0%) and cardiac triggers (37.4%) were most common. The most frequent interventions-pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%)-were noninvasive. Fluids were the most common medication ordered (19.3%), but new antibiotic orders were rare (1.2%). More than 10% of rapid response teams resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations.

Conclusions: Although patients requiring rapid response team activation have high inpatient mortality, most rapid response team activations involve relatively few interventions, which may limit these teams' ability to improve patient outcomes.
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http://dx.doi.org/10.1097/CCM.0000000000003912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189351PMC
October 2019

Factors Associated With Clinical Deterioration Among Patients Hospitalized on the Wards at a Tertiary Cancer Hospital.

J Oncol Pract 2019 08 15;15(8):e652-e665. Epub 2019 Jul 15.

1Washington University School of Medicine, St Louis, MO.

Purpose: Patients hospitalized outside the intensive care unit (ICU) frequently experience clinical deterioration. Little has been done to describe the landscape of clinical deterioration among inpatients with cancer. We aimed to describe the frequency of clinical deterioration among patients with cancer hospitalized on the wards at a major academic hospital and to identify independent risk factors for clinical deterioration among these patients.

Methods: This was a retrospective cohort study at a 1,300-bed urban academic hospital with a 138-bed inpatient cancer center. We included consecutive admissions to the oncology wards between January 1, 2014, and June 30, 2017. We defined clinical deterioration as the composite of ward death and transfer to the ICU.

Results: We evaluated 21,219 admissions from 9,058 patients. The composite outcome occurred during 1,945 admissions (9.2%): 1,365 (6.4%) had at least one ICU transfer, and 580 (2.7%) involved ward death. Logistic regression identified several independent risk factors for clinical deterioration, including the following: age (odds ratio [OR], 1.33 per decade; 95% CI, 1.07 to 1.67), male sex (OR, 1.15; 95% CI, 1.05 to 1.33), comorbidities, illness severity (OR, 1.11; 95% CI, 1.10 to 1.13), emergency admission (OR, 1.45; 95% CI, 1.26 to 1.67), hospitalization on particular wards (OR, 1.525; 95% CI, 1.326 to 1.67), bacteremia (OR, 1.24; 95% CI, 1.01 to 1.52), fungemia (OR, 3.76; 95% CI, 1.90 to 7.41), tumor lysis syndrome (OR, 3.01; 95% CI, 2.41 to 3.76), and receipt of antimicrobials (OR, 2.04; 95% CI, 1.72 to 2.42) and transfusions (OR, 1.65; 95% CI, 1.42 to 1.92).

Conclusion: Clinical deterioration was common; it occurred in more than 9% of admissions. Factors independently associated with deterioration included comorbidities, admission source, infections, and blood product transfusion.
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http://dx.doi.org/10.1200/JOP.18.00765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694031PMC
August 2019

Characterising ICU-ward handoffs at three academic medical centres: process and perceptions.

BMJ Qual Saf 2019 08 12;28(8):627-634. Epub 2019 Jan 12.

Department of Medicine, University of Chicago, Chicago, Illinois, USA.

Background: There is limited literature about physician handoffs between the intensive care unit (ICU) and the ward, and best practices have not been described. These patients are uniquely vulnerable given their medical complexity, diagnostic uncertainty and reduced monitoring intensity. We aimed to characterise the structure, perceptions and processes of ICU-ward handoffs across three teaching hospitals using multimodal methods: by identifying the handoff components involved in communication failures and describing common processes of patient transfer.

Methods: We conducted a study at three academic medical centres using two methods to characterise the structure, perceptions and processes of ICU-ward transfers: (1) an anonymous resident survey characterising handoff communication during ICU-ward transfer, and (2) comparison of process maps to identify similarities and differences between ICU-ward transfer processes across the three hospitals.

Results: Of the 295 internal medicine residents approached, 175 (59%) completed the survey. 87% of the respondents recalled at least one adverse event related to communication failure during ICU-ward transfer. 95% agreed that a well-structured handoff template would improve ICU-ward transfer. Rehabilitation needs, intravenous access/hardware and risk assessments for readmission to the ICU were the most frequently omitted or incorrectly communicated components of handoff notes. More than 60% of the respondents reported that notes omitted or miscommunicated pending results, active subspecialty consultants, nutrition and intravenous fluids, antibiotics, and healthcare decision-maker information at least twice per month. Despite variable process across the three sites, all process maps demonstrated flaws and potential for harm in critical steps of the ICU-ward transition.

Conclusion: In this multisite study, despite significant process variation across sites, almost all resident physicians recalled an adverse event related to the ICU-ward handoff. Future work is needed to determine best practices for ICU-ward handoffs at academic medical centres.
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http://dx.doi.org/10.1136/bmjqs-2018-008328DOI Listing
August 2019

Prevention of hospital-acquired pneumonia.

Curr Opin Crit Care 2018 10;24(5):370-378

Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.

Purpose Of Review: Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental.

Recent Findings: Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens.

Summary: Most potential HAP prevention strategies remain unproven.
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http://dx.doi.org/10.1097/MCC.0000000000000523DOI Listing
October 2018

Rapid response systems.

Resuscitation 2018 07 16;128:191-197. Epub 2018 May 16.

Department of Medicine, University of Chicago, Chicago, IL, United States. Electronic address:

Introduction: Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems.

Aims: We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation.

Data Sources: Articles written in English and published in PubMed.

Results: Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement.

Conclusions: Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.
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http://dx.doi.org/10.1016/j.resuscitation.2018.05.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6147149PMC
July 2018

Sepsis-Associated Coagulopathy Severity Predicts Hospital Mortality.

Crit Care Med 2018 05;46(5):736-742

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO.

Objectives: To assess whether sepsis-associated coagulopathy predicts hospital mortality.

Design: Retrospective cohort study.

Setting: One-thousand three-hundred beds urban academic medical center.

Patients: Six-thousand one-hundred forty-eight consecutive patients hospitalized between January 1, 2010, and December 31, 2015.

Interventions: Mild sepsis-associated coagulopathy was defined as an international normalized ratio greater than or equal to 1.2 and less than 1.4 plus platelet count less than or equal to 150,000/µL but greater than 100,000/µL; moderate sepsis-associated coagulopathy was defined with either an international normalized ratio greater than or equal to 1.4 but less than 1.6 or platelets less than or equal to 100,000/µL but greater than 80,000/µL; severe sepsis-associated coagulopathy was defined as an international normalized ratio greater than or equal to 1.6 and platelets less than or equal to 80,000/µL.

Measurements And Main Results: Hospital mortality increased progressively from 25.4% in patients without sepsis-associated coagulopathy to 56.1% in patients with severe sepsis-associated coagulopathy. Similarly, duration of hospitalization and ICU care increased progressively as sepsis-associated coagulopathy severity increased. Multivariable analyses showed that the presence of sepsis-associated coagulopathy, as well as sepsis-associated coagulopathy severity, was independently associated with hospital mortality regardless of adjustments made for baseline patient characteristics, hospitalization variables, and the sepsis-associated coagulopathy-cancer interaction. Odds ratios ranged from 1.33 to 2.14 for the presence of sepsis-associated coagulopathy and from 1.18 to 1.51 for sepsis-associated coagulopathy severity for predicting hospital mortality (p < 0.001 for all comparisons).

Conclusions: The presence of sepsis-associated coagulopathy identifies a group of patients with sepsis at higher risk for mortality. Furthermore, there is an incremental risk of mortality as the severity of sepsis-associated coagulopathy increases.
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http://dx.doi.org/10.1097/CCM.0000000000002997DOI Listing
May 2018

Summary for Clinicians: Lymphangioleiomyomatosis Diagnosis and Management Clinical Practice Guideline.

Ann Am Thorac Soc 2017 07;14(7):1073-1075

8 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1513/AnnalsATS.201609-685CMEDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566288PMC
July 2017

Association Between Opioid and Benzodiazepine Use and Clinical Deterioration in Ward Patients.

J Hosp Med 2017 06;12(6):428-434

The University of Chicago Medicine, Department of Medicine, Section of Pulmonary and Critical Care Medicine, Chicago, Illinois.

Background: Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications.

Objective: To determine the association between opioid and benzodiazepine administration and clinical deterioration.

Design: Observational cohort study.

Setting: 500-bed academic urban tertiary-care hospital.

Patients: All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were "comfort care" status, had tracheostomies, sickle-cell disease, and patients at risk for alcohol withdrawal or seizures were excluded.

Measurements: The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete-time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score.

Results: In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013-1.026; P < 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16- 1.45; P < 0.001).

Conclusion: Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward-monitoring strategies. Journal of Hospital Medicine 2017;12:428-434.
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http://dx.doi.org/10.12788/jhm.2749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695213PMC
June 2017

Treatment of Drug-Susceptible Tuberculosis.

Ann Am Thorac Soc 2016 11;13(11):2060-2063

4 Division of Pulmonary Disease and Critical Care Medicine, Mount Auburn Hospital, Cambridge, Massachusetts.

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http://dx.doi.org/10.1513/AnnalsATS.201607-567CMEDOI Listing
November 2016

In response to "Obstructive sleep apnea and adverse outcomes in surgical and nonsurgical patients on the wards".

J Hosp Med 2016 Feb 25;11(2):157. Epub 2015 Nov 25.

Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1002/jhm.2516DOI Listing
February 2016

Obstructive sleep apnea and adverse outcomes in surgical and nonsurgical patients on the wards.

J Hosp Med 2015 Sep 13;10(9):592-8. Epub 2015 Jun 13.

Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Chicago Medicine, Chicago, Illinois.

Background: Obstructive sleep apnea (OSA) has been associated with clinical deterioration in postoperative patients and patients hospitalized with pneumonia. Paradoxically, OSA has also been associated with decreased risk of inpatient mortality in these same populations.

Objectives: To investigate the association between OSA and in-hospital mortality in a large cohort of surgical and nonsurgical ward patients.

Design: Observational cohort study.

Setting: A 500-bed academic tertiary care hospital in the United States.

Patients: A total of 93,676 ward admissions from 53,150 unique adult patients between November 1, 2008 and October 1, 2013.

Intervention: None.

Measurements: OSA diagnoses and comorbidities were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Logistic regression was used to control for patient characteristics, location prior to ward admission, and admission severity of illness. The primary outcome was in-hospital death. Secondary outcomes included rapid response team (RRT) activation, intensive care unit (ICU) transfer, intubation, and cardiac arrest on the wards.

Main Results: OSA was identified in 5,625 (10.6%) patients. Patients with OSA were more likely to be older, male, and obese, and had higher rates of comorbidities. OSA patients had more frequent RRT activations (1.5% vs 1.1%) and ICU transfers (8% vs 7%) than controls (P < 0.001 for both comparisons), but a lower inpatient mortality rate (1.1% vs 1.4%, P < 0.05). OSA was associated with decreased adjusted odds for ICU transfer (odds ratio [OR]: 0.91 [0.84-0.99]), cardiac arrest (OR: 0.72 [0.55-0.95]), and in-hospital mortality (OR: 0.70 [0.58-0.85]).

Conclusions: After adjustment for important confounders, OSA was not associated with clinical deterioration on the wards and was associated with significantly decreased in-hospital mortality.
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http://dx.doi.org/10.1002/jhm.2404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560995PMC
September 2015

Diagnosis and management of obstructive sleep apnea in the perioperative setting.

Semin Respir Crit Care Med 2014 Oct 29;35(5):571-81. Epub 2014 Oct 29.

Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois.

Obstructive sleep apnea (OSA) is a chronic prevalent condition which may be under-recognized in surgical populations. Patients with OSA may be at increased perioperative risk, in part due to the effects sedatives and anesthetics have on upper airway tone and respiratory drive. A growing amount of data suggests that OSA patients have increased odds for adverse postoperative outcomes including intensive care unit transfer, respiratory failure, arrhythmias, and cardiac ischemia. Several screening tools have been developed to identify patients at risk for OSA preoperatively, but it remains to be seen whether routine implementation of these tools improves outcomes. In this review, we discuss the perioperative complications of OSA, the tools with which physicians can screen surgical patients, and the perioperative management of these patients.
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http://dx.doi.org/10.1055/s-0034-1390079DOI Listing
October 2014