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1.
Int J Emerg Med ; 14(1): 31, 2021 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-33980142

RESUMO

BACKGROUND: Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician. DISCUSSION: The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest. CONCLUSION: Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.

2.
PLoS One ; 16(3): e0249038, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33765049

RESUMO

BACKGROUND: Observational studies have consistently described poor clinical outcomes and increased ICU mortality in patients with severe coronavirus disease 2019 (COVID-19) who require mechanical ventilation (MV). Our study describes the clinical characteristics and outcomes of patients with severe COVID-19 admitted to ICU in the largest health care system in the state of Florida, United States. METHODS: Retrospective cohort study of patients admitted to ICU due to severe COVID-19 in AdventHealth health system in Orlando, Florida from March 11th until May 18th, 2020. Patients were characterized based on demographics, baseline comorbidities, severity of illness, medical management including experimental therapies, laboratory markers and ventilator parameters. Major clinical outcomes analyzed at the end of the study period were: hospital and ICU length of stay, MV-related mortality and overall hospital mortality of ICU patients. RESULTS: Out of total of 1283 patients with COVID-19, 131 (10.2%) met criteria for ICU admission (median age: 61 years [interquartile range (IQR), 49.5-71.5]; 35.1% female). Common comorbidities were hypertension (84; 64.1%), and diabetes (54; 41.2%). Of the 131 ICU patients, 109 (83.2%) required MV and 9 (6.9%) received ECMO. Lower positive end expiratory pressure (PEEP) were observed in survivors [9.2 (7.7-10.4)] vs non-survivors [10 (9.1-12.9] p = 0.004]. Compared to non-survivors, survivors had a longer MV length of stay (LOS) [14 (IQR 8-22) vs 8.5 (IQR 5-10.8) p< 0.001], Hospital LOS [21 (IQR 13-31) vs 10 (7-1) p< 0.001] and ICU LOS [14 (IQR 7-24) vs 9.5 (IQR 6-11), p < 0.001]. The overall hospital mortality and MV-related mortality were 19.8% and 23.8% respectively. After exclusion of hospitalized patients, the hospital and MV-related mortality rates were 21.6% and 26.5% respectively. CONCLUSIONS: Our study demonstrates an important improvement in mortality of patients with severe COVID-19 who required ICU admission and MV in comparison to previous observational reports and emphasizes the importance of standard of care measures in the management of COVID-19.


Assuntos
COVID-19/patologia , Atenção à Saúde , Adolescente , Adulto , Idoso , COVID-19/mortalidade , COVID-19/virologia , Comorbidade , Oxigenação por Membrana Extracorpórea , Feminino , Florida , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos Retrospectivos , SARS-CoV-2 , Índice de Gravidade de Doença , Adulto Jovem
5.
Case Rep Crit Care ; 2020: 2425973, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32566322

RESUMO

Objective: This case describes symptomatic pulmonary cement embolism as a rare postvertebroplasty complication and highlights its critical yet ill-defined management. Background: Pulmonary cement embolism (PCE) is a feared complication of vertebroplasty in the treatment of vertebral fractures. While the majority of PCEs are asymptomatic, symptomatic PCEs often present with chest pain, tachycardia, signs of severe respiratory distress, and death. Computer tomography angiogram (CTA) allows visualization of cement within the pulmonary vasculature. Despite the well-established risk of PCE, clinical management is unclear with limited research on treatment options. Reported treatments include anticoagulation, embolectomy, CPR, and supportive care and observation. Report. We report the case of a 75-year-old woman who experienced shortness of breath, tachypnea, tachycardia, hypertension, and hypoxemia five days following a corrective surgery for a compression fracture of L3 with pedicle screw fixation, fusion of L2 through L4, and L2 vertebral body cement augmentation with polymethyl methacrylate. Results: Breath sounds were diminished bilaterally with respiratory alkalosis and hypoxemia evident on arterial blood gas. CTA revealed intravasated cement throughout the right lung, including the pulmonary artery and upper and middle lobar arteries. The proposed mechanism is embolization of cement particles from the lumbar veins, which also showed intravasation. Due to the inorganic nature of the occluding material, the use of a thrombolytic agent was ruled against. Treatment included bronchodilators, 3 L of oxygen via nasal cannula, and prophylactic antibiotics, pulmonary toilet, and incentive spirometry. Symptomatic management was continued until she was discharged from the hospital in a stable condition. Conclusions: Postvertebroplasty pulmonary cement embolisms can be managed conservatively, without the use of anticoagulant or thrombolytic agents. This case illustrates a variation of care for this rare presentation and adds to the sparse literature on the management of PCEs.

6.
Case Rep Neurol Med ; 2019: 9285460, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31428488

RESUMO

Takotsubo cardiomyopathy is a rare syndrome of transient, reversible left ventricular systolic dysfunction. It mimics myocardial infarction clinically and includes elevated cardiac enzymes, but echocardiography reveals apical ballooning and basal hyperkinesis. Infrequently, midventricular or even reverse Takotsubo patterns have been described, involving ballooning of the basal heart without the characteristic 'Takotsubo' appearance. There are cases in the literature that support a connection between reverse Takotsubo cardiomyopathy (r-TTC) and neurological insults as inciting factors. We report a case of r-TTC in an otherwise healthy 23-year-old man presenting with back pain, urinary retention, bradycardia, and hypertension. Troponin levels and brain natriuretic peptide (BNP) were elevated, and echocardiogram revealed an ejection fraction (EF) of less than 20%. In addition, MRI demonstrated a spinal subdural hematoma from T1-S1 with no cord compression. Repeated echocardiogram demonstrated an EF of 20-25% with a reverse Takotsubo pattern of cardiomyopathy. With supportive care, his clinical picture improved with normalization of cardiac enzyme and BNP values. This case represents a r-TTC presenting as heart failure in a young, apparently healthy male likely incited by a spinal subdural hematoma. To our knowledge, it is the first of its kind reported.

7.
J Gen Intern Med ; 33(12): 2078-2084, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30276655

RESUMO

BACKGROUND: Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized. OBJECTIVE: To identify the association between insurance coverage and mortality of patients transferred between hospitals. DESIGN: We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers. SETTING: Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers. PATIENTS: The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals. MEASUREMENTS: Adjusted inpatient mortality and 24-h mortality, stratified by insurance status. RESULTS: Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13-1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11-1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses. LIMITATIONS: This is an observational study where transfer appropriateness cannot be directly assessed. CONCLUSIONS: Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.


Assuntos
Disparidades em Assistência à Saúde/tendências , Cobertura do Seguro/tendências , Mortalidade/tendências , Transferência de Pacientes/tendências , Centros de Atenção Terciária/tendências , Adulto , Idoso , Estudos Transversais , Bases de Dados Factuais/tendências , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto
8.
Liver Transpl ; 24(3): 380-393, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29171941

RESUMO

Severe alcoholic hepatitis (sAH) is associated with a poor prognosis. There is no proven effective treatment for sAH, which is why early transplantation has been increasingly discussed. Hepatoblastoma-derived C3A cells express anti-inflammatory proteins and growth factors and were tested in an extracorporeal cellular therapy (ELAD) study to establish their effect on survival for subjects with sAH. Adults with sAH, bilirubin ≥8 mg/dL, Maddrey's discriminant function ≥ 32, and Model for End-Stage Liver Disease (MELD) score ≤ 35 were randomized to receive standard of care (SOC) only or 3-5 days of continuous ELAD treatment plus SOC. After a minimum follow-up of 91 days, overall survival (OS) was assessed by using a Kaplan-Meier survival analysis. A total of 203 subjects were enrolled (96 ELAD and 107 SOC) at 40 sites worldwide. Comparison of baseline characteristics showed no significant differences between groups and within subgroups. There was no significant difference in serious adverse events between the 2 groups. In an analysis of the intent-to-treat population, there was no difference in OS (51.0% versus 49.5%). The study failed its primary and secondary end point in a population with sAH and with a MELD ranging from 18 to 35 and no upper age limit. In the prespecified analysis of subjects with MELD < 28 (n = 120), ELAD was associated with a trend toward higher OS at 91 days (68.6% versus 53.6%; P = .08). Regression analysis identified high creatinine and international normalized ratio, but not bilirubin, as the MELD components predicting negative outcomes with ELAD. A new trial investigating a potential benefit of ELAD in younger subjects with sufficient renal function and less severe coagulopathy has been initiated. Liver Transplantation 24 380-393 2018 AASLD.


Assuntos
Circulação Extracorpórea/métodos , Hepatite Alcoólica/terapia , Hepatoblastoma/metabolismo , Neoplasias Hepáticas/metabolismo , Adulto , Austrália , Linhagem Celular Tumoral , Circulação Extracorpórea/efeitos adversos , Circulação Extracorpórea/mortalidade , Feminino , Hepatite Alcoólica/sangue , Hepatite Alcoólica/diagnóstico , Hepatite Alcoólica/mortalidade , Humanos , Análise de Intenção de Tratamento , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Reino Unido , Estados Unidos
10.
PLoS One ; 12(5): e0178091, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28542336

RESUMO

INTRODUCTION: Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a sensitive and specific diagnostic test for acute kidney injury (AKI) in the Emergency Department (ED), but its economic impact has not been investigated. We hypothesized that uNGAL used in combination with serum creatinine (sCr) would reduce costs in the management of AKI in patients presenting to the ED in comparison to using sCr alone. MATERIALS AND METHODS: A cost simulation model was developed for clinical algorithms to diagnose AKI based on sCr alone vs. uNGAL plus sCr (uNGAL+sCr). A cost minimization analysis was performed to determine total expected costs for patients with AKI. uNGAL test characteristics were validated with eight-hundred forty-nine patients with sCr ≥1.5 from a completed study of 1635 patients recruited from EDs at two U.S. hospitals from 2007-8. Biomarker test, AKI work-up, and diagnostic imaging costs were incorporated. RESULTS: For a hypothetical cohort of 10,000 patients, the model predicted that the expected costs were $900 per patient (pp) in the sCr arm and $950 in the uNGAL+sCr arm. uNGAL+sCr resulted in 1,578 fewer patients with delayed diagnosis and treatment than sCr alone (2,013 vs. 436 pts) at center 1 and 1,973 fewer patients with delayed diagnosis and treatment than sCr alone at center 2 (2,227 vs. 254 patients). Although initial evaluation costs at each center were $50 pp higher in with uNGAL+sCr, total costs declined by $408 pp at Center 1 and by $522 pp at Center 2 due to expected reduced delays in diagnosis and treatment. Sensitivity analyses confirmed savings with uNGAL + sCr for a range of cost inputs. DISCUSSION: Using uNGAL with sCr as a clinical diagnostic test for AKI may improve patient management and reduce expected costs. Any cost savings would likely result from avoiding delays in diagnosis and treatment and from avoidance of unnecessary testing in patients given a false positive AKI diagnosis by use of sCr alone.


Assuntos
Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/economia , Biomarcadores/análise , Custos e Análise de Custo , Creatinina/sangue , Lipocalina-2/urina , Urinálise/economia , Injúria Renal Aguda/sangue , Injúria Renal Aguda/urina , Estudos de Coortes , Humanos
11.
J Crit Care ; 36: 240-245, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27591388

RESUMO

PURPOSE: Patients transferred between hospitals are at high risk of adverse events and mortality. This study aims to identify which components of the transfer handoff process are important predictors of adverse events and mortality. MATERIALS AND METHODS: We conducted a retrospective, observational study of 335 consecutive patient transfers to 3 intensive care units at an academic tertiary referral center. We assessed the relationship between handoff documentation completeness and patient outcomes. The primary outcome was in-hospital mortality. Secondary outcomes included adverse events, duplication of labor, disposition error, and length of stay. RESULTS: Transfer documentation was frequently absent with overall completeness of 58.3%. Adverse events occurred in 42% of patients within 24 hours of arrival, with an overall in-hospital mortality of 17.3%. Higher documentation completeness was associated with reduced in-hospital mortality (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.02 to 0.38; P = .002), reduced adverse events (coefficient, -2.08; 95% CI, -2.76 to -1.390; P < .001), and reduced duplication of labor (OR, 0.19; 95% CI, 0.04 to 0.88; P = .033) when controlling for severity of illness. CONCLUSIONS: Documentation completeness is associated with improved outcomes and resource utilization in patients transferred between hospitals.


Assuntos
Estado Terminal/mortalidade , Documentação/normas , Mortalidade Hospitalar , Transferência da Responsabilidade pelo Paciente/normas , Transferência de Pacientes , Idoso , Feminino , Recursos em Saúde , Hospitais , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Projetos Piloto , Estudos Retrospectivos , Centros de Atenção Terciária
12.
J Hosp Med ; 11(6): 413-7, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27042950

RESUMO

BACKGROUND: Interhospital transfer is an understudied area within transitions of care. The process by which hospitals accept and transfer patients is not well described. National trends and best practices are unclear. OBJECTIVE: To describe the demographics of large transfer centers, to identify common handoff practices, and to describe challenges and notable innovations involving the interhospital transfer handoff process. DESIGN AND PARTICIPANTS: A convenience sample of 32 tertiary care centers in the United States was studied. Respondents were typically transfer center directors surveyed by phone. MAIN MEASURES: Data regarding transfer center demographics, handoff communication practices, electronic infrastructure, and data sharing were obtained. RESULTS: The median number of patients transferred each month per receiving institution was 700 (range, 250-2500); on average, 28% of these patients were transferred to an intensive care unit. Transfer protocols and practices varied by institution. Transfer center coordinators typically had a medical background (78%), and critical care-trained registered nurse was the most prevalent (38%). Common practices included: mandatory recorded 3-way physician-to-physician conversation (84%) and mandatory clinical status updates prior to patient arrival (81%). However, the timeline of clinical status updates was variable. Less frequent transfer practices included: electronic medical record (EMR) cross-talk availability and utilization (23%), real-time transfer center documentation accessibility in the EMR (32%), and referring center clinical documentation available prior to transport (29%). A number of innovative strategies to address challenges involving interhospital handoffs are reported. CONCLUSIONS: Interhospital transfer practices vary widely amongst tertiary care centers. Practices that lead to improved patient handoffs and reduced medical errors need additional prospective evaluation. Journal of Hospital Medicine 2016;11:413-417. © 2016 Society of Hospital Medicine.


Assuntos
Transferência da Responsabilidade pelo Paciente/organização & administração , Transferência de Pacientes/normas , Centros de Atenção Terciária , Comunicação , Documentação/normas , Humanos , Unidades de Terapia Intensiva , Transferência de Pacientes/métodos , Estudos Prospectivos , Inquéritos e Questionários , Estados Unidos
14.
Pharmacotherapy ; 35(6): 631-48, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26032691

RESUMO

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is a substantial source of disability in the United States. Moderate-to-severe acute exacerbations of COPD (AECOPD) can progress to respiratory failure, necessitating ventilator assistance in patients in the intensive care unit (ICU). Patients in the ICU with AECOPD requiring ventilator support have higher morbidity and mortality rates as well as costs compared with hospitalized patients not in the ICU. The mainstay of management for patients with AECOPD in the ICU includes ventilator support (noninvasive or invasive), rapid-acting inhaled bronchodilators, systemic corticosteroids, and antibiotics. However, evidence supporting these interventions for the treatment of AECOPD in critically ill patients admitted to the ICU is scant. Corticosteroids have gained widespread acceptance in the management of patients with AECOPD necessitating ventilator assistance, despite their lack of evaluation in clinical trials as well as controversies surrounding optimal dosage regimens and duration of treatment. Recent studies evaluating the safety and efficacy of corticosteroids have found that higher doses are associated with increased adverse effects, which therefore support lower dosing strategies, particularly for patients admitted to the ICU for COPD exacerbations. This review highlights recent findings from the current body of evidence on nonpharmacologic and pharmacologic treatment and prevention of AECOPD in critically ill patients. In addition, the administration of bronchodilators using novel delivery devices in the ventilated patient and the conflicting evidence surrounding antibiotic use in AECOPD in the critically ill is explored. Further clinical trials, however, are warranted to clarify the optimal pharmacotherapy management for AECOPD, particularly in critically ill patients admitted to the ICU.


Assuntos
Estado Terminal , Doença Pulmonar Obstrutiva Crônica , Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Broncodilatadores/uso terapêutico , Ensaios Clínicos como Assunto , Cuidados Críticos , Progressão da Doença , Humanos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/prevenção & controle , Respiração Artificial , Fatores de Risco
20.
BMC Nephrol ; 15: 47, 2014 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-24641586

RESUMO

BACKGROUND: Previous studies have shown that treatment with ergocalciferol in patients with CKD stage 3 + 4 is not effective with less than 33% of patients achieving a 25-OH vitamin D target of >30 ng/ml. The aim of this study was to test the response to cholecalciferol in CKD. We attempted to replete 25-OH vitamin D to a target level of 40-60 ng/ml using the response to treatment and PTH suppression as an outcome measure. METHODS: This retrospective cohort study identified patients (Stages 2-5 and Transplant) from 2001-2010 who registered at the Chronic Kidney Disease Clinic. Patients received cholecalciferol 10,000 IU capsules weekly as initial therapy. When levels above 40 ng/ml were not achieved, doses were titrated up to a maximum of 50,000 IU weekly. Active vitamin D analogs were also used in some Stage 4-5 CKD patients per practice guidelines. Patients reaching at least one level of 40 ng/mL were designated RESPONDER, and if no level above 40 ng/mL they were designated NON-RESPONDER. Patients were followed for at least 6 months and up to 5 years. RESULTS: 352 patients were included with a mean follow up of 2.4 years. Of the CKD patients, the initial 25-OH vitamin D in the NON-RESPONDER group was lower than the RESPONDER group (18 vs. 23 ng/ml) (p = 0.03). Among all patients, the initial eGFR in the RESPONDER group was significantly higher than the NON-RESPONDER group (36 vs. 30 ml/min/1.73 m2) (p < 0.001). Over time, the eGFR of the RESPONDER group stabilized or increased (p < 0.001). Over time, the eGFR in the NON-RESPONDER group decreased toward a trajectory of ESRD. Proteinuria did not impact the response to 25-OH vitamin D replacement therapy. There were no identifiable variables associated with the response or lack of response to cholecalciferol treatment. CONCLUSIONS: CKD patients treated with cholecalciferol experience treatment resistance in raising vitamin D levels to a pre-selected target level. The mechanism of vitamin D resistance remains unknown and is associated with progressive loss of eGFR. Proteinuria modifies but does not account for the vitamin D resistance.


Assuntos
Hiperparatireoidismo Secundário/sangue , Hiperparatireoidismo Secundário/prevenção & controle , Insuficiência Renal Crônica/tratamento farmacológico , Deficiência de Vitamina D/prevenção & controle , Vitamina D/farmacocinética , Vitamina D/uso terapêutico , Idoso , Resistência a Medicamentos , Feminino , Humanos , Hiperparatireoidismo Secundário/etiologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/complicações , Resultado do Tratamento , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/etiologia , Vitaminas/uso terapêutico
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