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Grim CCA, van der Wal LI, Bouwens JA, van Westerloo DJ, de Jonge E, Helmerhorst HJF. Volume of oxygen administered during mechanical ventilation predicts mortality in ICU patients. Crit Care 2023; 27:242. [PMID: 37337286 DOI: 10.1186/s13054-023-04499-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/18/2023] [Indexed: 06/21/2023] Open
Affiliation(s)
- C C A Grim
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - L I van der Wal
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J A Bouwens
- PrioCura Psychiatry, Rotterdam, The Netherlands
| | - D J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - E de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - H J F Helmerhorst
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Bos MK, Lam SW, Motta G, Helmijr JCA, Beaufort CM, de Jonge E, Martens JWM, Boven E, Jansen MPHM, Jager A, Sleijfer S. Plasma ESR1 mutations and outcome to first-line paclitaxel and bevacizumab in patients with advanced ER-positive/HER2-negative breast cancer. Breast Cancer Res Treat 2023:10.1007/s10549-023-06965-5. [PMID: 37226020 DOI: 10.1007/s10549-023-06965-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/02/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND ESR1 mutations have been identified as mechanism for endocrine resistance and are also associated with a decreased overall survival. We assessed ESR1 mutations in circulating tumor DNA (ctDNA) for impact on outcome to taxane-based chemotherapy in advanced breast cancer patients. METHODS ESR1 mutations were determined in archived plasma samples from patients treated with paclitaxel and bevacizumab (AT arm, N = 91) in the randomized phase II ATX study. Samples collected at baseline (n = 51) and at cycle 2 (n = 13, C2) were analyzed using a breast cancer next-generation sequencing panel. This study was powered to detect a benefit in progression-free survival (PFS) at six months for patients treated with paclitaxel/bevacizumab compared to historical trials with fulvestrant. PFS, overall survival (OS), and ctDNA dynamics were exploratory analyses. RESULTS PFS at six months was 86% (18/21) in patients with an ESR1 mutation detected and 85% (23/27) in wildtype ESR1 patients. In our exploratory analysis, median progression-free survival (PFS) was 8.2 months [95% CI, 7.6-8.8] for ESR1 mutant patients versus 8.7 months [95% confidence interval (CI), 8.3-9.2] for ESR1 wildtype patients [p = 0.47]. The median overall survival (OS) was 20.7 months [95% CI, 6.6-33.7] for ESR1 mutant patients versus 28.1 months [95% confidence interval (CI), 19.3-36.9] for ESR1 wildtype patients [p = 0.27]. Patients with ≥ two ESR1 mutations had a significantly worse OS, but not PFS, compared to those who did not [p = 0.003]. Change in ctDNA level at C2 was not different between ESR1 and other mutations. CONCLUSIONS Presence of ESR1 mutations in baseline ctDNA might not be associated with inferior PFS and OS in advanced breast cancer patients treated with paclitaxel/bevacizumab.
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Affiliation(s)
- M K Bos
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - S W Lam
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam/Cancer Center Amsterdam, De Boelelaan 1117, 1081 , HV, Amsterdam, The Netherlands
- Department of Radiology, The Netherlands, Cancer Institute/Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands
| | - G Motta
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
- IOM (Mediterranean Institute of Oncology) Research, Viagrande, Catania, Italy
- Department of Clinical and Experimental Medicine, A.O.U. Policlinico-Vittorio Emanuele, Center of Experimental Oncology and Hematology, University of Catania, Catania, Italy
| | - J C A Helmijr
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - C M Beaufort
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - E de Jonge
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J W M Martens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - E Boven
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam/Cancer Center Amsterdam, De Boelelaan 1117, 1081 , HV, Amsterdam, The Netherlands
| | - M P H M Jansen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - A Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - S Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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Verhoeven J, Hesselink D, Peeters A, de Jonge E, von der Thüsen J, van Schaik R, Baan C, Manintveld O, Boer K. Donor-Derived Cell-Free DNA for the Detection of Heart Allograft Injury: Impact of Timing of the Liquid Biopsy. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Grim CCA, van der Wal LI, Helmerhorst HJF, van Westerloo DJ, Pelosi P, Schultz MJ, de Jonge E, del Prado MR, Wigbers J, Sigtermans MJ, Dawson L, van der Heijden PLJ, den Berg EYSV, Loef BG, Reidinga AC, de Vreede E, Qualm J, Boerma EC, Rijnhart-de Jong H, Koopmans M, Cornet AD, Krol T, Rinket M, Vermeijden JW, Beishuizen A, Schoonderbeek FJ, van Holten J, Tsonas AM, Botta M, Winters T, Horn J, Paulus F, Loconte M, Battaglini D, Ball L, Brunetti I. ICONIC study—conservative versus conventional oxygenation targets in intensive care patients: study protocol for a randomized clinical trial. Trials 2022; 23:136. [PMID: 35152909 PMCID: PMC8842972 DOI: 10.1186/s13063-022-06065-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/29/2022] [Indexed: 12/02/2022] Open
Abstract
Background Oxygen therapy is a widely used intervention in acutely ill patients in the intensive care unit (ICU). It is established that not only hypoxia, but also prolonged hyperoxia is associated with poor patient-centered outcomes. Nevertheless, a fundamental knowledge gap remains regarding optimal oxygenation for critically ill patients. In this randomized clinical trial, we aim to compare ventilation that uses conservative oxygenation targets with ventilation that uses conventional oxygen targets with respect to mortality in ICU patients. Methods The “ConservatIve versus CONventional oxygenation targets in Intensive Care patients” trial (ICONIC) is an investigator-initiated, international, multicenter, randomized clinical two-arm trial in ventilated adult ICU patients. The ICONIC trial will run in multiple ICUs in The Netherlands and Italy to enroll 1512 ventilated patients. ICU patients with an expected mechanical ventilation time of more than 24 h are randomized to a ventilation strategy that uses conservative (PaO2 55–80 mmHg (7.3–10.7 kPa)) or conventional (PaO2 110–150 mmHg (14.7–20 kPa)) oxygenation targets. The primary endpoint is 28-day mortality. Secondary endpoints are ventilator-free days at day 28, ICU mortality, in-hospital mortality, 90-day mortality, ICU- and hospital length of stay, ischemic events, quality of life, and patient opinion of research and consent in the emergency setting. Discussion The ICONIC trial is expected to provide evidence on the effects of conservative versus conventional oxygenation targets in the ICU population. This study may guide targeted oxygen therapy in the future. Trial registration Trialregister.nl NTR7376. Registered on 20 July, 2018.
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Kaptein FHJ, Stals MAM, Grootenboers M, Braken SJE, Burggraaf JLI, van Bussel BCT, Cannegieter SC, Ten Cate H, Endeman H, Gommers DAMPJ, van Guldener C, de Jonge E, Juffermans NP, Kant KM, Kevenaar ME, Koster S, Kroft LJM, Kruip MJHA, Leentjens J, Marechal C, Soei YL, Tjepkema L, Visser C, Klok FA, Huisman MV. Incidence of thrombotic complications and overall survival in hospitalized patients with COVID-19 in the second and first wave. Thromb Res 2021; 199:143-148. [PMID: 33535120 PMCID: PMC7832218 DOI: 10.1016/j.thromres.2020.12.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In the first wave, thrombotic complications were common in COVID-19 patients. It is unknown whether state-of-the-art treatment has resulted in less thrombotic complications in the second wave. METHODS We assessed the incidence of thrombotic complications and overall mortality in COVID-19 patients admitted to eight Dutch hospitals between September 1st and November 30th 2020. Follow-up ended at discharge, transfer to another hospital, when they died, or on November 30th 2020, whichever came first. Cumulative incidences were estimated, adjusted for competing risk of death. These were compared to those observed in 579 patients admitted in the first wave, between February 24th and April 26th 2020, by means of Cox regression techniques adjusted for age, sex and weight. RESULTS In total 947 patients with COVID-19 were included in this analysis, of whom 358 patients were admitted to the ICU; 144 patients died (15%). The adjusted cumulative incidence of all thrombotic complications after 10, 20 and 30 days was 12% (95% confidence interval (CI) 9.8-15%), 16% (13-19%) and 21% (17-25%), respectively. Patient characteristics between the first and second wave were comparable. The adjusted hazard ratio (HR) for overall mortality in the second wave versus the first wave was 0.53 (95%CI 0.41-0.70). The adjusted HR for any thrombotic complication in the second versus the first wave was 0.89 (95%CI 0.65-1.2). CONCLUSIONS Mortality was reduced by 47% in the second wave, but the thrombotic complication rate remained high, and comparable to the first wave. Careful attention to provision of adequate thromboprophylaxis is invariably warranted.
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Affiliation(s)
- F H J Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M Grootenboers
- Department of Pulmonology, Amphia Hospital Breda, the Netherlands
| | - S J E Braken
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L I Burggraaf
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - B C T van Bussel
- Department of Intensive Care Medicine, Maastricht, UMC+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - S C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - H Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - H Endeman
- Department of Adult Intensive Care, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - D A M P J Gommers
- Department of Adult Intensive Care, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - C van Guldener
- Department of Internal Medicine, Amphia Hospital Breda, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - K M Kant
- Department of Intensive Care Medicine, Amphia Hospital Breda, the Netherlands
| | - M E Kevenaar
- Department of Internal Medicine, Franciscus Gasthuis& Vlietland, Rotterdam, the Netherlands
| | - S Koster
- Department of Intensive Care Medicine, Zaans Medical Center, Zaandam, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Leentjens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C Marechal
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Y L Soei
- Department of Internal Medicine, Franciscus Gasthuis& Vlietland, Rotterdam, the Netherlands
| | - L Tjepkema
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Bakker T, Abu-Hanna A, Dongelmans DA, Vermeijden WJ, Bosman RJ, de Lange DW, Klopotowska JE, de Keizer NF, Hendriks S, Ten Cate J, Schutte PF, van Balen D, Duyvendak M, Karakus A, Sigtermans M, Kuck EM, Hunfeld NGM, van der Sijs H, de Feiter PW, Wils EJ, Spronk PE, van Kan HJM, van der Steen MS, Purmer IM, Bosma BE, Kieft H, van Marum RJ, de Jonge E, Beishuizen A, Movig K, Mulder F, Franssen EJF, van den Bergh WM, Bult W, Hoeksema M, Wesselink E. Clinically relevant potential drug-drug interactions in intensive care patients: A large retrospective observational multicenter study. J Crit Care 2020; 62:124-130. [PMID: 33352505 DOI: 10.1016/j.jcrc.2020.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/16/2020] [Accepted: 11/27/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. MATERIALS & METHODS In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. RESULTS The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when considering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. CONCLUSIONS Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients.
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Affiliation(s)
- Tinka Bakker
- Amsterdam UMC (location AMC), Department of Medical Informatics, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - Ameen Abu-Hanna
- Amsterdam UMC (location AMC), Department of Medical Informatics, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - Dave A Dongelmans
- Amsterdam UMC (location AMC), Department of Intensive Care Medicine, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - Wytze J Vermeijden
- Department of Intensive Care, Medisch Spectrum Twente, Koningsplein 1, 7512, KZ, Enschede, the Netherlands.
| | - Rob J Bosman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091, AC, Amsterdam, the Netherlands.
| | - Dylan W de Lange
- Department of Intensive Care and Dutch Poison Information Center, University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
| | - Joanna E Klopotowska
- Amsterdam UMC (location AMC), Department of Medical Informatics, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - Nicolette F de Keizer
- Amsterdam UMC (location AMC), Department of Medical Informatics, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | | | - S Hendriks
- Department of Intensive Care, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | - J Ten Cate
- Department of Intensive Care, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - P F Schutte
- Department of Intensive Care, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - D van Balen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Duyvendak
- Department of Hospital Pharmacy, Antonius Hospital, Sneek, The Netherlands
| | - A Karakus
- Department of Intensive Care Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - M Sigtermans
- Department of Intensive Care Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - E M Kuck
- Department of Hospital Pharmacy, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - N G M Hunfeld
- Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands; Department of Hospital Pharmacy, ErasmusMC, Rotterdam, The Netherlands
| | - H van der Sijs
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - P W de Feiter
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - E-J Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - P E Spronk
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - H J M van Kan
- Department of Clinical Pharmacy, Gelre Hospitals, Apeldoorn, The Netherlands
| | - M S van der Steen
- Department of Intensive Care, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - I M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - B E Bosma
- Department of Hospital Pharmacy, Haga Hospital, The Hague, The Netherlands
| | - H Kieft
- Department of Intensive Care, Isala Hospital, Zwolle, The Netherlands
| | - R J van Marum
- Department of Clinical Pharmacology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands; Amsterdam UMC (location VUmc), Department of Elderly Care Medicine, Amsterdam, The Netherlands
| | - E de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - A Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | - K Movig
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands
| | - F Mulder
- Department of Pharmacology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - E J F Franssen
- OLVG Hospital, Department of Clinical Pharmacy, Amsterdam, The Netherlands
| | - W M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Bult
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M Hoeksema
- Zaans Medisch Centrum, Department of Anesthesiology, Intensive Care and Painmanagement, Zaandam, The Netherlands
| | - E Wesselink
- Department of Clinical Pharmacy, Zaans Medisch Centrum, Zaandam, The Netherlands
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild 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Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins 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Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020. [PMID: 32876697 DOI: 10.1001/jama.2020.1702221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020; 324:1317-1329. [PMID: 32876697 PMCID: PMC7489418 DOI: 10.1001/jama.2020.17022] [Citation(s) in RCA: 542] [Impact Index Per Article: 135.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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9
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van Dam LF, Kroft LJM, van der Wal LI, Cannegieter SC, Eikenboom J, de Jonge E, Huisman MV, Klok FA. Clinical and computed tomography characteristics of COVID-19 associated acute pulmonary embolism: A different phenotype of thrombotic disease? Thromb Res 2020; 193:86-89. [PMID: 32531548 PMCID: PMC7274953 DOI: 10.1016/j.thromres.2020.06.010] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION COVID-19 infections are associated with a high prevalence of venous thromboembolism, particularly pulmonary embolism (PE). It is suggested that COVID-19 associated PE represents in situ immunothrombosis rather than venous thromboembolism, although the origin of thrombotic lesions in COVID-19 patients remains largely unknown. METHODS In this study, we assessed the clinical and computed tomography (CT) characteristics of PE in 23 consecutive patients with COVID-19 pneumonia and compared these to those of 100 consecutive control patients diagnosed with acute PE before the COVID-19 outbreak. Specifically, RV/LV diameter ratio, pulmonary artery trunk diameter and total thrombus load (according to Qanadli score) were measured and compared. RESULTS We observed that all thrombotic lesions in COVID-19 patients were found to be in lung parenchyma affected by COVID-19. Also, the thrombus load was lower in COVID-19 patients (Qanadli score -8%, 95% confidence interval [95%CI] -16 to -0.36%) as was the prevalence of the most proximal PE in the main/lobar pulmonary artery (17% versus 47%; -30%, 95%CI -44% to -8.2). Moreover, the mean RV/LV ratio (mean difference -0.23, 95%CI -0.39 to -0.07) and the prevalence of RV/LV ratio >1.0 (prevalence difference -23%, 95%CI -41 to -0.86%) were lower in the COVID-19 patients. CONCLUSION Our findings therefore suggest that the phenotype of COVID-19 associated PE indeed differs from PE in patients without COVID-19, fuelling the discussion on its pathophysiology.
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Affiliation(s)
- L F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L I van der Wal
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - S C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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10
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Grim CCA, Cornet AD, Kroner A, Meiners AJ, Brouwers AJBW, Reidinga AC, van Westerloo DJ, Bergmans DCJJ, Gommers D, Versluis D, Weller D, Christiaan Boerma E, van Driel E, de Jonge E, Schoonderbeek FJ, Helmerhorst HJF, Jongsma-van Netten HG, Weenink J, Woittiez KJ, Simons KS, van Ewelie L, Petjak M, Sigtermans MJ, van der Woude M, Cremer OL, Bijlstra P, van der Heiden P, So RKL, Vink R, Jansen T, de Ruijter W. Attitudes of Dutch intensive care unit clinicians towards oxygen therapy. Neth J Med 2020; 78:167-174. [PMID: 32641541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Over the last decade, there has been an increasing awareness for the potential harm of the administration of too much oxygen. We aimed to describe self-reported attitudes towards oxygen therapy by clinicians from a large representative sample of intensive care units (ICUs) in the Netherlands. METHODS In April 2019, 36 ICUs in the Netherlands were approached and asked to send out a questionnaire (59 questions) to their nursing and medical staff (ICU clinicians) eliciting self-reported behaviour and attitudes towards oxygen therapy in general and in specific ICU case scenarios. RESULTS In total, 1361 ICU clinicians (71% nurses, 24% physicians) from 28 ICUs returned the questionnaire. Of responding ICU clinicians, 64% considered oxygen-induced lung injury to be a major concern. The majority of respondents considered a partial pressure of oxygen (PaO2) of 6-10 kPa (45-75 mmHg) and an arterial saturation (SaO2) of 85-90% as acceptable for 15 minutes, and a PaO2 7-10 kPa (53-75 mmHg) and SaO2 90-95% as acceptable for 24-48 hours in an acute respiratory distress syndrome (ARDS) patient. In most case scenarios, respondents reported not to change the fraction of inspired oxygen (FiO2) if SaO2 was 90-95% or PaO2 was 12 kPa (90 mmHg). CONCLUSION A representative sample of ICU clinicians from the Netherlands were concerned about oxygen-induced lung injury, and reported that they preferred PaO2 and SaO2 targets in the lower physiological range and would adjust ventilation settings accordingly.
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Affiliation(s)
- C C A Grim
- Leiden University Medical Centre, Leiden, the Netherlands
| | - A D Cornet
- Leiden University Medical Centre, Leiden, the Netherlands
| | - A Kroner
- Leiden University Medical Centre, Leiden, the Netherlands
| | - A J Meiners
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - A C Reidinga
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | - D Gommers
- Leiden University Medical Centre, Leiden, the Netherlands
| | - D Versluis
- Leiden University Medical Centre, Leiden, the Netherlands
| | - D Weller
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - E van Driel
- Leiden University Medical Centre, Leiden, the Netherlands
| | - E de Jonge
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | | | - J Weenink
- Leiden University Medical Centre, Leiden, the Netherlands
| | - K J Woittiez
- Leiden University Medical Centre, Leiden, the Netherlands
| | - K S Simons
- Leiden University Medical Centre, Leiden, the Netherlands
| | - L van Ewelie
- Leiden University Medical Centre, Leiden, the Netherlands
| | - M Petjak
- Leiden University Medical Centre, Leiden, the Netherlands
| | - M J Sigtermans
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - O L Cremer
- Leiden University Medical Centre, Leiden, the Netherlands
| | - P Bijlstra
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - R K L So
- Leiden University Medical Centre, Leiden, the Netherlands
| | - R Vink
- Leiden University Medical Centre, Leiden, the Netherlands
| | - T Jansen
- Leiden University Medical Centre, Leiden, the Netherlands
| | - W de Ruijter
- Leiden University Medical Centre, Leiden, the Netherlands
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11
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Uyl N, de Jonge E, Uyl-de Groot C, van der Marel C, Duvekot J. Difficult epidural placement in obese and non-obese pregnant women: a systematic review and meta-analysis. Int J Obstet Anesth 2019; 40:52-61. [DOI: 10.1016/j.ijoa.2019.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 11/17/2022]
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12
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Bakker T, Klopotowska JE, Eslami S, de Lange DW, van Marum R, van der Sijs H, de Jonge E, Dongelmans DA, de Keizer NF, Abu-Hanna A. The effect of ICU-tailored drug-drug interaction alerts on medication prescribing and monitoring: protocol for a cluster randomized stepped-wedge trial. BMC Med Inform Decis Mak 2019; 19:159. [PMID: 31409338 PMCID: PMC6692933 DOI: 10.1186/s12911-019-0888-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 08/02/2019] [Indexed: 11/10/2022] Open
Abstract
Background Drug-drug interactions (DDIs) can cause patient harm. Between 46 and 90% of patients admitted to the Intensive Care Unit (ICU) are exposed to potential DDIs (pDDIs). This rate is twice as high as patients on general wards. Clinical decision support systems (CDSSs) have shown their potential to prevent pDDIs. However, the literature shows that there is considerable room for improvement of CDSSs, in particular by increasing the clinical relevance of the pDDI alerts they generate and thereby reducing alert fatigue. However, consensus on which pDDIs are clinically relevant in the ICU setting is lacking. The primary aim of this study is to evaluate the effect of alerts based on only clinically relevant interactions for the ICU setting on the prevention of pDDIs among Dutch ICUs. Methods To define the clinically relevant pDDIs, we will follow a rigorous two-step Delphi procedure in which a national expert panel will assess which pDDIs are perceived clinically relevant for the Dutch ICU setting. The intervention is the CDSS that generates alerts based on the clinically relevant pDDIs. The intervention will be evaluated in a stepped-wedge trial. A total of 12 Dutch adult ICUs using the same patient data management system, in which the CDSS will operate, were invited to participate in the trial. Of the 12 ICUs, 9 agreed to participate and will be enrolled in the trial. Our primary outcome measure is the incidence of clinically relevant pDDIs per 1000 medication administrations. Discussion This study will identify pDDIs relevant for the ICU setting. It will also enhance our understanding of the effectiveness of alerts confined to clinically relevant pDDIs. Both of these contributions can facilitate the successful implementation of CDSSs in the ICU and in other domains as well. Trial registration Nederlands Trial register Identifier: NL6762. Registered November 26, 2018.
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Affiliation(s)
- T Bakker
- Department of Medical Informatics, Amsterdam UMC (location AMC), Amsterdam, The Netherlands.
| | - J E Klopotowska
- Department of Medical Informatics, Amsterdam UMC (location AMC), Amsterdam, The Netherlands
| | - S Eslami
- Department of Medical Informatics, Amsterdam UMC (location AMC), Amsterdam, The Netherlands.,Pharmaceutical Research Center, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - D W de Lange
- Department of Intensive Care and Dutch Poison Information Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - R van Marum
- Department of Geriatrics, Jeroen Bosch Hospital, s-Hertogenbosch, The Netherlands.,Department of General Practice and Elderly Care Medicine, Amsterdam UMC (location VUmc), Amsterdam, The Netherlands
| | - H van der Sijs
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - E de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - D A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC (location AMC), Amsterdam, The Netherlands
| | - N F de Keizer
- Department of Medical Informatics, Amsterdam UMC (location AMC), Amsterdam, The Netherlands
| | - A Abu-Hanna
- Department of Medical Informatics, Amsterdam UMC (location AMC), Amsterdam, The Netherlands
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13
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de Jonge E, de Wilde RBP, Juffermans NP, Oostdijk EAN, Bernards AT, van Essen EHR, Kuijper EJ, Visser CE, Kesecioglu J, Bonten MJM. Carriage of antibiotic-resistant Gram-negative bacteria after discontinuation of selective decontamination of the digestive tract (SDD) or selective oropharyngeal decontamination (SOD). Crit Care 2018; 22:243. [PMID: 30268133 PMCID: PMC6162962 DOI: 10.1186/s13054-018-2170-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/27/2018] [Indexed: 12/04/2022]
Abstract
Background Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) reduce colonization with antibiotic-resistant Gram-negative bacteria (ARGNB), incidence of nosocomial infections and improve survival in ICU patients. The effect on bacterial gut colonization might be caused by growth suppression by antibiotics during SDD/SOD. We investigated intestinal colonization with ARGNB after discharge from ICU and discontinuation of SDD or SOD. Methods We performed a prospective, observational follow-up study in regular hospital wards of three teaching hospitals in the Netherlands in patients discharged from the ICU, who were participating in a cluster randomized trial comparing SDD with SOD. We determined rectal carriage with ARGNB at ICU discharge (time (T) = 0) and 3, 6 and 10 days after discharge. The primary endpoint was time to first colonization with ARGNB that was not present at T = 0. Bacteria that are intrinsically resistant to antibiotics were not included in the primary analysis, but were included in post-hoc analysis. Results Of 1370 patients screened for inclusion, 996 patients had samples at T = 0 (507 after SDD and 489 after SOD). At ICU discharge, the prevalence of intestinal carriage with any ARGNB was 22/507 (4.3%) after SDD and 87/489 (17.8%) after SOD (p < 0.0001): 426 (SDD) and 409 (SOD) patients had at least one follow-up sample for analysis. The hazard rate for acquiring carriage of ARGNB after discontinuation of SDD, compared to SOD, in the ICU was 0.61 (95% CI 0.40–0.91, p = 0.02), and cumulative risks of acquisition of at least one ARGNB until day 10 were 13% (SDD) and 18% (SOD). At day 10 after ICU discharge, the prevalence of intestinal carriage with ARGNB was 11.3% (26/230 patients) after SDD and 12.5% (28/224 patients) after SOD (p = 0.7). In post-hoc analysis of all ARGNB, including intrinsically resistant bacteria, colonization at ICU discharge was lower after SDD (4.9 vs. 22.3%, p < 0.0001), but acquisition rates after ICU discharge were similar in both groups. Conclusions Intestinal carriage at ICU discharge and the acquisition rate of ARGNB after ICU discharge are lower after SDD than after SOD. The prevalence of intestinal carriage with ARGNB at 10 days after ICU discharge was comparable in both groups, suggesting rapid clearance of ARGNB from the gut after ICU discharge. Trial registration Netherlands Trial Registry, NTR3311. Registered on 28 february 2012. Electronic supplementary material The online version of this article (10.1186/s13054-018-2170-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E de Jonge
- Department of Intensive Care, Leiden University Medical Center, B4-32, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - R B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, B4-32, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - N P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - E A N Oostdijk
- Department of Medical Microbiology, University Medical Center, Utrecht, The Netherlands
| | - A T Bernards
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E H R van Essen
- Department of Intensive Care, Leiden University Medical Center, B4-32, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - E J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - C E Visser
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
| | - J Kesecioglu
- Department of Intensive Care, University Medical Center, Utrecht, The Netherlands
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Center, Utrecht, The Netherlands
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14
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Abstract
Summary
Objectives:
The usability of terminological systems (TSs) strongly depends on the coverage and correctness of their content. The objective of this study was to create a literature overview of aspects related to the content of TSs and of methods for the evaluation of the content of TSs. The extent to which these methods overlap or complement each other is investigated.
Methods:
We reviewed literature and composed definitions for aspects of the evaluation of the content of TSs. Of the methods described in literature three were selected: 1) Concept matching in which two samples of concepts representing a) documentation of reasons for admission in daily care practice and b) aggregation of patient groups for research, are looked up in the TS in order to assess its coverage; 2) Formal algorithmic evaluation in which reasoning on the formally represented content is used to detect inconsistencies; and 3) Expert review in which a random sample of concepts are checked for incorrect and incomplete terms and relations. These evaluation methods were applied in a case study on the locally developed TS DICE (Diagnoses for Intensive Care Evaluation).
Results:
None of the applied methods covered all the aspects of the content of a TS. The results of concept matching differed for the two use cases (63% vs. 52% perfect matches). Expert review revealed many more errors and incompleteness than formal algorithmic evaluation.
Conclusions:
To evaluate the content of a TS, using a combination of evaluation methods is preferable. Different representative samples, reflecting the uses of TSs, lead to different results for concept matching. Expert review appears to be very valuable, but time consuming. Formal algorithmic evaluation has the potential to decrease the workload of human reviewers but detects only logical inconsistencies. Further research is required to exploit the potentials of formal algorithmic evaluation.
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Abstract
Summary
Objectives:
To develop a predictive model for the outcome length of stay at the Intensive Care Unit (ICU LOS), including the choice of an optimal dichotomization threshold for this outcome. Reduction of prediction problems of this type of outcome to a two-class problem is a common strategy to identify high-risk patients.
Methods:
Threshold selection and model development are performed simultaneously. From the range of possible threshold values, the value is chosen for which the corresponding predictive model has maximal precision based on the data. To compare the precision of models for different dichotomizations of the outcome, the MALOR performance statistic is introduced. This statistic is insensitive to the prevalence of positive cases in a two-class prediction problem.
Results:
The procedure is applied to data from cardiac surgery patients to dichotomize the outcome ICU LOS. The class probabilitytree method is used to develop predictive models. Within our data, the best model precision is found at the threshold of seven days.
Conclusions:
The presented method extends existing procedures for predictive modeling with optimization of the outcome definition for predictive purposes. The method can be applied to all prediction problems where the outcome variable needs to be dichotomized, and is insensitive to changes in the prevalence of positive cases with different dichotomization thresholds.
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Affiliation(s)
- Marion Verduijn
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.
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16
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Levi M, Berends F, Ende AEVD, Cate JWT, Stoutenbeek CP, Jonge ED. Impaired Haemostasis by Intravenous Administration of a Gelatin-based Plasma Expander in Human Subjects. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1614979] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryThe aim of this study was to investigate the effects of a gelatin-based plasma expander on blood coagulation and haemostasis in human subjects.Six healthy men were studied in a randomised, controlled cross-over study to investigate the effects of a 60 min intravenous infusion of either 1 l gelatin-based plasma substitute (Gelofusine) or 0.9% NaCl (control). The infusion of gelatin resulted in a 1.7 fold increase in bleeding time at 60 min and a 1.4 fold increase at 120 min, while saline had no effect (p <0.05). Aggregation studies revealed a significant impairment of ristocetin-induced platelet aggregation (p <0.05), associated with a substantial decrease of vWF:ag (–32% vs. –5%, p <0.05) and ristocetin co-factor (–29% vs. +1%, p <0.05) and without in vitro impairment of the platelet glycoprotein 1b receptor. Gelatin caused a decrease in thrombin-antithrombin complexes (–45% vs. –4%, p <0.05) and F1+2 (–40% vs. +1%, p <0.05). The decrease in circulating levels of vWF:ag, vWF R:Co, thrombin-antithrombin complexes and F1+ 2 was more than could be expected by the calculated plasma-dilution generated by Gelofusine.Our results demonstrated that the administration of a gelatin-based plasma substitute results in a significant impairment of primary haemostasis and thrombin generation. The defect in primary haemostasis appears to be related to a gelatin-induced reduction in von Willebrand factor, whereas the decreased thrombin generation may be due to the dilution of coagulation factors induced by Gelofusine.
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17
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Maeseele N, Faes J, Van de Putte T, Vlasselaer J, de Jonge E, Schobbens JC, Deraedt K, Debrock G, Van de Putte G. Axillary lymph node dissection on the run? Facts Views Vis Obgyn 2017; 9:45-49. [PMID: 28721184 PMCID: PMC5506769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The standard approach of performing a completion axillary lymph node dissection (cALND) after a positive sentinel node for breast cancer patients is no longer generally accepted. This study applied the criterion of a 27% risk of having residual positive lymph nodes calculated by the MD Anderson nomogram to perform a cALND. This 27% cut-off is based on the number of positive non-sentinels in the Z0011 trial. A cohort of 166 cN0, sentinel positive breast cancer patients was used to validate the MD Anderson nomogram. ROC (Receiver Operating Characteristic) analysis shows an AUC (Area Under the Curve) of 0.76 and an optimal cut-off at 34% risk of positive non- SLNs (sensitivity 86%, specificity 57%). The 27% cut-off has a sensitivity of 88% and a specificity of 41% to detect positive non-sentinels. In a second cohort (N= 114) the 27% cut-off criterion was prospectively applied and appeared to be practice changing. Although we take minimal risk to leave disease behind (2/166 patients >3 positive nodes), 30.7 % in the first cohort and 54.4 % of the patients in the second cohort could be spared a cALND. The Z0011 criteria would have had more impact, omitting 90% of the cALND, but leaves more disease behind. The impact of leaving disease behind on survival remains unanswered but is awaited by long term follow up of large prospective cohort studies.
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18
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de Wit F, van Vliet AL, de Wilde RB, Jansen JR, Vuyk J, Aarts LP, de Jonge E, Veelo DP, Geerts BF. The effect of propofol on haemodynamics: cardiac output, venous return, mean systemic filling pressure, and vascular resistances. Br J Anaesth 2016; 116:784-9. [PMID: 27199311 DOI: 10.1093/bja/aew126] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although arterial hypotension occurs frequently with propofol use in humans, its effects on intravascular volume and vascular capacitance are uncertain. We hypothesized that propofol decreases vascular capacitance and therefore decreases stressed volume. METHODS Cardiac output (CO) was measured using Modelflow(®) in 17 adult subjects after upper abdominal surgery. Mean systemic filling pressure (MSFP) and vascular resistances were calculated using venous return curves constructed by measuring steady-state arterial and venous pressures and CO during inspiratory hold manoeuvres at increasing plateau pressures. Measurements were performed at three incremental levels of targeted blood propofol concentrations. RESULTS Mean blood propofol concentrations for the three targeted levels were 3.0, 4.5, and 6.5 µg ml(-1). Mean arterial pressure, central venous pressure, MSFP, venous return pressure, Rv, systemic arterial resistance, and resistance of the systemic circulation decreased, stroke volume variation increased, and CO was not significantly different as propofol concentration increased. CONCLUSIONS An increase in propofol concentration within the therapeutic range causes a decrease in vascular stressed volume without a change in CO. The absence of an effect of propofol on CO can be explained by the balance between the decrease in effective, or stressed, volume (as determined by MSFP), the decrease in resistance for venous return, and slightly improved heart function. CLINICAL TRIAL REGISTRATION Netherlands Trial Register: NTR2486.
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Affiliation(s)
- F de Wit
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - A L van Vliet
- Department of Anaesthesiology, Alrijne Hospital, Leiderdorp, The Netherlands
| | - R B de Wilde
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - J R Jansen
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - J Vuyk
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - L P Aarts
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - E de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - D P Veelo
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B F Geerts
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands Department of Anaesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
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19
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Helmerhorst HJF, Arts DL, de Jonge E, van Westerloo DJ. Metrics of arterial hyperoxia and associated outcome in critical care. Intensive Care Med Exp 2015. [PMCID: PMC4798374 DOI: 10.1186/2197-425x-3-s1-a661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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20
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Müller MCA, Straat M, Meijers JCM, Klinkspoor JH, de Jonge E, Arbous MS, Schultz MJ, Vroom MB, Juffermans NP. Fresh frozen plasma transfusion fails to influence the hemostatic balance in critically ill patients with a coagulopathy. J Thromb Haemost 2015; 13:989-97. [PMID: 25809519 DOI: 10.1111/jth.12908] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/15/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coagulopathy has a high prevalence in critically ill patients. An increased International Normalized Ratio (INR) is a common trigger to transfuse fresh frozen plasma (FFP), even in the absence of bleeding. Therefore, FFP is frequently administered to these patients. However, the efficacy of FFP in correcting hemostatic disorders in non-bleeding recipients has been questioned. OBJECTIVES To assess whether INR prolongation parallels changes in the results of other tests investigating hemostasis, and to evaluate the coagulant effects of a fixed dose of FFP in non-bleeding critically ill patients with a coagulopathy. METHODS Markers of coagulation, individual factor levels and levels of natural anticoagulants were measured. Also, thrombin generation and thromboelastometry (ROTEM) assays were performed before and after FFP transfusion (12 mL kg(-1) ) to 38 non-bleeding critically ill patients with an increased INR (1.5-3.0). RESULTS At baseline, levels of factor II, FV, FVII, protein C, protein S and antithrombin were reduced, and thrombin generation was impaired. ROTEM variables were within reference ranges, except for a prolonged INTEM clot formation time. FFP transfusion increased the levels of coagulation factors (FII, 34% [interquartile range (IQR) 26-46] before vs. 44% [IQR 38-52] after; FV, 48% [IQR 28-76] before vs. 58% [IQR 44-90] after; and FVII, 25% [IQR 16-38] before vs. 37% [IQR 28-55] after), and the levels of anticoagulant proteins. Thrombin generation was unaffected by FFP transfusion (endogenous thrombin potential, 72% [IQR 51-88] before vs. 71% [IQR 42-89] after), whereas ROTEM EXTEM clotting time and maximum clot firmness slightly improved in response to FFP. CONCLUSION In non-bleeding critically ill patients with a coagulopathy, FFP transfusion failed to induce a more procoagulant state.
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Affiliation(s)
- M C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M Straat
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, the Netherlands
| | - J H Klinkspoor
- Department of Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M S Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M B Vroom
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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21
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Van Holsbeke C, Ameye L, Testa AC, Mascilini F, Lindqvist P, Fischerova D, Frühauf F, Fransis S, de Jonge E, Timmerman D, Epstein E. Development and external validation of new ultrasound-based mathematical models for preoperative prediction of high-risk endometrial cancer. Ultrasound Obstet Gynecol 2014; 43:586-595. [PMID: 24123609 DOI: 10.1002/uog.13216] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 09/02/2013] [Accepted: 09/17/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To develop and validate strategies, using new ultrasound-based mathematical models, for the prediction of high-risk endometrial cancer and compare them with strategies using previously developed models or the use of preoperative grading only. METHODS Women with endometrial cancer were prospectively examined using two-dimensional (2D) and three-dimensional (3D) gray-scale and color Doppler ultrasound imaging. More than 25 ultrasound, demographic and histological variables were analyzed. Two logistic regression models were developed: one 'objective' model using mainly objective variables; and one 'subjective' model including subjective variables (i.e. subjective impression of myometrial and cervical invasion, preoperative grade and demographic variables). The following strategies were validated: a one-step strategy using only preoperative grading and two-step strategies using preoperative grading as the first step and one of the new models, subjective assessment or previously developed models as a second step. RESULTS One-hundred and twenty-five patients were included in the development set and 211 were included in the validation set. The 'objective' model retained preoperative grade and minimal tumor-free myometrium as variables. The 'subjective' model retained preoperative grade and subjective assessment of myometrial invasion. On external validation, the performance of the new models was similar to that on the development set. Sensitivity for the two-step strategy with the 'objective' model was 78% (95% CI, 69-84%) at a cut-off of 0.50, 82% (95% CI, 74-88%) for the strategy with the 'subjective' model and 83% (95% CI, 75-88%) for that with subjective assessment. Specificity was 68% (95% CI, 58-77%), 72% (95% CI, 62-80%) and 71% (95% CI, 61-79%) respectively. The two-step strategies detected up to twice as many high-risk cases as preoperative grading only. The new models had a significantly higher sensitivity than did previously developed models, at the same specificity. CONCLUSION Two-step strategies with 'new' ultrasound-based models predict high-risk endometrial cancers with good accuracy and do this better than do previously developed models.
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Affiliation(s)
- C Van Holsbeke
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
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22
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Huson M, Bakhshi-Raiez F, Grobusch M, de Jonge E, de Keizer N, van der Poll T. Characteristics of AIDS patients in Dutch intensive care units. Int J Infect Dis 2014. [DOI: 10.1016/j.ijid.2014.03.693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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23
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de Jonge E. Patients with cancer on the ICU: time for optimism. Neth J Med 2014; 72:60-61. [PMID: 24659587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- E de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
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24
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de Jonge E. Editorial. Facts Views Vis Obgyn 2014; 6:109-10. [PMID: 25374653 PMCID: PMC4216975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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25
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Knoester M, de Boer MGJ, Maarleveld JJ, Claas ECJ, Bernards AT, de Jonge E, van Dissel JT, Veldkamp KE. An integrated approach to control a prolonged outbreak of multidrug-resistant Pseudomonas aeruginosa in an intensive care unit. Clin Microbiol Infect 2013; 20:O207-15. [PMID: 24707852 DOI: 10.1111/1469-0691.12372] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/22/2013] [Accepted: 08/22/2013] [Indexed: 01/05/2023]
Abstract
In this paper we aim to provide insight into the complexity of outbreak management in an intensive care unit (ICU) setting. In October 2010 four patients on the ICU of our tertiary care centre were colonized or infected with a multidrug-resistant strain of Pseudomonas aeruginosa (MDR-PA). An outbreak investigation was carried out and infection control measures were taken in an attempt to identify a potential source and stop transmission. The outbreak investigation included descriptive epidemiology, comprising retrospective case finding by reviewing the laboratory information system back to 2004 and prospective case finding by patient screening for MDR-PA. Furthermore, microbiological analysis, environmental screening and a case-control study were carried out. Infection control measures consisted of re-education of healthcare personnel on basic hygiene measures, auditing of hygiene procedures used in daily practice by infection control practitioners, and stepwise up-regulation of isolation measures. From February 2009 to January 2012, 44 patients on our ICU were found to be MDR-PA positive. MDR-PA isolates of the 44 patients showed two distinct AFLP patterns, with homology within each of the AFLP clusters of more than 93%. The VIM metallo-β-lactamase gene was detected in 20 of 21 tested isolates. A descriptive epidemiology investigation identified the rooms with the highest numbers of MDR-PA positive patients. The case-control study showed three factors to be independently associated with MDR-PA positivity: admission to ICU subunit 1 (OR, 6.1; 95% CI, 1.7, 22), surgery prior to or during admission (OR, 5.7; 95% CI, 1.6, 20) and being warmed-up with the warm-air blanket (OR, 3.6; 95% CI, 1.2, 11). After three environmental screening rounds, with sampling of sinks, furniture and devices in the ICU, without revealing a clear common source, a fourth environmental investigation included culturing of faucet aerators. Two faucets were found to be positive for MDR-PA and were replaced. The occurrence of new cases decreased with the strengthening of infection control measures and declined further with the removal of the common source. With this integrated approach a prolonged outbreak of P. aeruginosa was controlled. Contaminated faucet aerators on the ICU probably served as a persisting source, while interpatient transmission by medical staff was a likely way of spread. Seven months after the last case (January 2012) and 3 months after cessation of extended isolation measures (May 2012), single cases started to occur on the ICU, with a total of seven patients in the past year. No common source has yet been found.
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Affiliation(s)
- M Knoester
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
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26
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Werbrouck J, Bouche G, de Jonge E, Jacomen G, D'Hondt V, Denys H, Van Limbergen E, Vandermeersch B, De Schutter H, Van Eycken E, Goffin F, Amant F. Evaluation of the quality of the management of cancer of the corpus uteri--selection of relevant quality indicators and implementation in Belgium. Gynecol Oncol 2013; 131:512-9. [PMID: 24103471 DOI: 10.1016/j.ygyno.2013.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/30/2013] [Accepted: 10/01/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Describe the methodology and selection of quality indicators (QI) to be implemented in the EFFECT (EFFectiveness of Endometrial Cancer Treatment) project. EFFECT aims to monitor the variability in Quality of Care (QoC) of uterine cancer in Belgium, to compare the effectiveness of different treatment strategies to improve the QoC and to check the internal validity of the QI to validate the impact of process indicators on outcome. METHODS A QI list was retrieved from literature, recent guidelines and QI databases. The Belgian Healthcare Knowledge Center methodology was used for the selection process and involved an expert's panel rating the QI on 4 criteria. The resulting scores and further discussion resulted in a final QI list. An online EFFECT module was developed by the Belgian Cancer Registry including the list of variables required for measuring the QI. Three test phases were performed to evaluate the relevance, feasibility and understanding of the variables and to test the compatibility of the dataset. RESULTS 138 QI were considered for further discussion and 82 QI were eligible for rating. Based on the rating scores and consensus among the expert's panel, 41 QI were considered measurable and relevant. Testing of the data collection enabled optimization of the content and the user-friendliness of the dataset and online module. CONCLUSIONS This first Belgian initiative for monitoring the QoC of uterine cancer indicates that the previously used QI selection methodology is reproducible for uterine cancer. The QI list could be applied by other research groups for comparison.
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Affiliation(s)
- J Werbrouck
- Belgian Cancer Registry, Koningsstraat 215 bus 7, 1210 Brussel, Belgium.
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27
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Velders MA, van Boven N, Boden H, van der Hoeven BL, Heestermans AACM, Jukema JW, de Jonge E, Kuiper MA, van Boven AJ, Hofma SH, Schalij MJ, Umans VAWM. Association between angiographic culprit lesion and out-of-hospital cardiac arrest in ST-elevation myocardial infarction patients. Resuscitation 2013; 84:1530-5. [PMID: 23907098 DOI: 10.1016/j.resuscitation.2013.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 07/01/2013] [Accepted: 07/19/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Factors related to the occurrence of out-of-hospital cardiac arrest (OHCA) in ST-elevation myocardial infarction (STEMI) are still poorly understood. The current study sought to compare STEMI patients presenting with and without OHCA to identify angiographic factors related to OHCA. METHODS This multicenter registry consisted of consecutive STEMI patients, including OHCA patients with return-of-spontaneous circulation. Patients were treated with primary percutaneous coronary intervention (PCI) and therapeutic hypothermia when indicated. Outcome consisted of in-hospital neurological recovery, scored using the Cerebral Performance Categories (CPC) scale, and 1-year survival. Logistic regression was used to identify factors associated with OHCA and survival was displayed with Kaplan-Meier curves and compared using log rank tests. RESULTS In total, 224 patients presented with OHCA and 3259 without OHCA. Average age was 63.3 years and 75% of patients were male. OHCA occurred prior to ambulance arrival in 68% of patients and 48% required intubation. Culprit lesion was associated with OHCA: risk was highest for proximal left coronary lesions and lowest for right coronary lesions. Also, culprit lesion determined the risk of cardiogenic shock and sub-optimal reperfusion after PCI, which were strongly related to survival after OHCA. Neurological recovery was acceptable (CPC≤2) in 77.1% of OHCA patients and did not differ between culprit lesions. CONCLUSIONS In the present STEMI population, coronary culprit lesion was associated with the occurrence of OHCA. Moreover, culprit lesion influenced the risk of cardiogenic shock and success of reperfusion, both of which were related to prognosis of OHCA patients.
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Affiliation(s)
- M A Velders
- Leiden University Medical Center, Leiden, The Netherlands; Medical Center Leeuwarden, Leeuwarden, The Netherlands.
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Koetsier A, Peek N, de Jonge E, Dongelmans D, van Berkel G, de Keizer N. Reliability of in-hospital mortality as a quality indicator in clinical quality registries. A case study in an intensive care quality register. Methods Inf Med 2013; 52:432-40. [PMID: 23807704 DOI: 10.3414/me12-02-0070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 04/09/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Errors in the registration or extraction of patient outcome data, such as in-hospital mortality, may lower the reliability of the quality indicator that uses this (partly) incorrect data. Our aim was to measure the reliability of in-hospital mortality registration in the Dutch National Intensive Care Evaluation (NICE) registry. METHODS We linked data of the NICE registry with an insurance claims database, resulting in a list of discrepancies in in-hospital mortality. Eleven Intensive Care Units (ICUs) were visited where local data sources were investigated to find the true in-hospital mortality status of the discrepancies and to identify the causes of the data errors in the NICE registry. Original and corrected Standardized Mortality Ratios (SMRs) were calculated to determine if conclusions about quality of care changed compared to the national benchmark. RESULTS In eleven ICUs, 23,855 records with 460 discrepancies were identified of which 255 discrepancies (1.1% of all linked records) were due to incorrect in-hospital mortality registration in the NICE registry. Two programming errors in computer software of six ICUs caused 78% of errors, the remainder was caused by manual transcription errors and failure to record patient outcomes. For one ICU the performance became concordant with the national benchmark after correction, instead of being better. CONCLUSIONS The reliability of in-hospital mortality registration in the NICE registry was good. This was reflected by the low number of data errors and by the fact that conclusions about the quality of care were only affected for one ICU due to systematic data errors. We recommend that registries frequently verify the software used in the registration process, and compare mortality data with an external source to assure consistent quality of data.
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Affiliation(s)
- A Koetsier
- Antonie Koetsier, MSc Department of Medical Informatics, Academic Medical Center, Room J1b-115-2, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands, E-mail:
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Bos MMEM, Smeets LS, Dumay I, de Jonge E. Bloodstream infections in patients with or without cancer in a large community hospital. Infection 2013; 41:949-58. [PMID: 23645474 DOI: 10.1007/s15010-013-0468-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Cancer is associated with an increased risk of acquiring bloodstream infection (BSIs). Most knowledge on pathogens and outcome are derived from specialised cancer centres. We here sought to compare causative micro-organisms in BSIs in patients with or without cancer in a 600-bed teaching community hospital. METHODS We analysed all positive blood cultures from adult patients between January 2005 and January 2011. RESULTS A total of 4,918 episodes of BSI occurred in 2,891 patients, of whom 13.4% had a diagnosis of cancer (85.5% with a solid tumour). In both patient groups, Gram-positive isolates were more prevalent (58.7 and 61.4% in patients with and without cancer, respectively) than Gram-negative isolates (31.8 and 32.3%, respectively). Amongst Gram-positive organisms, coagulase-negative staphylococci, Staphylococcus aureus and enterococci were the most frequently isolated in both patient groups; in cancer patients, twice as many BSIs were caused by Enterococcus faecalis and E. faecium. Amongst Gram-negative organisms, Escherichia coli was the most common isolate; in cancer patients, twice as many BSIs were caused by Pseudomonas aeruginosa and Enterobacter cloacae. Yeasts were grown from 3.0% of blood cultures from cancer patients compared to 1.5% of cultures from non-cancer patients. Cancer patients had a 90-day mortality of 35.8% following BSI compared to 23.5% in patients without cancer. CONCLUSION These data demonstrate distinct BSI pathogens and impaired outcomes in patients with cancer in the setting of a large community teaching hospital.
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Affiliation(s)
- M M E M Bos
- Division of Medical Oncology, Department of Internal Medicine, Reinier de Graaf Hospital, Reinier de Graafweg 3-11, 2625 AD, Delft, The Netherlands,
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Bos MMEM, Bakhshi-Raiez F, Dekker JWT, de Keizer NF, de Jonge E. Outcomes of intensive care unit admissions after elective cancer surgery. Eur J Surg Oncol 2013; 39:584-92. [PMID: 23490335 DOI: 10.1016/j.ejso.2013.02.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 01/12/2013] [Accepted: 02/06/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Postoperative care for major elective cancer surgery is frequently provided on the Intensive Care Unit (ICU). OBJECTIVE To analyze the characteristics and outcome of patients after ICU admission following elective surgery for different cancer diagnoses. METHODS We analyzed all ICU admissions following elective cancer surgery in the Netherlands collected in the National Intensive Care Evaluation registry between January 2007 and January 2012. RESULTS 28,973 patients (9.0% of all ICU admissions; 40% female) were admitted to the ICU after elective cancer surgery. Of these admissions 77% were planned; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent malignancies were colorectal cancer (25.6%), lung cancer (18.5%) and tumors of the central nervous system (14.3%). Mechanical ventilation was necessary in 24.8% of all patients, most frequently after surgery for esophageal (62.5%) and head and neck cancer (50.2%); 20.7% of patients were treated with vasopressors in the acute postoperative phase, in particular after surgery for esophageal cancer (41.8%). The median length of stay on the ICU was 0.9 days (interquartile ranges [IQR] 0.8-1.5); surgery for esophageal cancer was associated with the longest ICU length of stay (median 2.0 days) with the largest variation (IQR 1.0-4.8 days). ICU mortality was 1.4%; surgery for gastrointestinal cancer was associated with the highest ICU mortality (colorectal cancer 2.2%, pancreatico-cholangiocarcinoma 2.0%). CONCLUSION Elective cancer surgery represents a significant part of all ICU admissions, with a short length of stay and low mortality.
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Affiliation(s)
- M M E M Bos
- Reinier de Graaf Hospital, Department of Internal Medicine, Division of Medical Oncology, Delft, The Netherlands
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Minne L, Eslami S, de Keizer N, de Jonge E, de Rooij SE, Abu-Hanna A. Statistical process control for monitoring standardized mortality ratios of a classification tree model. Methods Inf Med 2012; 51:353-8. [PMID: 22773038 DOI: 10.3414/me11-02-0044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 05/04/2012] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The ratio of observed to expected mortality (standardized mortality ratio, SMR), is a key indicator of quality of care. We use PreControl Charts to investigate SMR behavior over time of an existing tree-model for predicting mortality in intensive care units (ICUs) and its implications for hospital ranking. We compare the results to those of a logistic regression model. METHODS We calculated SMRs of 30 equally-sized consecutive subsets from a total of 12,143 ICU patients aged 80 years or older and plotted them on a PreControl Chart. We calculated individual hospital SMRs in 2009, with and without repeated recalibration of the models on earlier data. RESULTS The overall SMR of the tree-model was stable over time, in contrast to logistic regression. Both models were stable after repeated recalibration. The overall SMR of the tree on the whole validation set was statistically significantly different (SMR 1.00 ± 0.012 vs. 0.94 ± 0.01) and worse in performance than the logistic regression model (AUC 0.76 ± 0.005 vs. 0.79 ± 0.004; Brier score 0.17 ± 0.012 vs. 0.16 ± 0.010). The individual SMRs' range in 2009 was 0.53-1.31 for the tree and 0.64-1.27 for logistic regression. The proportion of individual hospitals with SMR >1, hinting at poor quality of care, reduced from 38% to 29% after recalibration for the tree, and increased from 15% to 35% for logistic regression. CONCLUSIONS Although the tree-model has seemingly a longer shelf life than the logistic regression model, its SMR may be less useful for quality of care assessment as it insufficiently responds to changes in the population over time.
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Affiliation(s)
- Lilian Minne
- Academic Medical Center, Department of Medical Informatics, Amsterdam, The Netherlands.
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Bos MMEM, Smeets L, Koning J, Dumay I, de Jonge E. Low complication rates in the use of port-a-caths in oncology patients. Neth J Med 2012; 70:184-189. [PMID: 22641626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Port-a-caths (PACs) represent an important component of the care of cancer patients, in particular for administration of chemotherapy. We sought to analyse the longevity and complications of PACs in cancer patients in a large community hospital. METHODS We retrospectively analysed the indications, duration of use, complications and reasons for removal of PACs in cancer patients treated in our centre from January 2005 to December 2010, and compared these with findings in patients who received a PAC in the same period for reasons not related to cancer. RESULTS During the study period 152 cancer patients received a total of 170 PACs; in the same period, 21 patients received a total of 35 PACs for reasons unrelated to cancer. The total analysis comprised 70,919 days of PAC use. Most cancer patients had a solid tumour (97%). PACs were removed because of a complication in 25 cases in cancer patients (14.7%) vs 15 cases in non-cancer patients (42.9%, p.
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Affiliation(s)
- M M E M Bos
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft, the Netherlands.
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Minne L, Dongelmans DA, de Jonge E, Abu-Hanna A. Consistency of nurses' daily predictions of survival in the intensive care. Stud Health Technol Inform 2012; 180:1060-1064. [PMID: 22874356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
In the Intensive Care Unit, clinicians are continuously faced with the difficult task of prognosis, but their predictions of patient survival status may not always be consistent. Specifically very little is known about consistency of predictions over time. The aim of this paper is to assess the consistency of nurses' daily predictions of survival in terms of inter-observer variance and variance of observers over time. We found a low consistency of these predictions between observers and over time, even though changes in the patients' condition are considered. Our findings have implications to the process of end-of-life decision-making, which pertains to withholding or withdrawing intensive care treatment.
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Affiliation(s)
- Lilian Minne
- Academic Medical Center, Department of Medical Informatics, Amsterdam, the Netherlands.
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Roeleveld PP, Guijt D, Kuijper EJ, Hazekamp MG, de Wilde RBP, de Jonge E. Ventilator-associated pneumonia in children after cardiac surgery in The Netherlands. Intensive Care Med 2011; 37:1656-63. [PMID: 21877210 PMCID: PMC3178014 DOI: 10.1007/s00134-011-2349-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 07/14/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE We conducted a retrospective cohort study in an academic tertiary care center to characterize ventilator-associated pneumonia (VAP) in pediatric patients after cardiac surgery in The Netherlands. METHODS All patients following cardiac surgery and mechanically ventilated for ≥24 h were included. The primary outcome was development of VAP. Secondary outcomes were duration of mechanical ventilation and length of ICU stay. RESULTS A total of 125 patients were enrolled. Their mean age was 16.5 months. The rate of VAP was 17.1/1,000 mechanical ventilation days. Frequently found organisms were Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus and Pseudomonas aeruginosa. Patients with VAP had longer duration of ventilation and longer ICU stay. Risk factors associated with the development of VAP were a PRISM III score of ≥10 and transfusion of fresh frozen plasma. CONCLUSION The mean VAP rate in this population is higher than that reported in general pediatric ICU populations. Children with VAP had a prolonged need for mechanical ventilation and a longer ICU stay.
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Affiliation(s)
- P P Roeleveld
- Pediatric Intensive Care Unit, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Bakhshi-Raiez F, Ahmadian L, Cornet R, de Jonge E, de Keizer NF. Construction of an interface terminology on SNOMED CT. Generic approach and its application in intensive care. Methods Inf Med 2010; 49:349-59. [PMID: 20582384 DOI: 10.3414/me09-01-0057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 03/03/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To provide a generic approach for developing a domain-specific interface terminology on SNOMED CT and to apply this approach to the domain of intensive care. METHODS The process of developing an interface terminology on SNOMED CT can be regarded as six sequential phases: domain analysis, mapping from the domain concepts to SNOMED CT concepts, creating the SNOMED CT subset guided by the mapping, extending the subset with non-covered concepts, constraining the subset by removing irrelevant content, and deploying the subset in a terminology server. RESULTS The APACHE IV classification, a standard in the intensive care with 445 diagnostic categories, served as the starting point for designing the interface terminology. The majority (89.2%) of the diagnostic categories from APACHE IV could be mapped to SNOMED CT concepts and for the remaining concepts a partial match was identified. The resulting initial set of mapped concepts consisted of 404 SNOMED CT concepts. This set could be extended to 83,125 concepts if all taxonomic children of these concepts were included. Also including all concepts that are referred to in the definition of other concepts lead to a subset of 233,782 concepts. An evaluation of the interface terminology should reveal what level of detail in the subset is suitable for the intensive care domain and whether parts need further constraining. In the final phase, the interface terminology is implemented in the intensive care in a locally developed terminology server to collect the reasons for intensive care admission. CONCLUSIONS We provide a structure for the process of identifying a domain-specific interface terminology on SNOMED CT. We use this approach to design an interface terminology on SNOMED CT for the intensive care domain. This work is of value for other researchers who intend to build a domain-specific interface terminology on SNOMED CT.
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Affiliation(s)
- F Bakhshi-Raiez
- Academic Medical Centre, University of Amsterdam, Dept. of Medical Informatics, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.
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de Jonge E. Editorial. Facts Views Vis Obgyn 2010; 2:VII. [PMID: 25009717 PMCID: PMC4086014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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de Jonge E, Nijman HLI, Lammers SMM. [Behavioural changes during forensic psychiatric treatment: a multicenter study]. Tijdschr Psychiatr 2009; 51:205-215. [PMID: 19434575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND In forensic psychiatry it is essential that patients' risks of reoffending are assessed as reliably as possible. The risk assessment instrument hkt-30 assesses both static and dynamic risk factors. It is assumed that dynamic risk factors should change when a patient receives treatment. AIM To find out whether dynamic risk factors changed during the course of forensic psychiatric treatment. METHOD The hkt-30 was administered 984 times for forensic psychiatric patients in 3 different forensic psychiatric centres, in the period June 2003-November 2006. For 513 patients the instrument was administered at least once, for 313 this was done at least twice and for 158 patients for three years in succession. By subdividing the research group into 'new', 'old' and 'transferred' patients we were able to examine in which phase of treatment the largest changes in hkt-30 scores occurred. RESULTS More than half the scores for dynamic risk factors, as well as the total score, declined significantly as treatment progressed, but the differences were small in absolute terms. The three subgroups of patients hardly differed from each other with regard to the degree of change. CONCLUSION The scores for the risk factors, assumed in theory to be changeable, seemed to become lower as the treatment progressed. However, it is not yet certain whether these lower scores were in fact directly linked to a reduction on the risk of reoffending.
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Smit MJ, van der Spoel JI, de Smet AMGA, de Jonge E, Kuiper RAJ, van Lieshout EJ. Answer to the comment of Dr. Petros et al. on our manuscript about accumulation of oral antibiotics as an adverse effect of selective decontamination of the digestive tract. Intensive Care Med 2008. [PMCID: PMC2517083 DOI: 10.1007/s00134-008-1137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M. J. Smit
- Department of Intensive Care, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584cx The Netherlands
| | | | - A. M. G. A. de Smet
- Department of Intensive Care, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584cx The Netherlands
| | - E. de Jonge
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - R. A. J. Kuiper
- Department of Pharmacology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - E. J. van Lieshout
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Zuurbier CJ, Hoek FJ, van Dijk J, Abeling NG, Meijers JCM, Levels JHM, de Jonge E, de Mol BA, Van Wezel HB. Perioperative hyperinsulinaemic normoglycaemic clamp causes hypolipidaemia after coronary artery surgery. Br J Anaesth 2008; 100:442-50. [PMID: 18305079 DOI: 10.1093/bja/aen018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Glucose-insulin-potassium (GIK) administration is advocated on the premise of preventing hyperglycaemia and hyperlipidaemia during reperfusion after cardiac interventions. Current research has focused on hyperglycaemia, largely ignoring lipids, or other substrates. The present study examines lipids and other substrates during and after on-pump coronary artery bypass grafting and how they are affected by a hyperinsulinaemic normoglycaemic clamp. METHODS Forty-four patients were randomized to a control group (n=21) or to a GIK group (n=23) receiving a hyperinsulinaemic normoglycaemic clamp during 26 h. Plasma levels of free fatty acid (FFA), total and lipoprotein (VLDL, HDL, and LDL)-triglycerides (TG), ketone bodies, and lactate were determined. RESULTS In the control group, mean FFA peaked at 0.76 (sem 0.05) mmol litre(-1) at early reperfusion and decreased to 0.3-0.5 mmol litre(-1) during the remaining part of the study. GIK decreased FFA levels to 0.38 (0.05) mmol litre(-1) at early reperfusion, and to low concentrations of 0.10 (0.01) mmol litre(-1) during the hyperinsulinaemic clamp. GIK reduced the area under the curve (AUC) for FFA by 75% and for TG by 53%. The reduction in total TG was reflected by a reduction in the VLDL (-54% AUC) and HDL (-42% AUC) fraction, but not in the LDL fraction. GIK prevented the increase in ketone bodies after reperfusion (-44 to -47% AUC), but was without effect on lactate levels. CONCLUSIONS Mild hyperlipidaemia was only observed during early reperfusion (before heparin reversal) and the hyperinsulinaemic normoglycaemic clamp actually resulted in hypolipidaemia during the largest part of reperfusion after cardiac surgery.
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Affiliation(s)
- C J Zuurbier
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Smit MJ, van der Spoel JI, de Smet AMGA, de Jonge E, Kuiper RAJ, van Lieshout EJ. Accumulation of oral antibiotics as an adverse effect of selective decontamination of the digestive tract: a series of three cases. Intensive Care Med 2007; 33:2025-6. [PMID: 17622511 DOI: 10.1007/s00134-007-0774-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 06/15/2007] [Indexed: 10/23/2022]
Affiliation(s)
- M J Smit
- Intensive Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 Utrecht, The Netherlands.
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Coosemans A, Nik SA, Caluwaerts S, Lambin S, Verbist G, Van Bree R, Schelfhout V, de Jonge E, Dalle I, Jacomen G, Cassiman JJ, Moerman P, Vergote I, Amant F. Upregulation of Wilms’ tumour gene 1 (WT1) in uterine sarcomas. Eur J Cancer 2007; 43:1630-7. [PMID: 17531467 DOI: 10.1016/j.ejca.2007.04.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Revised: 04/03/2007] [Accepted: 04/05/2007] [Indexed: 11/27/2022]
Abstract
AIM Overexpression of Wilms' tumour gene (WT1) has been proven in several tumours. Previous research of our group on the cell cycle of uterine leiomyosarcoma (LMS) and carcinosarcoma (CS) suggested a possible role for WT1. We therefore intended to further explore the expression pattern of WT1 in uterine sarcomas. METHODS 27 CS, 38 LMS, 15 endometrial stromal sarcomas (ESS) and seven undifferentiated sarcomas (US) were collected. WT1 expression was evaluated by immunohistochemistry (IHC) in 87 samples, by RT-PCR (m-RNA expression) in 23 random selected samples and by Western blotting in 12 samples, separating cytoplasmic and nuclear proteins. A pilot study to detect mutations (exons 7-10) was performed on eight samples. RESULTS IHC showed WT1 positivity in 12/27 CS, 29/38 LMS, 7/15 ESS and 4/7 US. All-but-one sample had a positive RT-PCR. All Western blottings were positive with more cytoplasmic expression in 9/12 cases. No mutations were found. CONCLUSIONS WT1 is overexpressed in uterine sarcomas. Since increased levels of mRNA determine the biological role, WT1 might contribute to uterine sarcoma tumour biology.
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Affiliation(s)
- A Coosemans
- Leuven Cancer Institute (LKI), UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
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Vlaar APJ, van Soest EJ, Levi M, van Lienden KP, Boermeester M, de Jonge E. [A patient with repeated, life-threatening gastro-intestinal haemorrhages treated by means of medication, open surgery, endoscopic surgery, intervention radiology and conservative methods]. Ned Tijdschr Geneeskd 2007; 151:1412-7. [PMID: 17668608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A 56-year-old man with Henoch Schönlein purpura vasculitis suffered from repeated and multiple life-threatening gastrointestinal haemorrhages. Over recent years a number of interventions for the treatment of gastrointestinal haemorrhaging have become available; choosing which option to use can present difficulties. The available interventions are carried out by different disciplines and include haemostatic drugs, endoscopic intervention, intervention radiology, and surgery. In this patient, following a severe drop in haemoglobin levels, CT and angiography revealed active bleeding in the distal jejunum. Transarterial embolization by means of a coiling procedure halted the bleeding. The patient was also given tranexamic acid, a fibrinolysis inhibitor. More episodes of bleeding subsequently followed which necessitated further coiling procedures, two bowel resections, the endoscopic clipping of a bleeding artery, treatment with the recombinant activated factor VII (rFVIIa) at a dosage of 90 microg/kg, as well as conservative treatment with multiple transfusions of filtered erythrocytes and fresh plasma. The patient eventually recovered.
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Affiliation(s)
- A P J Vlaar
- Academisch Medisch Centrum/Universiteit van Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam
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de Jonge E. [Placement of central venous catheters and patient safety]. Ned Tijdschr Geneeskd 2007; 151:226-7. [PMID: 17323876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Placement of a central venous catheter is one of the most common invasive procedures and is associated with septic and mechanical complications, such as bleeding and pneumothorax. Up to 30% of attempts to cannulate the central vein fail. Correct positioning of the patient can help to maximise the success rate. For placement of catheters in the subclavian vein, patients should be in the Trendelenburg position without the use of a shoulder roll to retract the shoulders. Traditionally, central venous catheters are placed using a 'blind' technique that relies on external anatomical reference marks to localise the vein. However, unnoticed anatomical variations or central venous thrombosis may contribute to cannulation failure with this technique. The use of ultrasound has been shown to increase the success rate and avoid mechanical complications when placing a catheter in the internal jugular vein. It may also increase the success rate in subclavian vein catheterisation. To increase patient safety, the use of ultrasound when placing a central venous catheter should be embraced and become the standard of care.
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Affiliation(s)
- E de Jonge
- Academisch Medisch Centrum/Universiteit van Amsterdam, afd. Intensive Care Volwassenen, Postbus 22.660, 1100 DD Amsterdam.
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van Wezel HB, Zuurbier CJ, de Jonge E, van Dam EWCM, van Dijk J, Endert E, de Mol BA, Fliers E. Differential effects of a perioperative hyperinsulinemic normoglycemic clamp on the neurohumoral stress response during coronary artery surgery. J Clin Endocrinol Metab 2006; 91:4144-53. [PMID: 16895948 DOI: 10.1210/jc.2006-1199] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND Hyperglycemia in patients undergoing coronary artery bypass grafting (CABG) is associated with adverse outcome. Although insulin infusion strategies are increasingly used to improve outcome, a pathophysiological rationale is currently lacking. The present study was designed to quantify the effects of a perioperative hyperinsulinemic normoglycemic clamp on the neurohumoral stress response during CABG. METHODS Forty-four nondiabetic patients, scheduled for elective CABG, were randomized to either a control group (n = 22) receiving standard care or to a clamp group (n = 22) receiving additionally a perioperative hyperinsulinemic (regular insulin at a fixed rate of 0.1 IU.kg(-1).h(-1)) normoglycemic (plasma glucose between 3.0 and 6.0 mmol.liter(-1)) clamp during 26 h. We measured the endocrine response of the hypothalamus-pituitary-adrenal (HPA) axis, the sympathoadrenal axis, and glucagon, as well as plasma glucose and insulin at regular intervals from the induction of anesthesia at baseline through the end of the second postoperative day (POD). RESULTS There were no differences in clinical outcome between the groups. In the control group, hyperglycemia developed at the end of surgery and remained present until the final measurement point on POD2, whereas plasma insulin levels remained unchanged until the morning of POD1. In the intervention group, normoglycemia was well maintained during the clamp, whereas insulin levels ranged between 600 and 800 pmol.liter(-1). In both groups, plasma ACTH and cortisol increased from 6 h after discontinuation of cardiopulmonary bypass onward. However, during the clamp period, a marked reduction in the HPA axis response was found in the intervention group, as reflected by a 47% smaller increase in area under the curve in plasma ACTH (P = 0.035) and a 27% smaller increase in plasma cortisol (P = 0.002) compared with the control group. Compared with baseline, epinephrine and norepinephrine increased by the end of the clamp interval until POD2 in both groups. Surprisingly, the area under the curve of epinephrine levels was 47% higher (P = 0.026) after the clamp interval in the intervention group as compared with the control group. CONCLUSION A hyperinsulinemic normoglycemic clamp during CABG delays and attenuates the HPA axis response during the first 18 h of the myocardial reperfusion period, whereas after the clamp, plasma epinephrine is higher. The impact of delaying cortisol responses on clinical outcome of CABG remains to be elucidated.
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Affiliation(s)
- H B van Wezel
- Department of Anesthesia, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Neven P, Vergote I, Amant F, Berteloot P, de Jonge E, DE Rop C, DE Sutter P, Makar A, VAN Ginderachter J. Endocrine Treatment and Prevention of Breast and Gynecological Cancers Vth International Symposium of the Flemish Gynecological Oncology Group, January 26?28, 2006. Int J Gynecol Cancer 2006; 16 Suppl 2:479-91. [PMID: 17010051 DOI: 10.1111/j.1525-1438.2006.00673.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- P Neven
- Department of Obstetrics and Gynecology and Multidisciplinary Breast Center, UZ Leuven, Leuven, Belgium
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de Rooij SE, Govers A, Korevaar JC, Abu-Hanna A, Levi M, de Jonge E. Short-term and long-term mortality in very elderly patients admitted to an intensive care unit. Intensive Care Med 2006; 32:1039-44. [PMID: 16791666 DOI: 10.1007/s00134-006-0171-0] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Accepted: 03/16/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortality DESIGN AND SETTING Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital. PATIENTS 578 consecutive ICU patients aged 80 years or older. RESULTS Demographic, physiological, and laboratory values derived from the first 24h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality. CONCLUSION Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.
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Affiliation(s)
- S E de Rooij
- Department of Internal Medicine, Academic Medical Center, 22700, 1100 DE, Amsterdam, The Netherlands.
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Levi M, de Jonge E. Effects of Plasma Substitutes on Coagulation. Intensive Care Med 2006. [DOI: 10.1007/0-387-35096-9_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE The Sequential Organ Failure Assessment (SOFA) score was developed to quantify the severity of patients' illness, based on the degree of organ dysfunction. This study aimed to evaluate the accuracy and the reliability of SOFA scoring. DESIGN Prospective study. SETTING Adult intensive care unit (ICU) in a tertiary academic center. SUBJECTS Thirty randomly selected patient cases and 20 ICU physicians. MEASUREMENTS AND MAIN RESULTS Each physician scored 15 patient cases. The intraclass correlation coefficient was .889 for the total SOFA score. The weighted kappa values were moderate (0.552) for the central nervous system, good (0.634) for the respiratory system, and almost perfect (>0.8) for the other organ systems. To assess accuracy, the physicians' scores were compared with a gold standard based on consensus of two experts. The total SOFA score was correct in 53% (n = 158) of the cases. The mean of the absolute deviations of the recorded total SOFA scores from the gold standard total SOFA scores was 0.82. Common causes of errors were inattention, calculation errors, and misinterpretation of scoring rules. CONCLUSIONS The results of this study indicate that the reliability and the accuracy of SOFA scoring among physicians are good. We advise implementation of additional measures to further improve reliability and accuracy of SOFA scoring.
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Affiliation(s)
- D G T Arts
- Department of Medical Informatics, Academic Medical Center-Universiteit van Amsterdam, Amsterdam, Netherlands
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de Rooij SEJA, Abu-Hanna A, Levi M, de Jonge E. [Admission of elderly patients to intensive care]. Ned Tijdschr Geneeskd 2005; 149:2215-20. [PMID: 16235798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Elderly patients have an increased probability of dying after treatment in an intensive care unit (ICU), compared with younger patients. The risk of dying is largely determined by the admission type (patients with planned admissions have a better prognosis than those with unplanned admissions), severity of illness and functional status prior to admission. Elderly patients surviving ICU often experience a decline in functional status. No data are available on the factors that predict functional outcome. Elderly patients do not necessarily prefer life-sustaining treatment to palliative care. The willingness to undergo ICU treatment depends on the likelihood of survival and beneficial functional outcome. New prognostic models should be developed specifically to predict both survival and functional outcome in individual elderly patients after admission to ICU.
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Affiliation(s)
- S E J A de Rooij
- Academisch Medisch Centrum/Universiteit van Amsterdam, Postbus 22.660, DD Amsterdam.
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Visser L, Zuurbier CJ, Hoek FJ, Opmeer BC, de Jonge E, de Mol BAJM, van Wezel HB. Glucose, insulin and potassium applied as perioperative hyperinsulinaemic normoglycaemic clamp: effects on inflammatory response during coronary artery surgery. Br J Anaesth 2005; 95:448-57. [PMID: 16100235 DOI: 10.1093/bja/aei220] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The clinical benefits of glucose-insulin-potassium (GIK) and tight glycaemic control in patients undergoing coronary artery bypass grafting (CABG) may be partly explained by an anti-inflammatory effect. We applied GIK as a hyperinsulinaemic normoglycaemic clamp for >25 h and quantified its effect on systemic inflammation in patients undergoing CABG. METHODS Data obtained in 21 non-diabetic patients with normal left ventricular function scheduled for elective coronary artery surgery, who were randomly allocated to a control or GIK group, were analysed. In GIK patients, regular insulin was infused at a fixed rate of 0.1 IU kg(-1) h(-1). The infusion rate of glucose (30%) was adjusted to maintain blood glucose levels within a target range of 4.0-5.5 mmol litre(-1). Plasma concentrations of interleukins 6, 8 and 10, C-reactive protein (CRP) and serum amyloid A (SAA) were measured on the day of surgery and on the first and second postoperative days (POD1 and POD2). RESULTS In the GIK group hypoglycaemia (glucose <2.2 mmol litre(-1)) did not occur, whereas hyperglycemia (glucose >6.1 mmol litre(-1)) developed in 15% of all measurements. In control patients, hyperglycaemia developed in >80% of all measurements in the presence of low endogenous insulin levels. CRP and SAA levels increased in both groups, with maximum levels measured on POD2. GIK treatment significantly reduced CRP and SAA levels. Interleukin levels increased significantly in both groups following cardiopulmonary bypass, but no differences were found between the groups. CONCLUSION Hyperinsulinaemic normoglycaemic clamp is an effective method of maintaining tight glycaemic control in patients undergoing CABG and it attenuates the systemic inflammatory response in these patients. This effect may partly contribute to the reported beneficial effect of glycaemic control in patients undergoing CABG.
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Affiliation(s)
- L Visser
- Department of Anaesthesia, Academic Medical Center, University of Amsterdam, The Netherlands
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