Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 19 de 19
Filtrar
1.
Aging (Albany NY) ; 13(3): 3190-3201, 2021 02 07.
Artigo em Inglês | MEDLINE | ID: mdl-33550276

RESUMO

Males are at a higher risk of dying from COVID-19 than females. Older age and cardiovascular disease are also associated with COVID-19 mortality. To better understand how age and sex interact in contributing to COVID-19 mortality, we stratified the male-to-female (sex) ratios in mortality by age group. We then compared the age-stratified sex ratios with those of cardiovascular mortality and cancer mortality in the general population. Data were obtained from official government sources in the US and five European countries: Italy, Spain, France, Germany, and the Netherlands. The sex ratio of deaths from COVID-19 exceeded one throughout adult life, increasing up to a peak in midlife, and declining markedly in later life. This pattern was also observed for the sex ratio of deaths from cardiovascular disease, but not cancer, in the general populations of the US and European countries. Therefore, the sex ratios of deaths from COVID-19 and from cardiovascular disease share similar patterns across the adult life course. The underlying mechanisms are poorly understood and warrant further investigation.


Assuntos
COVID-19 , Doenças Cardiovasculares , Mortalidade , Medição de Risco , Adulto , Fatores Etários , Idoso , COVID-19/diagnóstico , COVID-19/mortalidade , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , SARS-CoV-2/isolamento & purificação , Razão de Masculinidade
2.
Ann Am Thorac Soc ; 18(4): 668-677, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33202147

RESUMO

Rationale: Continuous positive airway pressure (CPAP) adherence is often poor in obstructive sleep apnea (OSA) and may be influenced by nasal resistance. CPAP with a reduction of expiratory pressure (CPAPflex) may reduce discomfort in those with high nasal resistance and improve adherence in this subgroup.Objectives: To evaluate the association of positive airway pressure (PAP) treatment adherence to nasal resistance and examine if CPAPflex improves adherence over CPAP in subjects with high nasal resistance.Methods: A randomized double-blind crossover trial of 4 weeks each of CPAPflex versus CPAP in subjects exposed to World Trade Center dust with OSA stratified by nasal resistance, measured by 4-Phase Rhinomanometry.Results: Three hundred seventeen subjects with OSA (mean, apnea-hypopnea index with 4% O2 desaturation for hypopnea = 17 ± 14/h) were randomized. Overall, PAP adherence was poor, but adherence to CPAP (n = 239; mean hours per night [95% confidence interval (CI)]), 1.97 h (1.68 to 2.26) was greater than adherence to CPAPflex (n = 249; 1.65 h [1.39 to 1.91]; difference of 0.31 h [0.03; 0.6]; P < 0.05). Contrary to our hypothesis there was no correlation between nasal resistance and adherence to CPAP (r = 0.098; P = not significant) or CPAPflex (r = 0.056; P = not significant). There was no difference in adherence between CPAP and CPAPflex (mean Δ hours [95% CI]) in subjects with low resistance (0.33 h [-0.10 to 0.76]) or high nasal resistance (0.26 h [-0.14 to 0.66]). No significant differences were observed in any of the secondary outcomes between PAP modes.Conclusions: Contrary to expectations, our data do not show better adherence to CPAPflex than to CPAP in subjects with high or low nasal resistance and do show clinically insignificant better adherence overall with CPAP.Clinical trial registered with www.clinicaltrials.gov (NCT01753999).


Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Apneia Obstrutiva do Sono , Estudos Cross-Over , Método Duplo-Cego , Humanos , Cooperação do Paciente , Apneia Obstrutiva do Sono/terapia
3.
BMJ ; 371: m3513, 2020 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-32998872

RESUMO

OBJECTIVES: To estimate the incidence, risk factors, and outcomes associated with in-hospital cardiac arrest and cardiopulmonary resuscitation in critically ill adults with coronavirus disease 2019 (covid-19). DESIGN: Multicenter cohort study. SETTING: Intensive care units at 68 geographically diverse hospitals across the United States. PARTICIPANTS: Critically ill adults (age ≥18 years) with laboratory confirmed covid-19. MAIN OUTCOME MEASURES: In-hospital cardiac arrest within 14 days of admission to an intensive care unit and in-hospital mortality. RESULTS: Among 5019 critically ill patients with covid-19, 14.0% (701/5019) had in-hospital cardiac arrest, 57.1% (400/701) of whom received cardiopulmonary resuscitation. Patients who had in-hospital cardiac arrest were older (mean age 63 (standard deviation 14) v 60 (15) years), had more comorbidities, and were more likely to be admitted to a hospital with a smaller number of intensive care unit beds compared with those who did not have in-hospital cardiac arrest. Patients who received cardiopulmonary resuscitation were younger than those who did not (mean age 61 (standard deviation 14) v 67 (14) years). The most common rhythms at the time of cardiopulmonary resuscitation were pulseless electrical activity (49.8%, 199/400) and asystole (23.8%, 95/400). 48 of the 400 patients (12.0%) who received cardiopulmonary resuscitation survived to hospital discharge, and only 7.0% (28/400) survived to hospital discharge with normal or mildly impaired neurological status. Survival to hospital discharge differed by age, with 21.2% (11/52) of patients younger than 45 years surviving compared with 2.9% (1/34) of those aged 80 or older. CONCLUSIONS: Cardiac arrest is common in critically ill patients with covid-19 and is associated with poor survival, particularly among older patients.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Pneumonia Viral/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19 , Estudos de Coortes , Infecções por Coronavirus/complicações , Infecções por Coronavirus/virologia , Feminino , Parada Cardíaca/virologia , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/virologia , SARS-CoV-2 , Estados Unidos/epidemiologia
4.
Front Neurol ; 11: 820, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32849248

RESUMO

Circadian rhythms play a vital role in metabolic, hormonal, and immunologic function and are often disrupted in patients in the ICU. Circadian rhythms modulate the molecular machinery that responds to injury and illness which can impact recovery. Potential factors contributing to the alteration in circadian rhythmicity in intensive care unit (ICU) patients include abnormal lighting, noise, altered feeding schedules, extensive patient care interactions and medications. These alterations in circadian rhythms in ICU patients may affect outcomes and therefore, normalization of circadian rhythmicity in critically ill patients may be an important part of ICU care.

5.
Sleep Breath ; 24(4): 1759-1765, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31938991

RESUMO

PURPOSE: The Epworth sleepiness scale (ESS) is a widely used tool which has been validated as a measure of sleepiness. However, the scores within individual patients referred for clinical sleep services vary considerably which may limit the clinical use of the ESS. We sought to determine the test-retest reliability of the ESS if scores were classified as either normal or sleepy. METHODS: We measured the ESS in patients presenting to our sleep center at a clinical visit and again when a sleep study was done. Demographic and clinical information was extracted from the electronic medical record. RESULTS: Average ESS scores were similar on 2 administrations, mean (SD) of 9.8 (5.4) and 10.2 (6.2). Bland-Altman analysis showed upper and lower limits of agreement of 7.5 and - 6.7, respectively. No demographic or clinical variables were identified which contributed to the intra-individual variability. Of the patients who presented with an initial ESS < 11, 80% had a second ESS < 11. Of the patients who presented with an initial ESS ≥ 11, 89% had a second ESS ≥ 11. Cohen's kappa for the two administrations of the ESS was 0.67 (95% CI of 0.51-0.83). Using previously published reports, we calculated Cohen's kappa for polysomnographic determination of the apnea-hypopnea index (AHI) with values ranging from 0.26 to 0.69. CONCLUSIONS: Individual ESS scores varied considerably within individual patients, but with classification into either normal or sleepy, the test-retest reliability was substantial and in line with other clinical measures including polysomnographic determination of the AHI.

6.
Artigo em Inglês | MEDLINE | ID: mdl-30959865

RESUMO

Background: World Trade Center (WTC) dust-exposed subjects have multiple comorbidities that affect sleep. These include obstructive sleep apnea (OSA), chronic rhinosinusitis (CRS), gastroesophageal-reflux disorder (GERD) and post-traumatic stress disorder (PTSD). We examined the impact of these conditions to sleep-related outcomes. Methods: Demographics, co-morbidities and symptoms were obtained from 626 WTC (109F/517M), 33⁻87years, BMI = 29.96 ± 5.53 kg/m²) subjects. OSA diagnosis was from a 2-night home sleep test (ARESTM). Subjective sleep quality, sleep-related quality of life (QOL, Functional Outcomes of Sleep Questionnaire), excessive daytime sleepiness (Epworth Sleepiness Scale), sleep duration and sleep onset and maintenance complaints were assessed. Results: Poor sleep quality and complaints were reported by 19⁻70% of subjects and average sleep duration was 6.4 h. 74.8% of subjects had OSA. OSA diagnosis/severity was not associated with any sleep-related outcomes. Sleep duration was lower in subjects with all conditions (p < 0.05) except OSA. CRS was a significant risk factor for poor sleep-related QOL, sleepiness, sleep quality and insomnia; PTSD for poor sleep-related QOL and insomnia; GERD for poor sleep quality. These associations remained significant after adjustment for, age, BMI, gender, sleep duration and other comorbidities. Conclusions: Sleep complaints are common and related to several health conditions seen in WTC responders. Initial interventions in symptomatic patients with both OSA and comorbid conditions may need to be directed at sleep duration, insomnia or the comorbid condition itself, in combination with intervention for OSA.


Assuntos
Refluxo Gastroesofágico/epidemiologia , Qualidade de Vida , Rinite/epidemiologia , Ataques Terroristas de 11 de Setembro , Sinusite/epidemiologia , Transtornos do Sono-Vigília/epidemiologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Adulto , Doença Crônica , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polissonografia , Fatores de Risco , Inquéritos e Questionários
7.
Artigo em Inglês | MEDLINE | ID: mdl-30845693

RESUMO

Sarcoid-like granulomatous diseases (SGD) have been previously identified in cohorts of World Trade Center (WTC) dust-exposed individuals. In the present studies, we analyzed lung and/or lymph node biopsies from patients referred to our clinic with suspected WTC dust-induced lung disease to evaluate potential pathophysiologic mechanisms. Histologic sections of lung and/or lymph node samples were analyzed for markers of injury, oxidative stress, inflammation, fibrosis, and epigenetic modifications. Out of seven patients examined, we diagnosed four with SGD and two with pulmonary fibrosis; one was diagnosed later with SGD at another medical facility. Patients with SGD were predominantly white, obese men, who were less than 50 years old and never smoked. Cytochrome b5, cytokeratin 17, heme oxygenase-1, lipocalin-2, inducible nitric oxide synthase, cyclooxygenase 2, tumor necrosis factor α, ADP-ribosylation factor-like GTPase 11, mannose receptor-1, galectin-3, transforming growth factor ß, histone-3 and methylated histone-3 were identified in lung and lymph nodes at varying levels in all samples examined. Three of the biopsy samples with granulomas displayed peri-granulomatous fibrosis. These findings are important and suggest the potential of WTC dust-induced fibrotic sarcoid. It is likely that patient demographics and/or genetic factors influence the response to WTC dust injury and that these contribute to different pathological outcomes.


Assuntos
Exposição Ocupacional , Sarcoidose/etiologia , Ataques Terroristas de 11 de Setembro , Adulto , Poeira , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
8.
Chest ; 155(2): 375-383, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30739642

RESUMO

BACKGROUND: Many respiratory conditions have been attributed to toxic dust and fume exposure in World Trade Center (WTC) rescue and recovery workers, who frequently report symptoms of OSA. We examined the prevalence of new-onset OSA and tested if the prevalence and severity of OSA are related to the presence of chronic rhinosinusitis (CRS). METHODS: A total of 601 subjects (83% men; age, 33-87 years; BMI, 29.9 ± 5.5 kg/m2) enrolled in the WTC Health Program, excluding those with significant pre-September 11, 2001, snoring or prior CRS, underwent two nights of home sleep testing. OSA was defined as Apnea Hypopnea Index 4% ≥ 5 events/h or respiratory disturbance index of ≥ 15 events/h. CRS was assessed using nasal symptom questionnaires. RESULTS: The prevalence of OSA was 75% (25% no OSA, 46% mild OSA, 19% moderate OSA, and 10% severe OSA), and the prevalence of CRS was 43.5%. Compared with no CRS, new and worsening CRS was a significant risk factor for OSA with an OR of 1.80 (95% CI, 1.18-2.73; P = .006) unadjusted and 1.76 (95% CI, 1.08-2.88; P = .02) after adjustment for age, BMI, sex, gastroesophageal reflux disorder, and alcohol use. CONCLUSIONS: The high prevalence of OSA in WTC responders was not explained fully by obesity and sex. Possible mechanisms for the elevated risk of OSA in subjects with CRS include increased upper airway inflammation and/or elevated nasal/upper airway resistance, but these need confirmation.


Assuntos
Socorristas/estatística & dados numéricos , Doenças Profissionais/epidemiologia , Rinite/epidemiologia , Ataques Terroristas de 11 de Setembro , Sinusite/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Exposição Ocupacional , Prevalência , Fatores de Risco
9.
Am J Respir Crit Care Med ; 199(1): 99-109, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29969291

RESUMO

RATIONALE: Obstructive sleep apnea (OSA) is associated with recurrent obstruction, subepithelial edema, and airway inflammation. The resultant inflammation may influence or be influenced by the nasal microbiome. OBJECTIVES: To evaluate whether the composition of the nasal microbiota is associated with obstructive sleep apnea and inflammatory biomarkers. METHODS: Two large cohorts were used: 1) a discovery cohort of 472 subjects from the WTCSNORE (Seated, Supine and Post-Decongestion Nasal Resistance in World Trade Center Rescue and Recovery Workers) cohort, and 2) a validation cohort of 93 subjects rom the Zaragoza Sleep cohort. Sleep apnea was diagnosed using home sleep tests. Nasal lavages were obtained from cohort subjects to measure: 1) microbiome composition (based on 16S rRNA gene sequencing), and 2) biomarkers for inflammation (inflammatory cells, IL-8, and IL-6). Longitudinal 3-month samples were obtained in the validation cohort, including after continuous positive airway pressure treatment when indicated. MEASUREMENTS AND MAIN RESULTS: In both cohorts, we identified that: 1) severity of OSA correlated with differences in microbiome diversity and composition; 2) the nasal microbiome of subjects with severe OSA were enriched with Streptococcus, Prevotella, and Veillonella; and 3) the nasal microbiome differences were associated with inflammatory biomarkers. Network analysis identified clusters of cooccurring microbes that defined communities. Several common oral commensals (e.g., Streptococcus, Rothia, Veillonella, and Fusobacterium) correlated with apnea-hypopnea index. Three months of treatment with continuous positive airway pressure did not change the composition of the nasal microbiota. CONCLUSIONS: We demonstrate that the presence of an altered microbiome in severe OSA is associated with inflammatory markers. Further experimental approaches to explore causal links are needed.


Assuntos
Microbiota , Cavidade Nasal/microbiologia , Apneia Obstrutiva do Sono/microbiologia , Adulto , Biomarcadores/análise , Feminino , Humanos , Interleucina-6/análise , Interleucina-8/análise , Masculino , Microbiota/genética , Pessoa de Meia-Idade , Líquido da Lavagem Nasal/química , RNA Ribossômico 16S/genética , Índice de Gravidade de Doença
10.
Sleep Breath ; 22(1): 139-147, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28823109

RESUMO

PURPOSE: Home sleep testing devices are being widely used in diagnosis/screening for obstructive sleep apnea (OSA). We examined differences in OSA metrics obtained from two devices with divergent home monitoring strategies, the Apnea Risk Evaluation System (ARES™, multiple signals plus forehead reflectance oximetry) and the Nonin WristOx2™ (single channel finger transmission pulse oximeter), compared to differences from night-night variability of OSA. METHODS: One hundred fifty-two male/26 female subjects (BMI = 30.3 ± 5.6 kg/m2, age = 52.5 ± 8.9 years) were recruited without regard to OSA symptoms and simultaneously wore both ARES™ and Nonin WristOx2™ for two nights (n = 351 nights). Automated analysis of the WristOx2 yielded oxygen desaturation index (ODIOx2, ≥4% O2 dips/h), and automated analysis with manual editing of ARES™ yielded AHI4ARES (apneas + hypopneas with ≥4% O2 dips/h) and RDIARES (apneas + hypopneas with ≥4% O2 dips/h or arousal surrogates). Baseline awake oxygen saturation, percent time < 90% O2 saturation (%time < 90%O2Sat), and O2 signal loss were compared between the two methods. RESULTS: Correlation between AHI4ARES and ODIOx2 was high (ICC = 0.9, 95% CI = 0.87-0.92, p < 0.001, bias ± SD = 0.7 ± 6.1 events/h). Agreement values for OSA diagnosis (77-85%) between devices were similar to those seen from night-to-night variability of OSA using a single device. Awake baseline O2 saturation was significantly higher in the ARES™ (96.2 ± 1.6%) than WristOx2™ (92.2 ± 2.1%, p < 0.01). There was a significantly lower %time < 90%O2Sat reported by the ARES™ compared to WristOx2 (median (IQR) 0.5 (0.0, 2.6) vs. 2.1 (0.3, 9.7), p < 0.001), and the correlation was low (ICC = 0.2). CONCLUSIONS: OSA severity metrics predominantly dependent on change in oxygen saturation and metrics used in diagnosis of OSA (AHI4 and ODI) correlated well across devices tested. However, differences in cumulative oxygen desaturation measures (i.e., %time < 90%O2Sat) between the devices suggest that caution is needed when interpreting this metric particularly in populations likely to have significant hypoxia.


Assuntos
Oximetria , Oxigênio/metabolismo , Polissonografia , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Sono/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
11.
J Appl Physiol (1985) ; 121(4): 944-952, 2016 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-27609199

RESUMO

Chronic intermittent hypoxia (CIH) increases sympathetic tone and respiratory instability. Our previous work showed that chronic hypoxia induces the oxygen-sensing enzyme heme oxygenase-1 (HO-1) within the C1 sympathoexcitatory region and the pre-Bötzinger complex (pre-BötC). We therefore examined the effect of CIH on time course of induced expression of HO-1 within these regions and determined whether the induction of HO-1 correlated with changes in respiratory, sigh frequency, and sympathetic responses (spectral analysis of heart rate) to acute hypoxia (10% O2) during 10 days of exposure to CIH in chronically instrumented awake wild-type (WT) and HO-1 null mice (HO-1-/-). HO-1 was induced within the C1 and pre-BötC regions after 1 day of CIH. There were no significant differences in the baseline respiratory parameters between WT and HO-1-/- Prior to CIH, acute hypoxia increased respiratory frequency in both WT and HO-1-/-; however, minute diaphragm electromyogram activity increased in WT but not HO-1-/- The hypoxic respiratory response after 1 and 10 days of CIH was restored in HO-1-/- CIH resulted in an initial significant decline in 1) the hypoxic sigh frequency response, which was restored in WT but not HO-1-/-, and 2) the baseline sympathetic activity in WT and HO-1-/-, which remained stable subsequently in WT but not in HO-1-/- We conclude that 1) CIH induces expression of HO-1 in the C1 and pre-BötC regions within 1 day and 2) HO-1 is necessary for hypoxia respiratory response and contributes to the maintenance of the hypoxic sigh responses and baseline sympathetic activity during CIH.


Assuntos
Diafragma/fisiopatologia , Frequência Cardíaca , Heme Oxigenase-1/metabolismo , Hipóxia/fisiopatologia , Bulbo/metabolismo , Proteínas de Membrana/metabolismo , Oxigênio/metabolismo , Sistema Nervoso Simpático/fisiopatologia , Adaptação Fisiológica , Animais , Doença Crônica , Diafragma/inervação , Camundongos , Camundongos Endogâmicos BALB C , Camundongos Knockout , Mecânica Respiratória
12.
Trials ; 16: 403, 2015 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-26357928

RESUMO

BACKGROUND: Following the World Trade Center disaster, a large number of individuals involved in rescue and recovery activity were exposed to significant amounts of dust, and reported symptoms of chronic nasal and sinus inflammation. An unusually high prevalence of obstructive sleep apnea (OSA) has also been observed in this World Trade Center Responder population. This project aims to examine the relationship between nasal pathology and OSA. Our hypothesis is that increased nasal resistance due to nasal inflammation predisposes to OSA in this population. Continuous Positive Airway Pressure (CPAP) is the standard therapy for OSA but despite its efficacy has poor adherence. Subjects with high nasal resistance may have greater difficulty in tolerating this therapy than those who do not have high nasal resistance. Reduction of excess expiratory positive pressure by the modality known as Cflex(™) during Continuous Positive Airway Pressure therapy (CPAP(Flex)) has been suggested to improve comfort without compromising efficacy. We will compare CPAP to CPAP(Flex) in subjects with OSA. STUDY DESIGN: Subjects with new onset habitual snoring will be screened for OSA using home sleep studies and rhinomanometry will be used to determine nasal resistance. In 400 subjects with OSA we will perform a randomized double blind cross-over study comparing CPAP to CPAP(flex), and relate nasal resistance to adherence to CPAP therapy. DISCUSSION: This is the first multicenter trial designed to test the hypothesis that adherence to CPAP therapy relates to nasal resistance and CPAP(Flex) will improve adherence to CPAP in those subjects with high nasal resistance. We anticipate the following results from this trial: 1. Increased nasal resistance is associated with decreased adherence to CPAP therapy. 2. Use of CPAP(Flex) improves adherence with CPAP therapy in subjects with high nasal resistance, but not in those with low nasal resistance. 3. The benefit of CPAP(Flex) on adherence is greatest when offered at CPAP therapy initiation rather than as a "rescue" therapy in subjects with high nasal resistance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01753999, Date: 12 December 2012.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Socorristas , Cavidade Nasal/fisiopatologia , Obstrução Nasal/fisiopatologia , Saúde do Trabalhador , Ataques Terroristas de 11 de Setembro , Apneia Obstrutiva do Sono/terapia , Resistência das Vias Respiratórias , Protocolos Clínicos , Pressão Positiva Contínua nas Vias Aéreas/efeitos adversos , Estudos Cross-Over , Método Duplo-Cego , Humanos , Obstrução Nasal/diagnóstico , Obstrução Nasal/etiologia , New Jersey , Cidade de Nova Iorque , Cooperação do Paciente , Projetos de Pesquisa , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/etiologia , Apneia Obstrutiva do Sono/fisiopatologia , Ronco/etiologia , Fatores de Tempo , Resultado do Tratamento
13.
J Emerg Med ; 49(6): 893-900, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26409680

RESUMO

BACKGROUND: Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients. OBJECTIVE: To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level. METHODS: We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex. RESULTS: We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged. CONCLUSIONS: A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Unidades de Terapia Intensiva/organização & administração , Tempo de Internação/estatística & dados numéricos , Política Organizacional , Admissão do Paciente/estatística & dados numéricos , APACHE , Idoso , Aglomeração , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Centros de Traumatologia
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
15.
J Transl Med ; 12: 79, 2014 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-24674294

RESUMO

It has been argued that circadian dysregulation is not only a critical inducer and promoter of adverse health effects, exacerbating symptom burden, but also hampers recovery. Therefore understanding the health-promoting roles of regulating (i.e., restoring) circadian rhythms, thus suppressing harmful effects of circadian dysregulation, would likely improve treatment. At a critical care setting it has been argued that studies are warranted to determine whether there is any use in restoring circadian rhythms in critically ill patients, what therapeutic goals should be targeted, and how these could be achieved. Particularly interesting are interventional approaches aiming at optimizing the time of feeding in relation to individualized day-night cycles for patients receiving enteral nutrition, in an attempt to re-establish circadian patterns of molecular expression. In this short review we wish to explore the idea of transiently imposing (appropriate, but yet to be determined) circadian rhythmicity via regulation of food intake as a means of exploring rhythm-setting properties of metabolic cues in the context of improving immune response. We highlight some of the key elements associated with his complex question particularly as they relate to: a) stress and rhythmic variability; and b) metabolic entrainment of peripheral tissues as a possible intervention strategy through time-restricted feeding. Finally, we discuss the challenges and opportunities for translating these ideas to the bedside.


Assuntos
Ritmo Circadiano , Nutrição Enteral , Pesquisa Médica Translacional , Humanos , Fatores de Tempo
16.
Teach Learn Med ; 25(2): 118-21, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23530672

RESUMO

BACKGROUND: Graduating medical students have reported concern regarding inadequate training in pharmacotherapy. Teaching by clinical pharmacists may improve medical students' pharmacotherapy knowledge. PURPOSE: To assess the impact of pharmacist led workshops on 4th year medical students' knowledge of pharmacotherapy and satisfaction. METHODS: Senior medical students enrolled in intensive care unit rotations at a US medical school were randomized to an intervention of pharmacist led case-based workshops or a control group without an explicit pharmacotherapy curriculum. Intervention group students attended four weekly 1-hour workshops that covered topics in pharmacokinetics, pharmacodynamics, drug interactions and toxicity. A multiple-choice test of clinical vignettes assessed students' knowledge of pharmacotherapy. An end of clerkship survey assessed student satisfaction with teaching. RESULTS: Of 176 medical students eligible, 148 agreed to participate and were randomized to the intervention (n = 63) or control groups (n = 85). Student satisfaction with pharmacist led workshops was high. End of clerkship performance on clinical vignettes (minimum score 0, maximum 100) was similar between the groups (mean score 47 (SD = 12.2) for intervention vs 44 (SD = 13.0) for control group, p = 0.16). On end of clerkship survey, only 8% of control group students agreed or strongly agreed that the standard curriculum provided sufficient teaching in pharmacotherapy. The majority of students (82%) felt that pharmacotherapy should be taught formally in the clinical years. CONCLUSION: Pharmacist led workshops on pharmacotherapy were well received by senior medical students but did not improve performance on a test of pharmacotherapy knowledge. Further study is needed to define optimal strategies for improving medical students' pharmacotherapy knowledge.


Assuntos
Tratamento Farmacológico , Educação em Farmácia , Farmacêuticos , Estudantes de Medicina , Educação Médica , Avaliação Educacional , Humanos , New Jersey , Estados Unidos
17.
Crit Rev Biomed Eng ; 40(4): 265-78, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23140119

RESUMO

Obstructive sleep apnea (OSA) is characterized by episodes of repeated airway obstruction resulting in cessation (apnea) or reduction (hypopnea) in airflow during sleep. These events lead to intermittent hypoxia and hypercapnia, sleep fragmentation, and changes in intrathoracic pressure, and are associated with a marked surge in sympathetic activity and an abrupt increase in blood pressure. Blood pressure remains elevated during wakefulness despite the absence of obstructive events resulting in a high prevalence of hypertension in patients with OSA. There is substantial evidence that suggests that chronic intermittent hypoxia (CIH) leads to sustained sympathoexcitation during the day and changes in vasculature resulting in hypertension in patients with OSA. Mechanisms of sympathoexcitation include augmentation of peripheral chemoreflex sensitivity and a direct effect on central sites of sympathetic regulation. Interestingly, the vascular changes that occur with CIH have been ascribed to the same molecules that have been implicated in the augmented sympathetic tone in CIH. This review will discuss the hypothesized molecular mechanisms involved in the development of hypertension with CIH, will build a conceptual model for the development of hypertension following CIH, and will propose a systems biology approach in further elucidating the relationship between CIH and the development of hypertension.


Assuntos
Citocinas/imunologia , Hipertensão/complicações , Hipertensão/imunologia , Modelos Imunológicos , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/imunologia , Espécies Reativas de Oxigênio/imunologia , Animais , Humanos , Hipóxia/complicações , Hipóxia/imunologia
18.
Respir Physiol Neurobiol ; 184(2): 178-85, 2012 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-22750196

RESUMO

A myriad of changes are necessary to adapt to chronic hypoxemia. Key among these changes increases in arterial oxygen carrying capacity, ventilation and sympathetic activity. This requires the induction of several gene products many of which are regulated by the activity of HIF-1α, including HO-1. Induction of HO-1 during chronic hypoxia is necessary for the continued breakdown of heme for the enhanced production of hemoglobin and the increased respiratory and sympathetic responses. Several human HO-1 polymorphisms have been identified that can affect the expression or activity of HO-1. Associations between these polymorphisms and the prevalence of hypertension have recently been assessed in specific populations. There are major gaps in our understanding of the mechanisms of how HO-1 mediates changes in the activity of the hypoxia-sensitive chemosensors and whether HO-1 polymorphisms are an important factor in the integrated response to chronic hypoxia. Understanding how HO-1 mediates cardiorespiratory responses could provide important insights into clinical syndromes such as obstructive sleep apnea.


Assuntos
Heme Oxigenase-1/fisiologia , Hipóxia/fisiopatologia , Adaptação Fisiológica/fisiologia , Animais , Sistema Nervoso Central/fisiologia , Doença Crônica , Heme Oxigenase-1/genética , Humanos , Oxigênio/fisiologia , Polimorfismo Genético/genética , Polimorfismo Genético/fisiologia
19.
J Occup Environ Med ; 53(9): 975-80, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21866046

RESUMO

OBJECTIVES: To compare obstructive sleep apnea (OSA) in World Trade Center (WTC) responders with aerodigestive disorders and snoring with non-WTC habitual snorers, and to distinguish features of OSA in a subset of responders with worsening of snoring after 9/11 from responders with previous habitual snoring. METHODS: Cross-sectional comparative study of 50 WTC Medical Monitoring and Treatment Program responders with aerodigestive disorders and snoring and 50 nonresponders with snoring. Responders with worsening of snoring after 9/11 were compared with previous habitual snorers. RESULTS: : While there was a strong correlation between body mass index (BMI), weight, and Apnea + Hypopnea Index (r = 0.36, P = 0.001; r = 0.29, P = 0.044) in the nonresponders, no correlation between either BMI or weight and Apnea + Hypopnea Index was found in the responders. Responders with worsening of snoring after 9/11 had a significantly lower BMI than previous habitual snorers. CONCLUSION: Mechanisms other than obesity are important in the pathogenesis of OSA in WTC responders with aerodigestive disorders.


Assuntos
Poeira , Exposição por Inalação/efeitos adversos , Exposição Ocupacional/efeitos adversos , Trabalho de Resgate , Ataques Terroristas de 11 de Setembro , Apneia Obstrutiva do Sono/etiologia , Adulto , Índice de Massa Corporal , Peso Corporal , Estudos Transversais , Progressão da Doença , Serviços Médicos de Emergência , Refluxo Gastroesofágico/complicações , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/complicações , Ronco/complicações
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...