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Maurer M, Aberer W, Caballero T, Bouillet L, Grumach AS, Botha J, Andresen I, Longhurst HJ. The Icatibant Outcome Survey: 10 years of experience with icatibant for patients with hereditary angioedema. Clin Exp Allergy 2022; 52:1048-1058. [PMID: 35861129 DOI: 10.1111/cea.14206] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
In patients with hereditary angioedema (HAE), bradykinin causes swelling episodes by activating bradykinin B2 receptors. Icatibant, a selective bradykinin B2 receptor antagonist, is approved for on-demand treatment of HAE attacks. The Icatibant Outcome Survey (IOS; NCT01034969) is an ongoing observational registry initiated in 2009 to monitor effectiveness/safety of icatibant in routine clinical practice. As of March 2019, 549 patients with HAE type 1 or 2 from the IOS registry had been treated, for 5995 total attacks. This article reviews data published from IOS over time which have demonstrated that effectiveness of icatibant in a real-world setting is comparable to efficacy in clinical trials; one dose is effective for the majority of attacks; early treatment (facilitated by self-administration) leads to faster resolution and shorter attack duration; effectiveness/safety of icatibant has been shown across a broad range of patient subgroups, including children/adolescents and patients with HAE with normal C1 inhibitor levels; and tolerability has been demonstrated in patients aged ≥65 years. Additionally, this review highlights how IOS data have provided valuable insights into patients' diagnostic journeys and treatment behaviors across individual countries. Such findings have helped to inform clinical strategies and guidelines to optimize HAE management and limit disease burden. This research was sponsored by Takeda Development Center Americas, Inc. Takeda Development Center Americas, Inc., provided funding to Excel Medical Affairs for support in writing and editing this manuscript.
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Affiliation(s)
- M Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - W Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Caballero
- Department of Allergy, Hospital Universitario La Paz, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - L Bouillet
- National Reference Centre for Angioedema, Internal Medicine Department, Grenoble University Hospital, Grenoble, France
| | - A S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario Saude ABC, Santo Andre, Brazil
| | - J Botha
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - I Andresen
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - H J Longhurst
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, and University College London Hospitals, London, UK
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Maurer M, Caballero T, Aberer W, Zanichelli A, Bouillet L, Bygum A, Grumach AS, Botha J, Andresen I, Longhurst HJ. Variability of disease activity in patients with hereditary angioedema type 1/2: longitudinal data from the Icatibant Outcome Survey. J Eur Acad Dermatol Venereol 2021; 35:2421-2430. [PMID: 34506666 DOI: 10.1111/jdv.17654] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hereditary angioedema due to C1 inhibitor deficiency (HAE-1/2) is a chronic and debilitating disease. The unpredictable clinical course represents a significant patient burden. OBJECTIVE To analyse longitudinal registry data from the Icatibant Outcome Survey (IOS) in order to characterize temporal changes in disease activity in patients with HAE-1/2. METHODS Icatibant Outcome Survey (NCT01034969) is an international observational registry monitoring the clinical outcomes of patients eligible for icatibant treatment. The current analyses are based on data collected between July 2009 and July 2019. Retrospective data for attacks recorded in the 12 months prior to IOS enrolment and for each 12-month period up to 7 years were analysed. RESULTS Included patients reported angioedema attacks without long-term prophylaxis (LTP; n = 315) and with LTP (n = 292) use at the time of attack onset. Androgens were the most frequently used LTP option (80.8%). At the population level, regardless of LTP use, most patients (52-80%) reporting <5 attacks in Year 1 continued experiencing this rate; similarly, many patients (25-76%) who reported high attack frequency continued reporting ≥10 attacks/year. However, year on year, 31-51% of patients experienced notable changes (increase/decrease of ≥5 attacks) in annual attack frequency. Of patients who reported an absolute change of ≥10 attacks from Year 1 to 2, 17-50% continued to experience a change of this magnitude in subsequent years. CONCLUSION At the population level, attack frequency was generally consistent over 7 years. At the small group level, 28.8-34.5% of patients reported a change in attack frequency of ≥5 attacks from Year 1 to Year 2; up to half of these patients continued to experience this magnitude of variation in disease activity in later years, reflecting high intra-patient variability.
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Affiliation(s)
- M Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - T Caballero
- Department of Allergy, Hospital Universitario La Paz, Hospital La Paz Institute for Health Research (IdiPaz), Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - W Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - A Zanichelli
- Department of Internal Medicine, Ospedale Luigi Sacco, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | - L Bouillet
- National Reference Centre for Angioedema, Internal Medicine Department, Grenoble University Hospital, Grenoble, France
| | - A Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - A S Grumach
- Clinical Immunology, Medical School, University Center Health ABC, Santo Andre, Brazil
| | - J Botha
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - I Andresen
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - H J Longhurst
- Formerly Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Formerly University College London Hospitals, London, UK.,Auckland District Health Board, Auckland, New Zealand
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Abstract
Vanishing bile duct syndrome (VBDS) refers to a group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts. We report a case of meropenem-induced VBDS in a patient who had undergone surgical repair of a ruptured abdominal aortic aneurysm. Meropenem was used to treat Serratia marcescens isolated from blood, urine, sputum, and wound swab cultures. The patient developed severe mixed liver injury with no obstruction noted in radiological imaging. Because of the patient's increasing serum bilirubin level, VBDS was suspected and the meropenem was therefore changed to ciprofloxacin on postoperative day 18. Although the bilirubin level decreased, meropenem was restarted 3 days later because of clinical concerns regarding worsening fever and sepsis. Restarting meropenem was associated with an immediate increase in the serum bilirubin level. This further increase in bilirubin after reintroduction of meropenem strongly suggested meropenem-induced VBDS. The antibiotic therapy was changed from meropenem to ciprofloxacin and metronidazole, leading to a dramatic decrease in the bilirubin level to normal within a few weeks. In patients receiving meropenem, VBDS as a cause of deranged liver function and cholestasis should be considered after ruling out mechanical and other probable causes of liver injury.
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Affiliation(s)
- Alexandr Zubarev
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC 3800, Australia
| | - Matthew Li
- Department of Pharmacy, Frankston Hospital, Frankston, VIC 3199, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC 3800, Australia
- Ravindranath Tiruvoipati, Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road (PO Box 52), Frankston, Victoria 3199, Australia. E-mail:
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC 3800, Australia
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Tiruvoipati R, Botha J. Fighting a pandemic with mechanical ventilators. Intern Med J 2020; 50:1019-1020. [PMID: 32881219 PMCID: PMC7436369 DOI: 10.1111/imj.14951] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/14/2020] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Brannigan L, Botha J. An argument for a rational and balanced risk approach to transplantation during the COVID-19 pandemic. S AFR J SURG 2020. [DOI: 10.17159/2078-5151/2020/v58n3a3446] [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: 11/05/2022]
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Dempster M, Bouter C, Maher H, Gaylard P, Etheredge H, Fabian J, Mohamed A, Botha J. Adult liver transplant for hepatocellular carcinoma at Wits Donald Gordon Medical Centre in Johannesburg, South Africa. S AFR J SURG 2019; 57:6-10. [PMID: 31392858] [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: 06/10/2023]
Abstract
BACKGROUND For those with unresectable hepatocellular carcinoma, liver transplantation is considered the treatment of choice. Since 2006, the transplant programme at Wits Donald Gordon Medical Centre (WDGMC) has offered liver transplantation for selected patients with hepatocellular carcinoma. While the number of patients transplanted was small, we are unaware of any published data from Southern Africa describing outcomes in this group of liver transplant recipients. The aim of this study was to describe our experience as a case series. METHODS The records of all patients with HCC who underwent deceased donor liver transplantation between April 2006 and March 2018 were reviewed retrospectively. Data were extracted from transplant clinic patient files, histopathology and pathology laboratory reports and an existing database of all liver transplant recipients at WDGMC. Patient survival was calculated from the time of transplant and survival estimates were determined by the Kaplan-Meier method. RESULTS Thirty-one liver transplants were reviewed. The most common causes of underlying liver disease were infectious, mostly hepatitis B virus, and diseases of lifestyle including alcoholic/non-alcoholic steatohepatitis. Median age at transplant, 57 years (IQR 44-65 years), was younger than observed internationally, but consistent with reports from Africa. Male recipients predominated, in keeping with published trends. Overall, outcomes were worse than expected but for recipients who were within the University of California at San Francisco (UCSF) criteria for transplantation; survival was comparable to previously published data. CONCLUSION Despite limitations, this is the first documented series of patients undergoing liver transplantation for HCC in South Africa and demonstrates that good results can be achieved in appropriately selected patients.
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Affiliation(s)
- M Dempster
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - C Bouter
- Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - H Maher
- Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - P Gaylard
- Data Management and Statistical Analysis, University of the Witwatersrand, Johannesburg, South Africa
| | - H Etheredge
- Wits Donald Gordon Medical Centre, Johannesburg, South Africa and Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Fabian
- Wits Donald Gordon Medical Centre, Johannesburg, South Africa and Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A Mohamed
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa and Transplant Unit, Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - J Botha
- Transplant Unit, Wits Donald Gordon Medical Centre, Johannesburg, South Africa and Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Botha J, Ströbele B, Loveland J, Rambarran S, Britz R, Etheredge H, Maher H, Bolon S, Eager M, Beeton A, Brannigan L, Mononyane R, Bannan S, Smith O, Fabian J. Living donor liver transplantation in South Africa: the donor experience. S AFR J SURG 2019; 57:11-16. [PMID: 31392859] [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: 06/10/2023]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) plays a crucial role in liver transplant programmes, particularly in regions with a scarcity of deceased donor organs and especially for paediatric recipients. LDLT is a complex and demanding procedure which places a healthy living donor in harm's way. Donor safety is therefore the overriding concern. This study aimed to report our standardised approach to the evaluation, technical aspects and outcomes of LDLT donor hepatectomy at Wits Donald Gordon Medical Centre. METHOD The study population consisted of all patients undergoing LDLT donor hepatectomy since the inception of the programme in March 2013 until 2018. Sixty five living donor hepatectomies were performed. Primary outcome measures included donor demographics, operative time, peak bilirubin, aspartate and alanine transaminase levels postoperatively, length of hospital stay and postoperative complications using the Clavien-Dindo classification. RESULTS The majority of the donors were female, most were parents with mothers being the donor almost 85% of the time. The median operative time was 374 minutes with a downward trend over time as experience was gained. The median length of hospital stay was 7 days. There was no mortality and the complication rate was 30% with the majority being minor (Grade 1). CONCLUSION Living donor liver transplant from adult-to-child has been successfully initiated in South Africa. Living donor hepatectomy can be safely performed with acceptable outcomes for the donor. Wait-list mortality however remains unacceptably high. Expansion of LDLT as well as real change in deceased donor policy is required to address this issue.
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Affiliation(s)
- J Botha
- Wits Donald Gordon Medical Centre, Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - B Ströbele
- Wits Donald Gordon Medical Centre, Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - J Loveland
- Wits Donald Gordon Medical Centre, Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - S Rambarran
- Wits Donald Gordon Medical Centre, Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - R Britz
- Wits Donald Gordon Medical Centre, Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - H Etheredge
- Wits Donald Gordon Medical Centre and Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - H Maher
- Wits Donald Gordon Medical Centre and Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S Bolon
- Department of Anaesthesia and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, South Africa
| | - M Eager
- Wits Donald Gordon Medical Centre Transplant Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - A Beeton
- Wits Donald Gordon Medical Centre Transplant Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - L Brannigan
- Wits Donald Gordon Medical Centre Transplant Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - R Mononyane
- Wits Donald Gordon Medical Centre Transplant Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - S Bannan
- Wits Donald Gordon Medical Centre Transplant Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - O Smith
- Department of Anaesthesia and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, South Africa
| | - J Fabian
- Wits Donald Gordon Medical Centre and Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Van Heerden Y, Maher H, Etheredge H, Fabian J, Grieve A, Loveland J, Botha J. Outcomes of paediatric liver transplant for biliary atresia. S AFR J SURG 2019; 57:17-23. [PMID: 31392860] [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: 06/10/2023]
Abstract
BACKGROUND Despite the widespread use of Kasai Portoenterostomy (KPE) for biliary atresia, more than two thirds of these patients require liver transplant. Liver transplantation is not widely available in South Africa, and Wits Donald Gordon Medical Centre is one of two centres performing paediatric liver transplantation in the country, and the only centre performing living related donor transplants. METHOD A retrospective review was performed at the centre. Demographic data were collected, and tabulated. Survival analysis was performed using the Kaplan Meier method. Complication rates were categorised into biliary, vascular and enteric, and classified as early and late. RESULTS Sixty-seven first time liver transplants were performed for biliary atresia at WDGMC from 2005 to 2017. Sixty-nine percent were female patients and thirty-one percent were male patients. Forty-eight percent of patients under the age of 5 years had a z-score of -2 or worse for mid upper arm circumference (MUAC). One year overall survival of the cohort is 84.5%, and overall graft survival is 82.9%. Overall mortality was 22%, with infection being the most common cause of death. CONCLUSION Early referral of all patients with biliary atresia to a paediatric liver transplant centre is essential for early assessment of indications, and medical and nutritional optimisation of patients. Primary liver transplant should be considered for a select group of patients with unique clinical indications.
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Affiliation(s)
- Y Van Heerden
- Department of Paediatric Surgery, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa
| | - H Maher
- Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - H Etheredge
- Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa and Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Fabian
- Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa and Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A Grieve
- Department of Paediatric Surgery, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa
| | - J Loveland
- Department of Paediatric Surgery, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa and Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - J Botha
- Wits Donald Gordon Medical Centre, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa and Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Nicholls K, West M, Gurevich A, Botha J, Cybulla M. SUN-194 RENOPROTECTIVE EFFECT OF AGALSIDASE ALFA: 12-YEAR FOLLOW-UP OF FABRY PATIENTS. Kidney Int Rep 2019. [DOI: 10.1016/j.ekir.2019.05.597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Toolis M, Tiruvoipati R, Botha J, Green C, Subramaniam A. A practice survey of airway management in Australian and New Zealand intensive care units. CRIT CARE RESUSC 2019; 21:139-147. [PMID: 31142245 DOI: pmid/31142245] [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: 02/08/2023]
Abstract
OBJECTIVE To characterise intubation practices in Australian and New Zealand intensive care units (ICUs) and investigate clinician support for establishing airway management guidelines in Australian and New Zealand ICUs. DESIGN An online survey was designed, piloted and distributed to members of the mailing list of the Australian and New Zealand Intensive Care Society (ANZICS), with medical members invited to participate. Respondents were excluded if their primary practice was in paediatric ICUs. MAIN OUTCOME MEASURES Data collected included the respondents' demographics and airway management practices and whether respondents supported the formulation of Australian and New Zealand intubation guidelines for critically ill patients in ICU and mandatory airway management training for Fellows of the College of Intensive Care Medicine of Australia and New Zealand (CICM). RESULTS Over a quarter of ANZICS medical members completed the survey (203/756, 27%), of which 166 (22%) were included in the analysis. The majority of respondents were male (80%), consultant intensivists (80%), and from tertiary centres (59%). Seventeen per cent worked concurrently in ICU and anaesthesia, and 52% had not completed formal airway training within the previous 3 years. Propofol was the preferred induction agent (67%) and rocuronium was the preferred neuromuscular blocking agent (58%). Videolaryngoscopy was immediately available in 97% of the ICUs and used first-line by 43% of respondents. Sixty-one per cent of respondents were in favour of the development of Australian and New Zealand ICU airway management guidelines, and 80% agreed that airway management training should be mandatory for CICM Fellows. CONCLUSION Variation of practices in intubation was noted in the participants. Approximately 61% of respondents supported the development of Australian and New Zealand ICU airway management guidelines, and 80% supported mandatory airway management training.
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Affiliation(s)
| | | | - John Botha
- Frankston Hospital, Melbourne, VIC, Australia
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Gupta S, Tiruvoipati R, Wang WC, Green C, Botha J. How do intensivists treat their patients, their loved ones and themselves? Results of a survey of intensivists facing an evolving hypothetical clinical scenario. N Z Med J 2019; 132:13-22. [PMID: 31095540 DOI: pmid/31095540] [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: 02/08/2023]
Abstract
AIM Prognostication and decisions regarding ineffectiveness of treatment remain challenging for clinicians and are some of the most difficult yet understudied aspects of clinical medicine. We sought to explore what management intensivists would advocate for a patient, for themselves or for a loved one at different points in an evolving hypothetical clinical scenario of a critically ill patient admitted to the intensive care unit (ICU). METHOD An online survey was constructed and was circulated to fellows of the College of Intensive Care Medicine (CICM) of Australia and New Zealand. Participants were presented with an evolving hypothetical clinical scenario of a patient admitted to ICU following out-of-hospital cardiac arrest (OHCA) at four time-points (day 3,7,14 and 28) during their conceptual ICU stay. RESULTS One hundred and twenty-six CICM fellows participated. Survey responses revealed significant differences in the proportion of respondents that would advocate for aggressive treatment, conservative management or withdrawal of treatment for themselves compared to patients; for a family member as compared to a patient at several time points. CONCLUSIONS The management that intensivists would advocate for patients differs from the management that they would advocate for their loved ones and themselves.
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Affiliation(s)
- Sachin Gupta
- Intensivist, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia; School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
| | - Ravindranath Tiruvoipati
- Intensivist, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia; School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
| | - Wei Chun Wang
- Statistician, Peninsula Clinical School, Monash University, Australia
| | - Cameron Green
- Research Coordinator, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia
| | - John Botha
- Director of Intensive Care Medicine, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia; School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
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Naka T, Egi M, Bellomo R, Cole L, French C, Botha J, Wan L, Fealy N, Baldwin I. Commercial Low-citrate Anticoagulation Haemofiltration in High Risk Patients with Frequent Filter Clotting. Anaesth Intensive Care 2019; 33:601-8. [PMID: 16235478 DOI: 10.1177/0310057x0503300509] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 11/15/2022]
Abstract
This study assessed the safety and efficacy of a commercial low-citrate concentration-based pre-filter replacement fluid during continuous veno-venous haemofiltration (CVVH) in patients with frequent filter clotting and high risk of bleeding. We used a commercial low-citrate fluid as pre-dilution replacement fluid during CVVH (citrate: 11 mmol/l (33 meq/l), sodium: 140 mmol/l, chloride: 108 mmol/l and potassium: 1 mmol/l). A calcium and magnesium infusion was delivered separately by central line for the maintenance of serum ionized calcium (Cai) and total magnesium (Mg). In this prospective observational study, 30 patients, 124 filters and 1,515 treatment-hours were observed. Median filter life of citrate CVVH was 9.5 hours. Filter life in the 48 hours prior to citrate CVVH was also observed. In the patients on prior non-anticoagulant CVVH (n=14) filter life increased significantly with citrate (9.5 hours vs 5 hours; P<0.0001). In patients on prior heparin CVVH (n=15), filter life was similar with citrate (10 hours vs 8 hours; P=0.68). However, in patients with prior early/frequent filter clotting despite heparin (n=11) filter life increased significantly (10 hours vs 7 hours; P=0.038). Of 411 serum Cai measurements, none showed a Cai<0.85 mmol/l and, of 84 observations, none showed a serum Mg<0.6mmol/l. One patient with sepsis and shock needed to cease citrate CVVH because of progressive ionized hypocalcaemia and increasing anion gap. No other adverse effects were observed. In selected patients, CVVH with a commercial low-citrate concentration solution as pre-filter replacement fluid and a simultaneous calcium and magnesium infusion protocol appears generally safe. Filter life was acceptable and superior to that achieved with previous treatment.
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Affiliation(s)
- T Naka
- Department of Intensive Care and Medicine (University of Melbourne), Austin Hospital, Austin Health, Victoria
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Pillay Mauree A, De Maayer T, Botes A, Fabian J, Etheredge H, Duncan EM, Botha J. Amanita phalloides poisoning: one harvest, three outcomes. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2018/v56n4a2891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Botha J, Ströbele B, Loveland J, Rambarran S, Britz R, Etheredge H, Maher H, Bolon S, Eagar M, Beeton A, Brannigan L, Mononyane R, Bannan S, Morford M, Smith O, Fabian J. Living donor liver transplantation in South Africa: the donor experience. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n3a2998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dempster M, Bouter C, Maher H, Gaylard P, Etheredge H, Fabian J, Mohamed A, Botha J. Adult liver transplant for hepatocellular carcinoma at Wits Donald Gordon Medical Centre in Johannesburg, South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n3a3067] [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: 11/05/2022]
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Fabian J, Loveland J, Maher H, Gaylard P, Etheredge H, Bouter C, Cantrell J, Sanyika C, Britz R, Strobele B, Rambarran S, van der Schyff F, Brannigan L, Demopoulos D, Campbell Lang A, Archibald-Durham L, Beretta M, Bobat B, Mahomed A, Terblanche A, Botha J. Wits Transplant Annual Data Report 2018 Adult and Paediatric Liver Transplantation. ACTA ACUST UNITED AC 2019. [DOI: 10.18772/26180197.2019.v1n3a2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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van Heerden Y, Maher H, Etheredge H, Fabian J, Grieve A, Loveland J, Botha J. Outcomes of paediatric liver transplant for biliary atresia. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n3a3069] [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: 11/05/2022]
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18
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Maurer M, Bork K, Martinez-Saguer I, Aygören-Pürsün E, Botha J, Andresen I, Magerl M. Management of patients with hereditary angioedema in Germany: comparison with other countries in the Icatibant Outcome Survey. J Eur Acad Dermatol Venereol 2018; 33:163-169. [PMID: 30176179 PMCID: PMC6587717 DOI: 10.1111/jdv.15232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 07/12/2018] [Accepted: 08/20/2018] [Indexed: 11/28/2022]
Abstract
Background The Icatibant Outcome Survey (IOS; NCT01034969) is a Shire‐sponsored, international, observational study monitoring the safety and effectiveness of icatibant, a bradykinin B2 receptor antagonist approved for the acute treatment of adults with hereditary angioedema with C1 inhibitor deficiency (HAE‐C1‐INH). Objective To report IOS data comparing demographic and icatibant treatment outcomes in patients with HAE‐C1‐INH from Germany to HAE‐C1‐INH patients from 11 other IOS countries. Methods A descriptive, retrospective, comparative analysis of data from 685 IOS patients with HAE‐C1‐INH from seven centres in Germany (n = 93) vs. centres from Austria, Brazil, Czech Republic, Denmark, France, Greece, Israel, Italy, Spain, Sweden and the United Kingdom (n = 592, July 2009–January 2017). Icatibant treatment outcomes were retrieved from patients with complete attack outcome data for time to treatment, time to resolution and attack duration (160 attacks in 42 German patients and 1442 attacks in 251 patients from other IOS countries). Results German patients reported significantly fewer severe/very severe attacks (38.7% vs. 57.5%, respectively; P < 0.001). The proportion of attacks treated with a single icatibant injection was significantly higher in German patients (97.1% vs. 91.6%, P = 0.0003). The median time to treatment (0.0 h vs. 1.5 h), time to resolution (3.0 h vs. 7.0 h) and attack duration (4.3 h vs. 10.5 h) in German patients vs. other IOS countries were all significantly shorter (all P < 0.0001). No meaningful differences were identified between patients from Germany and other countries with regard to sex, median age at enrolment, median age at symptom onset and median age at diagnosis. Conclusion German IOS patients share similar demographic characteristics to patients from other IOS countries yet treat their attacks with icatibant significantly earlier and have markedly fewer severe or very severe attacks. Factors including regional access to and availability of icatibant may drive these outcomes and warrant further investigation.
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Affiliation(s)
- M Maurer
- Department of Dermatology and Allergy, Allergy Center Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - K Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany
| | | | - E Aygören-Pürsün
- Department for Children and Adolescents, Angioedema Centre, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | | | | | - M Magerl
- Department of Dermatology and Allergy, Allergy Center Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Tiruvoipati R, Pilcher D, Botha J, Buscher H, Simister R, Bailey M. Association of Hypercapnia and Hypercapnic Acidosis With Clinical Outcomes in Mechanically Ventilated Patients With Cerebral Injury. JAMA Neurol 2018; 75:818-826. [PMID: 29554187 PMCID: PMC5885161 DOI: 10.1001/jamaneurol.2018.0123] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 02/05/2023]
Abstract
IMPORTANCE Clinical studies investigating the effects of hypercapnia and hypercapnic acidosis in acute cerebral injury are limited. The studies performed so far have mainly focused on the outcomes in relation to the changes in partial pressure of carbon dioxide and pH in isolation and have not evaluated the effects of partial pressure of carbon dioxide and pH in conjunction. OBJECTIVE To review the association of compensated hypercapnia and hypercapnic acidosis during the first 24 hours of intensive care unit admission on hospital mortality in adult mechanically ventilated patients with cerebral injury. DESIGN, SETTING, AND PARTICIPANTS Multicenter, binational retrospective review of patients with cerebral injury (traumatic brain injury, cardiac arrest, and stroke) admitted to 167 intensive care units in Australia and New Zealand between January 2000 and December 2015. Patients were classified into 3 groups based on combination of arterial pH and arterial carbon dioxide (normocapnia and normal pH, compensated hypercapnia, and hypercapnic acidosis) during the first 24 hours of intensive care unit stay. MAIN OUTCOMES AND MEASURES Hospital mortality. RESULTS A total of 30 742 patients (mean age, 55 years; 21 827 men [71%]) were included. Unadjusted hospital mortality rates were highest in patients with hypercapnic acidosis. Multivariable logistic regression analysis and Cox proportional hazards analysis in 3 diagnostic categories showed increased odds of hospital mortality (cardiac arrest odds ratio [OR], 1.51; 95% CI, 1.34-1.71; stroke OR, 1.43; 95% CI, 1.27-1.6; and traumatic brain injury OR, 1.22; 95% CI, 1.06-1.42; P <.001) and hazard ratios (HR) (cardiac arrest HR, 1.23; 95% CI, 1.14-1.34; stroke HR, 1.3; 95% CI, 1.21-1.4; traumatic brain injury HR, 1.13; 95% CI, 1-1.27), in patients with hypercapnic acidosis compared with normocapnia and normal pH. There was no difference in mortality between patients who had compensated hypercapnia compared with patients who had normocapnia and normal pH. In patients with hypercapnic acidosis, the adjusted OR of hospital mortality increased with increasing partial pressure of carbon dioxide, while no such increase was noted in patients with compensated hypercapnia. CONCLUSIONS AND RELEVANCE Hypercapnic acidosis was associated with increased risk of hospital mortality in patients with cerebral injury. Hypercapnia, when compensated to normal pH during the first 24 hours of intensive care unit admission, may not be harmful in mechanically ventilated patients with cerebral injury.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Australian and New Zealand Intensive Care Research Center, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Center, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Sydney, Australia
- Department of Intensive Care, The Alfred Hospital, Prahran, Victoria, Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent’s Hospital, Sydney, Australia
- University of New South Wales, Australia, Sydney, Australia
| | - Robert Simister
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Center, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Sydney, Australia
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Bishop EJ, Tiruvoipati R, Metcalfe J, Marshall C, Botha J, Kelley PG. The outcome of patients with severe and severe-complicated Clostridium difficile infection treated with tigecycline combination therapy: a retrospective observational study. Intern Med J 2018; 48:651-660. [PMID: 29363242 DOI: 10.1111/imj.13742] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 12/07/2017] [Revised: 12/29/2017] [Accepted: 01/08/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tigecycline is a third-line therapy for severe Clostridium difficile infection (CDI) in Australasian guidelines. Differences in strain types make it difficult to extrapolate international tigecycline efficacy data with combination or monotherapy to Australian practice, where experience is limited. AIM To evaluate the efficacy and adverse effects associated with tigecycline combination therapy for severe and severe-complicated CDI in an Australian healthcare setting. METHODS This was a retrospective observational study at a metropolitan university-affiliated hospital. All patients between February 2013 and October 2016 treated with adjunctive intravenous tigecycline for >48 h for severe or severe-complicated CDI were included. Tigecycline was given in addition to oral vancomycin ± intravenous metronidazole. The primary outcome was all-cause mortality at 30 days from start of tigecycline combination therapy. Secondary outcomes included clinical cure, colectomy, adverse events and recurrence rates. RESULTS Thirteen patients with median age of 61 years had severe (n = 9) or severe-complicated (n = 4) CDI at tigecycline commencement. In 92% of patients, tigecycline started within 48 h after in-hospital CDI treatment, for median duration of 9 days. All-cause mortality at 30 days was 8% with no mortality in severe CDI and 25% (1/4) in patients with severe-complicated fulminant CDI, comparing favourably with historical rates of 9-38% and 30-80% in similar respective groups. Clinical cure was achieved in 77% of cases. There were no colectomies and one attributable tigecycline adverse reaction. CONCLUSIONS Tigecycline appears safe and effective as a part of combination therapy in severe CDI, and may be given earlier and for shorter durations than in current guidelines.
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Affiliation(s)
- Emma J Bishop
- Department of Infectious Diseases, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Julie Metcalfe
- Department of Infectious Diseases, Melbourne, Victoria, Australia
| | | | - John Botha
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter G Kelley
- Department of Infectious Diseases, Melbourne, Victoria, Australia
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Botha J, Green C, Carney I, Haji K, Gupta S, Tiruvoipati R. Proportional assist ventilation versus pressure support ventilation in weaning ventilation: a pilot randomised controlled trial. CRIT CARE RESUSC 2018; 20:33-40. [PMID: 29458319 DOI: pmid/29458319] [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: 02/08/2023]
Abstract
OBJECTIVE Proportional assist ventilation with load-adjustable gain factors (PAV+) is a mode of ventilation that provides assistance in proportion to patient effort. This may have physiological and clinical advantages when compared with pressure support ventilation (PSV). Our objective was to compare these two modes in patients being weaned from mechanical ventilation. DESIGN Prospective randomised controlled trial comparing PSV with PAV+. SETTING University-affiliated, tertiary referral intensive care unit (ICU). PARTICIPANTS Mechanically ventilated patients on a controlled mode of ventilation for at least 24 hours, who were anticipated to be spontaneously ventilated for at least 48 hours after randomisation. INTERVENTIONS Nil. MAIN OUTCOME MEASURES The primary outcome was time to successful liberation from the ventilator after the commencement of a spontaneous mode of ventilation. Secondary outcomes were requirement of rescue (mandatory) ventilation, requirement of sedative drugs, requirement for tracheostomy, re-intubation within 48 hours of extubation, ICU length of stay (LOS), hospital LOS, and ICU and hospital mortality. RESULTS 50 patients were randomised to either PSV (n = 25) or PAV+ (n = 25). There was no significant difference between the PAV+ and PSV groups in time to successful weaning (84.3 v 135.9 hours, respectively; P = 0.536). Four patients randomised to PAV+ were crossed over to PSV during weaning. There was no significant difference between groups for rescue ventilation, reintubation within 48 hours, tracheostomy, sedatives and analgesics prescribed, and ICU and hospital LOS. ICU mortality was higher in the PSV group (25% v 4 %; P = 0.002). CONCLUSIONS Both modes of ventilation were comparable in time to liberation from the ventilator.
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Affiliation(s)
- John Botha
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia.
| | - Cameron Green
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Ian Carney
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
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Patel N, Grieve A, Hiddema J, Botha J, Loveland J. Surgery for portal hypertension in children: A 12-year review. S Afr Med J 2017; 107:12132. [PMID: 29183424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/06/2017] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Portal hypertension is a common and potentially devastating condition in children. Notwithstanding advances in the nonsurgical management of portal hypertension, surgery remains an important treatment modality in select patients. We report here on our experience in the past 12 years. OBJECTIVES To describe the profile of, indication for, and complications of shunt surgery in children with portal hypertension. METHODS Twelve children underwent shunt surgery between 2005 and 2017. Patient records were reviewed. RESULTS Fourteen procedures were performed on 12 patients during the study period. The median age at surgery was 6.5 (range 1 - 18) years. Six patients were male. Gastrointestinal bleeding that was not amenable to endoscopic control was the most common indication for surgery. Portal vein thrombosis was the most common cause of portal hypertension in our series (n=11). Two-thirds (8/12) of all patients had an identifiable underlying risk factor for portal vein thrombosis. One-third of all patients (4/12) underwent a meso-portal bypass procedure (Rex shunt), while 58% (7/12) were managed with a distal splenorenal shunt. All patients received postoperative thromboprophylaxis. We experienced a single mortality, 1 patient experienced shunt thrombosis that required revision shunt surgery, and 2 patients experienced anastomotic strictures, with one being managed with revision surgery and the other currently awaiting radiological venoplasty. CONCLUSIONS Surgery is a safe and important tool in the management of children with non-cirrhotic portal hypertension and those with sufficient hepatic reserve who fail to respond to more conservative methods for the treatment of side effects of portal hypertension.
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Affiliation(s)
- N Patel
- Department of Paediatric Surgery, University of the Witwatersrand, Johannesburg, South Africa.
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Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of Hypercapnia and Hypercapnic Acidosis on Hospital Mortality in Mechanically Ventilated Patients. Crit Care Med 2017; 45:e649-e656. [PMID: 28406813 DOI: 10.1097/ccm.0000000000002332] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Lung-protective ventilation is used to prevent further lung injury in patients on invasive mechanical ventilation. However, lung-protective ventilation can cause hypercapnia and hypercapnic acidosis. There are no large clinical studies evaluating the effects of hypercapnia and hypercapnic acidosis in patients requiring mechanical ventilation. DESIGN Multicenter, binational, retrospective study aimed to assess the impact of compensated hypercapnia and hypercapnic acidosis in patients receiving mechanical ventilation. SETTINGS Data were extracted from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database over a 14-year period where 171 ICUs contributed deidentified data. PATIENTS Patients were classified into three groups based on a combination of pH and carbon dioxide levels (normocapnia and normal pH, compensated hypercapnia [normal pH with elevated carbon dioxide], and hypercapnic acidosis) during the first 24 hours of ICU stay. Logistic regression analysis was used to identify the independent association of hypercapnia and hypercapnic acidosis with hospital mortality. INTERVENTIONS Nil. MEASUREMENTS AND MAIN RESULTS A total of 252,812 patients (normocapnia and normal pH, 110,104; compensated hypercapnia, 20,463; and hypercapnic acidosis, 122,245) were included in analysis. Patients with compensated hypercapnia and hypercapnic acidosis had higher Acute Physiology and Chronic Health Evaluation III scores (49.2 vs 53.2 vs 68.6; p < 0.01). The mortality was higher in hypercapnic acidosis patients when compared with other groups, with the lowest mortality in patients with normocapnia and normal pH. After adjusting for severity of illness, the adjusted odds ratio for hospital mortality was higher in hypercapnic acidosis patients (odds ratio, 1.74; 95% CI, 1.62-1.88) and compensated hypercapnia (odds ratio, 1.18; 95% CI, 1.10-1.26) when compared with patients with normocapnia and normal pH (p < 0.001). In patients with hypercapnic acidosis, the mortality increased with increasing PCO2 until 65 mm Hg after which the mortality plateaued. CONCLUSIONS Hypercapnic acidosis during the first 24 hours of intensive care admission is more strongly associated with increased hospital mortality than compensated hypercapnia or normocapnia.
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Affiliation(s)
- Ravindranath Tiruvoipati
- 1Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia.2Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.3ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, VIC, Australia.4Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia.5University of New South Wales, Kensington, NSW, Australia
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Tiruvoipati R, Botha J, Fletcher J, Gangopadhyay H, Majumdar M, Vij S, Paul E, Pilcher D. Intensive care discharge delay is associated with increased hospital length of stay: A multicentre prospective observational study. PLoS One 2017; 12:e0181827. [PMID: 28750010 PMCID: PMC5531506 DOI: 10.1371/journal.pone.0181827] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 07/08/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Some patients experience a delayed discharge from the intensive care unit (ICU) where the intended and actual discharge times do not coincide. The clinical implications of this remain unclear. OBJECTIVE To determine the incidence and duration of delayed ICU discharge, identify the reasons for delay and evaluate the clinical consequences. METHODS Prospective multi-centre observational study involving five ICUs over a 3-month period. Delay in discharge was defined as >6 hours from the planned discharge time. The primary outcome measure was hospital length stay after ICU discharge decision. Secondary outcome measures included ICU discharge after-hours, incidence of delirium, survival to hospital discharge, discharge destination, the incidence of ICU acquired infections, revocation of ICU discharge decision, unplanned readmissions to ICU within 72 hours, review of patients admitting team after ICU discharge decision. RESULTS A total of 955 out of 1118 patients discharged were included in analysis. 49.9% of the patients discharge was delayed. The most common reason (74%) for delay in discharge was non-availability of ward bed. The median duration of the delay was 24 hours. On univariable analysis, the duration of hospital stay from the time of ICU discharge decision was significantly higher in patients who had ICU discharge delay (Median days-5 vs 6; p = 0.003). After-hours discharge was higher in patients whose discharge was delayed (34% Vs 10%; p<0.001). There was no statistically significant difference in the other secondary outcomes analysed. Multivariable analysis adjusting for known confounders revealed delayed ICU discharge was independently associated with increased hospital length of stay. CONCLUSION Half of all ICU patients experienced a delay in ICU discharge. Delayed discharge was associated with increased hospital length of stay.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- * E-mail:
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Sanjiv Vij
- Dandenong Hospital, Dandenong, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Haematology Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Alfred Hospital, Melbourne, Victoria, Australia
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Tiruvoipati R, Buscher H, Winearls J, Breeding J, Ghosh D, Chaterjee S, Braun G, Paul E, Fraser JF, Botha J. Early experience of a new extracorporeal carbon dioxide removal device for acute hypercapnic respiratory failure. CRIT CARE RESUSC 2016; 18:261-269. [PMID: 27903208 DOI: pmid/27903208] [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: 02/08/2023]
Abstract
BACKGROUND Recent advances in the technology of extracorporeal respiratory assist systems have led to a renewed interest in extracorporeal carbon dioxide removal (ECCOR). The Hemolung is a new, low-flow, venovenous, minimally invasive, partial ECCOR device that has recently been introduced to clinical practice to aid in avoiding invasive ventilation or to facilitate lung-protective ventilation. OBJECTIVE We report our early experience on use, efficacy and safety of the Hemolung in three Australian intensive care units. METHODS Retrospective review of all patients with acute or acute-on-chronic respiratory failure (due to chronic obstructive pulmonary disease [COPD] with severe hypercapnic respiratory failure when non-invasive ventilation failed; acute respiratory distress syndrome; COPD; or asthma when lung-protective ventilation was not feasible due to hypercapnia) for whom the Hemolung was used. RESULTS Fifteen patients were treated with ECCOR. In four out of five patients, the aim of avoiding intubation was achieved. In the remaining 10 patients, the strategy of instituting lung-protective ventilation was successful. The median duration for ECCOR was 5 days (interquartile range, 3-7 days). The pH and PCO2 improved significantly within 6 hours of instituting ECCOR, in conjunction with a significant reduction in minute ventilation. The CO2 clearance was 90-100 mL/min. A total of 93% of patients survived to weaning from ECCOR, 73% survived to ICU discharge and 67% survived to hospital discharge. CONCLUSION Our data shows that ECCOR was safe and effective in this cohort. Further experience is vital to identify the patients who may benefit most from this promising therapy.
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Affiliation(s)
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - James Winearls
- Department of Intensive Care Medicine, Gold Coast University Hospital, Gold Coast, Brisbane, QLD, Australia
| | - Jeff Breeding
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Debasish Ghosh
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Shimonti Chaterjee
- Department of Intensive Care Medicine, Gold Coast University Hospital, Gold Coast, Brisbane, QLD, Australia
| | - Gary Braun
- Department of Respiratory Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, VIC, Australia
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Thandar Y, Gray A, Botha J, Mosam A. Topical herbal medicines for atopic eczema: a systematic review of randomized controlled trials. Br J Dermatol 2016; 176:330-343. [DOI: 10.1111/bjd.14840] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Y. Thandar
- Department of Basic Medical Sciences Faculty of Heath Sciences Durban University of Technology Durban South Africa
| | - A. Gray
- Division of Pharmacology Discipline of Pharmaceutical Sciences University of KwaZulu‐Natal Durban South Africa
| | - J. Botha
- Division of Pharmacology Discipline of Pharmaceutical Sciences University of KwaZulu‐Natal Durban South Africa
| | - A. Mosam
- Department of Dermatology Nelson R. Mandela School of Medicine University of KwaZulu‐Natal Durban South Africa
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Botha J, O'Brien Y, Malouf S, Cole E, Ansari ES, Green C, Tiruvoipati R. The Outcome and Predictors of Mortality in Patients Therapeutically Cooled Postcardiac Arrest. J Intensive Care Med 2016; 31:603-10. [PMID: 25572332 DOI: 10.1177/0885066614566792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 06/08/2014] [Accepted: 11/10/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE To review the outcomes of patients postcardiac arrest admitted to a metropolitan intensive care unit (ICU) where therapeutic hypothermia is practiced. MATERIALS AND METHODS Patients admitted from 2004 to 2012 were reviewed. The management protocol included cooling to 33°C for 24 hours. The primary outcome assessed was hospital mortality. Secondary outcome measures included mortality in patients admitted to ICU after in-hospital cardiac arrest (IHCA) when compared to those with out-of-hospital cardiac arrest (OHCA) and to review initial cardiac rhythm as an indicator of mortality. RESULTS A total of 330 patients were included. The overall hospital mortality was 58.1%. Hospital mortality was significantly higher in patients who had OHCA when compared to IHCA (62.5% vs 51%; P = .04). Patients who had asystole and pulseless electrical activity (PEA) had a higher mortality when compared to ventricular tachycardia/ventricular fibrillation (VT/VF) arrest (81.7% vs 67.8% vs 41.9%, respectively; P < .01). CONCLUSION Patients admitted to ICU postcardiac arrest after therapeutic cooling have a high mortality. An initial rhythm of VT/VF confers a mortality benefit when compared to asystole and PEA.
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Affiliation(s)
- John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia Faculty of Medicine, Nursing and Health Sciences, School of Public Health, Monash University, Melbourne, Victoria, Australia
| | - Yvette O'Brien
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Saada Malouf
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Elizabeth Cole
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Erum Sahid Ansari
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia Faculty of Medicine, Nursing and Health Sciences, School of Public Health, Monash University, Melbourne, Victoria, Australia
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Subramaniam A, Botha J, Tiruvoipati R. The limitations in implementing and operating a rapid response system. Intern Med J 2016; 46:1139-1145. [PMID: 26913367 DOI: 10.1111/imj.13042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 09/16/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 02/05/2023]
Abstract
Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.
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Affiliation(s)
- A Subramaniam
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia.
| | - J Botha
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
| | - R Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
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Tiruvoipati R, Haji K, Gupta S, Braun G, Carney I, Botha J. Low-flow veno-venous extracorporeal carbon dioxide removal in the management of severe status asthmatics: a case report. Clin Respir J 2016; 10:653-6. [PMID: 25515844 DOI: 10.1111/crj.12252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 05/21/2014] [Revised: 11/18/2014] [Accepted: 12/07/2014] [Indexed: 02/05/2023]
Abstract
Status asthmaticus is a life-threatening condition that requires intensive care management. Most of these patients have severe hypercapnic acidosis that requires lung protective mechanical ventilation. A small proportion of these patients do not respond to conventional lung protective mechanical ventilation or pharmacotherapy. Such patients have an increased mortality and morbidity. Successful use of extracorporeal membrane oxygenation (ECMO) is reported in such patients. However, the use of ECMO is invasive with its associated morbidity and is limited to specialised centres. In this report, we report the use of a novel, minimally invasive, low-flow extracorporeal carbon dioxide removal device in management of severe hypercapnic acidosis in a patient with life threatening status asthmaticus.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia.
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia.
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
| | - Gary Braun
- Department of Respiratory Medicine, Frankston Hospital, Melbourne, Vic., Australia
| | - Ian Carney
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Vic., Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
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Botha J, Burger H, Trauernicht C. O18. An interactive tool to improve patient throughput in radiotherapy. Phys Med 2016. [DOI: 10.1016/j.ejmp.2016.07.026] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Banakh I, Lam A, Tiruvoipati R, Carney I, Botha J. Imatinib for bleomycin induced pulmonary toxicity: a case report and evidence-base review. Clin Case Rep 2016; 4:486-90. [PMID: 27190613 PMCID: PMC4856242 DOI: 10.1002/ccr3.549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 09/28/2015] [Revised: 02/12/2016] [Accepted: 03/08/2016] [Indexed: 11/26/2022] Open
Abstract
The evidence supporting therapy with imatinib for bleomycin‐induced pneumonitis (BIP) is equivocal. Further experience is needed to establish its role in BIP management. While it may be considered in the management of BIP, it is important to be mindful of the adverse effects including thrombocytopenia and gastrointestinal bleeding.
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Affiliation(s)
- Iouri Banakh
- Department of Pharmacy Frankston Hospital Peninsula Health Frankston Vic. Australia
| | - Alice Lam
- Department of Pharmacy Frankston Hospital Peninsula Health Frankston Vic. Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine Frankston Hospital Frankston Vic.3199 Australia; School of Public Health Faculty of Medicine, Nursing and Health Sciences Monash University Clayton Vic. 3800 Australia
| | - Ian Carney
- Department of Intensive Care Medicine Frankston Hospital Frankston Vic.3199 Australia; School of Public Health Faculty of Medicine, Nursing and Health Sciences Monash University Clayton Vic. 3800 Australia
| | - John Botha
- Department of Intensive Care Medicine Frankston Hospital Frankston Vic.3199 Australia; School of Public Health Faculty of Medicine, Nursing and Health Sciences Monash University Clayton Vic. 3800 Australia
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Haji K, Royse A, Green C, Botha J, Canty D, Royse C. Interpreting diaphragmatic movement with bedside imaging, review article. J Crit Care 2016; 34:56-65. [PMID: 27288611 DOI: 10.1016/j.jcrc.2016.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 12/18/2015] [Revised: 02/09/2016] [Accepted: 03/04/2016] [Indexed: 12/11/2022]
Abstract
The diaphragm is the most important muscle of respiration. At equilibrium, the load imposed on the diaphragmatic muscles from transdiaphragmatic pressure balances the force generated by diaphragmatic muscles. However, procedural and nonprocedural thoracic and abdominal conditions may disrupt this equilibrium and impair diaphragmatic function. Diaphragmatic dysfunction is associated with respiratory insufficiency and poor outcome. Therefore, rapid diagnosis and early intervention may be useful. Ultrasound imaging provides quick and accurate bedside assessment of the diaphragm. Various imaging techniques have been suggested, using 2-dimensional and M-mode technology. Diaphragm viewing depends on the degree of robe movement, determined by the angle of incidence of the ultrasound beam and by the direction of probe movement. In this review, we will discuss the function of the diaphragm focusing on clinically important anatomical and physiological properties of the diaphragm. We will review the literature regarding various sonographic techniques for diaphragm assessment. We will also explore the evidence for the role of the tidal displacement of subdiaphragmatic organs as a surrogate for diaphragm movement.
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Affiliation(s)
- K Haji
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
| | - A Royse
- Department of Surgery, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - C Green
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - J Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - D Canty
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - C Royse
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Gupta S, Tiruvoipati R, Green C, Botha J, Tran H. Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums. World J Crit Care Med 2015; 4:202-212. [PMID: 26261772 PMCID: PMC4524817 DOI: 10.5492/wjccm.v4.i3.202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 02/25/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023] Open
Abstract
Thrombocytopenia is often noted in critically ill patients. While there are many reasons for thrombocytopenia, the use of heparin and its derivatives is increasingly noted to be associated with thrombocytopenia. Heparin induced thrombocytopenia syndrome (HITS) is a distinct entity that is characterised by the occurrence of thrombocytopenia in conjunction with thrombotic manifestations after exposure to unfractionated heparin or low molecular weight heparin. HITS is an immunologic disorder mediated by antibodies to heparin-platelet factor 4 (PF4) complex. HITS is an uncommon cause of thrombocytopenia. Reported incidence of HITS in patients exposed to heparin varies from 0.2% to up to 5%. HITS is rare in ICU populations, with estimates varying from 0.39%-0.48%. It is a complex problem which may cause diagnostic dilemmas and management conundrum. The diagnosis of HITS centers around detection of antibodies against PF4-heparin complexes. Immunoassays performed by most pathology laboratories detect the presence of antibodies, but do not reveal whether the antibodies are pathological. Platelet activation assays demonstrate the presence of clinically relevant antibodies, but only a minority of laboratories conduct them. Several anticoagulants are used in management of HITS. In this review we discuss the incidence, pathogenesis, diagnosis and management of HITS.
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Patel N, Loveland J, Zuckerman M, Moshesh P, Britz R, Botha J. Heterozygote to homozygote related living donor liver transplantation in maple syrup urine disease: a case report. Pediatr Transplant 2015; 19:E62-5. [PMID: 25677046 DOI: 10.1111/petr.12439] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 01/18/2023]
Abstract
Liver transplantation is an accepted treatment modality in the management of MSUD. To our knowledge, ours is only the second successful case to date of a patient with MSUD receiving an allograft from an RLD who is a heterozygous carrier for the disease. In view of the worldwide shortage of available organs for transplantation, heterozygote to homozygote transplantation in the setting of MSUD may provide a viable alternative for those awaiting transplantation. We report on the case of a two-yr-old infant with MSUD, who received a left lateral segment (segments II and III) liver transplant from his mother, a heterozygote carrier of one of the three abnormal genes implicated in MSUD. Post-operative BCAA levels normalized in our patient and remained so on an unrestricted protein diet and during times of physiological stress. To date, this is only the second case of a successful RLD liver transplant in a child with MSUD. Preliminary results indicate that RLD liver transplants are at least equivalent to deceased donor liver transplants in the treatment of MSUD, although longer term follow-up is required. Heterozygote to homozygote RLD transplant in patients with MSUD presents a new pool of potential liver donors.
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Affiliation(s)
- N Patel
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Doig GS, Simpson F, Bellomo R, Heighes PT, Sweetman EA, Chesher D, Pollock C, Davies A, Botha J, Harrigan P, Reade MC. Intravenous amino acid therapy for kidney function in critically ill patients: a randomized controlled trial. Intensive Care Med 2015; 41:1197-208. [PMID: 25925203 DOI: 10.1007/s00134-015-3827-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/15/2015] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Acute kidney injury (AKI) is characterized by severe loss of glomerular filtration rate (GFR) and is associated with a prolonged intensive care unit (ICU) stay and increased risk of death. No interventions have yet been shown to prevent AKI or preserve GFR in critically ill patients. Evidence from mammalian physiology and small clinical trials suggests higher amino acid intake may protect the kidney from ischemic insults and thus may preserve GFR during critical illness. OBJECTIVE To determine whether amino acid therapy, achieved through daily intravenous (IV) supplementation with standard amino acids, preserves kidney function in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS Multicenter, phase II, randomized clinical trial conducted between December 2010 and February 2013 in the ICUs of 16 community and tertiary hospitals in Australia and New Zealand. Participants were adult critically ill patients expected to remain in the study ICU for longer than 2 days. INTERVENTIONS Random allocation to receive a daily supplement of up to 100 g of IV amino acids or standard care. MAIN OUTCOMES AND MEASURES Duration of renal dysfunction (primary outcome); estimated GFR (eGFR) derived from creatinine; eGFR derived from cystatin C; urinary output; renal replacement therapy (RRT) use; fluid balance and other measures of renal function. RESULTS 474 patients were enrolled and randomized (235 to standard care, 239 to IV amino acid therapy). At time of enrollment, patients allocated to receive amino acid therapy had higher APACHE II scores (20.2 ± 6.8 vs. 21.7 ± 7.6, P = 0.02) and more patients had pre-existing renal dysfunction (29/235 vs. 44/239, P = 0.07). Duration of renal dysfunction after enrollment did not differ between groups (mean difference 0.21 AKI days per 10 patient ICU days, 95 % CI -0.27 to 1.04, P = 0.45). Amino acid therapy significantly improved eGFR (treatment group × time interaction, P = 0.004), with an early peak difference of 7.7 mL/min/1.73 m(2) (95 % CI 1.0-14.5 mL/min/1.73 m(2), P = 0.02) on study day 4. Daily urine output was also significantly increased (+300 mL/day, 95 % CI 145-455 mL, P = 0.0002). There was a trend towards increased RRT use in patients receiving amino acid therapy (13/235 vs. 25/239, P = 0.062); however, this trend was not present after controlling for baseline imbalance (P = 0.21). CONCLUSION AND RELEVANCE Treatment with a daily IV supplement of standard amino acids did not alter our primary outcome, duration of renal dysfunction. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12609001015235.
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Affiliation(s)
- Gordon S Doig
- The Northern Clinical School Intensive Care Research Unit, University of Sydney, Sydney, Australia,
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Haji K, Royse A, Tharmaraj D, Haji D, Botha J, Royse C. Diaphragmatic regional displacement assessed by ultrasound and correlated to subphrenic organ movement in the critically ill patients—an observational study. J Crit Care 2015; 30:439.e7-13. [DOI: 10.1016/j.jcrc.2014.10.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 09/19/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
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Abstract
Therapeutic hypothermia (TH), where patients are cooled to between 32°C and 36°C for a period of 12-24 hours and then gradually rewarmed, may reduce the risk of ischemic injury to cerebral tissue following a period of insufficient blood flow. This strategy of TH could improve mortality and neurological function in patients who have experienced out-of-hospital cardiac arrest (OOHCA). The necessity of TH in OOHCA was challenged in late 2013 by a fascinating and potentially practice changing publication, which found that targeting a temperature of 36°C had similar outcomes to cooling patients to 33°C. This article reviews the current literature and summarizes the uncertainties and questions raised when considering cooling of patients at risk of hypoxic brain injury. Irrespective of whether TH or targeted temperature management is deployed in patients at risk of hypoxic brain injury, it would seem that avoiding hyperpyrexia is important and that a more rigorous approach to neurological evaluation is mandated.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital , Frankston, Victoria, Australia
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Gupta S, Green C, Tiruvoipati R, Botha J. Do intensivists prognosticate patients differently from themselves or their loved ones? Crit Care 2015. [PMCID: PMC4471179 DOI: 10.1186/cc14649] [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: 11/25/2022] Open
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Lala SG, Britz R, Botha J, Loveland J. Paediatric liver transplantation for children treated at public health facilities in South Africa: time for change. S Afr Med J 2014; 104:829-832. [PMID: 26038799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
Paediatric liver transplantation (PLT) is the only therapeutic option for many children with end-stage chronic liver disease or irreversible fulminant hepatic failure, and is routinely considered as a therapy by paediatric gastroenterologists and surgeons working in developed countries. In South Africa (SA), a PLT programme has been available at Red Cross War Memorial Children's Hospital in Cape Town since November 1991, and another has rapidly developed at the Wits Donald Gordon Medical Centre in Johannesburg over the past decade. However, for most children with progressive chronic liver disease who are reliant on the services provided at state facilities in SA, PLT is not an option because of a lack of resources in a mismanaged public health system. This article briefly outlines the services offered at Chris Hani Baragwanath Academic Hospital--which is typical of state facilities in SA--and proposes that resources be allocated to establish an innovative, nationally funded centre that would enable greater numbers of children access to a PLT programme.
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Kurnatowska I, Grzelak P, Masajtis-Zagajewska A, Kaczmarska M, Stefa czyk L, Vermeer C, Maresz K, Nowicki M, Patel L, Bernard LM, Elder GJ, Leonardis D, Mallamaci F, Tripepi G, D'Arrigo G, Postorino M, Enia G, Caridi G, Marino F, Parlongo G, Zoccali C, Genovese F, Boor P, Papasotiriou M, Leeming DJ, Karsdal MA, Floege J, Delmas-Frenette C, Troyanov S, Awadalla P, Devuyst O, Madore F, Jensen JM, Mose FH, Kulik AEO, Bech JN, Fenton RA, Pedersen EB, Lucisano S, Villari A, Benedetto F, Pettinato G, Cernaro V, Lupica R, Trimboli D, Costantino G, Santoro D, Buemi M, Carmone C, Robben JH, Hadchouel J, Rongen G, Deinum J, Navis GJ, Wetzels JF, Deen PM, Block G, Fishbane S, Shemesh S, Sharma A, Wolf M, Chertow G, Gracia M, Arroyo D, Betriu A, Valdivielso JM, Fernandez E, Cantaluppi V, Medica D, Quercia AD, Dellepiane S, Gai M, Leonardi G, Guarena C, Migliori M, Panichi V, Biancone L, Camussi G, Covic A, Ketteler M, Rastogi A, Spinowitz B, Sprague SM, Botha J, Rakov V, Floege J, Floege J, Ketteler M, Rastogi A, Spinowitz B, Sprague SM, Botha J, Braunhofer P, Covic A, Kaku Y, Ookawara S, Miyazawa H, Ito K, Ueda Y, Hirai K, Hoshino T, Mori H, Nabata A, Yoshida I, Tabei K, El-Shahawy M, Cotton J, Kaupke J, Wooldridge TD, Weiswasser M, Smith WT, Covic A, Ketteler M, Rastogi A, Spinowitz B, Sprague SM, Botha J, Braunhofer P, Floege J, Hanowski T, Jager K, Rong S, Lesch T, Knofel F, Kielstein H, McQuarrie EP, Mark PB, Freel EM, Taylor A, Jardine AG, Wang CL, Du Y, Nan L, :Hess K, Savvaidis A, Lysaja K, Dimkovic N, Floege J, Marx N, Schlieper G, Skrunes R, Larsen KK, Svarstad E, Tondel C, Singh B, Ash SR, Lavin PT, Yang A, Rasmussen HS, Block GA, Egbuna O, Zeig S, Pergola PE, Singh B, Braun A, Yu Y, Sohn W, Padhi D, Block G, Chertow G, Fishbane S, Rodriguez M, Chen M, Shemesh S, Sharma A, Wolf M, Delgado G, Kleber ME, Grammer TB, Kraemer BK, Maerz W, Scharnagl H, Ichii M, Ishimura E, Shima H, Ohno Y, Tsuda A, Nakatani S, Ochi A, Mori K, Inaba M, Filiopoulos V, Manolios N, Hadjiyannakos D, Arvanitis D, Karatzas I, Vlassopoulos D, Floege J, Botha J, Chong E, Sprague SM, Cosmai L, Porta C, Foramitti M, Masini C, Sabbatini R, Malberti F, Elewa U, Nastou D, Fernandez B, Egido J, Ortiz A, Hara S, Tanaka K, Kushiyama A, Sakai K, Sawa N, Hoshino J, Ubara Y, Takaichi K, Bouquegneau A, Vidal-Petiot E, Vrtovsnik F, Cavalier E, Krzesinski JM, Flamant M, Delanaye P, Kilis-Pstrusinska K, Prus-Wojtowicz E, Szepietowski JC, Raj DS, Amdur R, Yamamoto J, Mori M, Sugiyama N, Inaguma D, Youssef DM, Alshal AA, Elbehidy RM, Bolignano D, Palmer S, Navaneethan S, Strippoli G, Kim YN, Park K, Gwoo S, Shin HS, Jung YS, Rim H, Rhew HY, Tekce H, Kin Tekce B, Aktas G, Schiepe F, Draz Y, Rakov V, Yilmaz MI, Siriopol D, Saglam M, Kurt YG, Unal H, Eyileten T, Gok M, Cetinkaya H, Oguz Y, Sari S, Vural A, Mititiuc I, Covic A, Kanbay M, Filiopoulos V, Manolios N, Hadjiyannakos D, Arvanitis D, Karatzas I, Vlassopoulos D, Okarska-Napierala M, Ziolkowska H, Pietrzak R, Skrzypczyk P, Jankowska K, Werner B, Roszkowska-Blaim M, Cernaro V, Trifiro G, Lorenzano G, Lucisano S, Buemi M, Santoro D, Krause R, Fuhrmann I, Degenhardt S, Daul AE, Sallee M, Dou L, Cerini C, Poitevin S, Gondouin B, Jourde-Chiche N, Brunet P, Dignat-George F, Burtey S, Massimetti C, Achilli P, Madonna MPP, Muratore MTT, Fabbri GDD, Brescia F, Feriozzi S, Unal HU, Kurt YG, Gok M, Cetinkaya H, Karaman M, Eyileten T, Vural A, Oguz Y, Y lmaz MI, Sugahara M, Sugimoto I, Aoe M, Chikamori M, Honda T, Miura R, Tsuchiya A, Hamada K, Ishizawa K, Saito K, Sakurai Y, Mise N, Gama-Axelsson T, Quiroga B, Axelsson J, Lindholm B, Qureshi AR, Carrero JJ, Pechter U, Raag M, Ots-Rosenberg M, Vande Walle J, Greenbaum LA, Bedrosian CL, Ogawa M, Kincaid JF, Loirat C, Liborio A, Leite TT, Neves FMDO, Torres De Melo CB, Leitao RDA, Cunha L, Filho R, Sheerin N, Loirat C, Greenbaum L, Furman R, Cohen D, Delmas Y, Bedrosian CL, Legendre C, Koibuchi K, Aoki T, Miyagi M, Sakai K, Aikawa A, Pozna Ski P, Sojka M, Kusztal M, Klinger M, Fakhouri F, Bedrosian CL, Ogawa M, Kincaid JF, Loirat C, Heleniak Z, Aleksandrowicz E, Wierblewska E, Kunicka K, Bieniaszewski L, Zdrojewski Z, Rutkowski B. CKD PATHOPHYSIOLOGY AND CLINICAL STUDIES. Nephrol Dial Transplant 2014. [DOI: 10.1093/ndt/gfu148] [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: 11/12/2022] Open
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Ali A, Botha J, Tiruvoipati R. Fatal skin and soft tissue infection of multidrug resistant Acinetobacter baumannii: A case report. Int J Surg Case Rep 2014; 5:532-6. [PMID: 25016080 PMCID: PMC4147652 DOI: 10.1016/j.ijscr.2014.04.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [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: 03/25/2013] [Revised: 01/22/2014] [Accepted: 04/17/2014] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Acinetobacter baumannii is usually associated with respiratory tract, urinary tract and bloodstream infections. Recent reports suggest that it is increasingly causing skin and soft tissue infections. It is also evolving as a multidrug resistant organism that can be difficult to treat. We present a fatal case of multidrug resistant A. baumannii soft tissue infection and review of relevant literature. PRESENTATION OF CASE A 41 year old morbidly obese man, with history of alcoholic liver disease presented with left superficial pre-tibial abrasions and cellulitis caused by multidrug resistant (MDR) A. baumannii. In spite of early antibiotic administration he developed extensive myositis and fat necrosis requiring extensive and multiple surgical debridements. He deteriorated despite appropriate antibiotic therapy and multiple surgical interventions with development of multi-organ failure and died. DISCUSSION Managing Acinetobacter infections remains difficult due to the array of resistance and the pathogens ability to develop new and ongoing resistance. The early diagnosis of necrotizing soft tissue infection may be challenging, but the key to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. CONCLUSION A. baumannii is emerging as an important cause of severe, life-threatening soft tissue infections. Multidrug resistant A. baumannii soft tissue infections may carry a high mortality in spite of early and aggressive treatment. Clinicians need to consider appropriate early empirical antibiotic coverage or the use of combination therapy to include MDR A. baumannii as a cause of skin and soft tissue infections.
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Affiliation(s)
- Aqsa Ali
- Department of Intensive Care Medicine Frankston Hospital, Frankston, Victoria 3199, Australia.
| | - John Botha
- Department of Intensive Care Medicine Frankston Hospital, Frankston, Victoria 3199, Australia.
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Botha J, Tiruvoipati R, Goldberg D. Futility of medical treatment in current medical practice. N Z Med J 2013; 126:58-71. [PMID: 24157992 DOI: pmid/24157992] [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: 02/08/2023]
Abstract
Intensive care provides support for acute reversible organ failure and most patients who receive intensive care recover from their illness. In some patients organ failure may become irreversible and in these patients further treatment or organ support may be considered futile. Emerging technologies and expertise can enable the medical profession to prolong life / death indefinitely without curing or controlling the underlying disease process. Introduction of ultramodern organ supports such as extracorporeal life-support systems, ventricular assist devices and organ transplantation surgeries have introduced some degree of ambiguity in defining futility of care. Furthermore medico legal implications of futility of care introduce further complexities in defining and instituting futile treatments. In this review we discuss the evolution of the concept of futility of care, review the various meanings of the term "futility of care", explore the complexities of management when care is considered futile, offer suggestions as to how such patients and their families could be managed. We also review the legal framework when consensus is not achieved.
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Affiliation(s)
- John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria 3199, Australia.
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Botha J, de Ridder JH, Potgieter JC, Steyn HS, Malan L. Structural vascular disease in Africans: Performance of ethnic-specific waist circumference cut points using logistic regression and neural network analyses: The SABPA study. Exp Clin Endocrinol Diabetes 2013; 121:515-20. [PMID: 23934678 DOI: 10.1055/s-0033-1351289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A recently proposed model for waist circumference cut points (RPWC), driven by increased blood pressure, was demonstrated in an African population. We therefore aimed to validate the RPWC by comparing the RPWC and the Joint Statement Consensus (JSC) models via Logistic Regression (LR) and Neural Networks (NN) analyses. Urban African gender groups (N=171) were stratified according to the JSC and RPWC cut point models. Ultrasound carotid intima media thickness (CIMT), blood pressure (BP) and fasting bloods (glucose, high density lipoprotein (HDL) and triglycerides) were obtained in a well-controlled setting. The RPWC male model (LR ROC AUC: 0.71, NN ROC AUC: 0.71) was practically equal to the JSC model (LR ROC AUC: 0.71, NN ROC AUC: 0.69) to predict structural vascular -disease. Similarly, the female RPWC model (LR ROC AUC: 0.84, NN ROC AUC: 0.82) and JSC model (LR ROC AUC: 0.82, NN ROC AUC: 0.81) equally predicted CIMT as surrogate marker for structural vascular disease. Odds ratios supported validity where prediction of CIMT revealed -clinical -significance, well over 1, for both the JSC and RPWC models in African males and females (OR 3.75-13.98). In conclusion, the proposed RPWC model was substantially validated utilizing linear and non-linear analyses. We therefore propose ethnic-specific WC cut points (African males, ≥90 cm; -females, ≥98 cm) to predict a surrogate marker for structural vascular disease.
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Affiliation(s)
- J Botha
- Physical Activity Sport and Recreation (PhASRec), North-West University, Potchefstroom, South Africa
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Rissanen A, Howard CP, Botha J, Thuren T. Effect of anti-IL-1β antibody (canakinumab) on insulin secretion rates in impaired glucose tolerance or type 2 diabetes: results of a randomized, placebo-controlled trial. Diabetes Obes Metab 2012; 14:1088-96. [PMID: 22726220 DOI: 10.1111/j.1463-1326.2012.01637.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 03/30/2012] [Accepted: 06/16/2012] [Indexed: 12/11/2022]
Abstract
AIMS Evaluate anti-interleukin-1β (IL-1β) antibody, canakinumab, in patients with type 2 diabetes and impaired glucose tolerance (IGT) in whom hyperglycaemia may trigger IL-1β-associated inflammation leading to suppressed insulin secretion and β-cell dysfunction. METHODS This 4-week, parallel-group study randomized 190 patients with type 2 diabetes 2 : 1, canakinumab versus placebo, into the following treatment arms: metformin monotherapy, metformin + sulfonylurea, metformin + sulfonylurea + thiazolidinedione or insulin ± metformin. IGT population (n = 54) was randomized 1 : 1, canakinumab versus placebo. Primary efficacy assessment was change from baseline in insulin secretion rate (ISR) relative to glucose 0-2 h. RESULTS Mean changes from baseline to week 4 in ISR relative to glucose at 0-2 h or other time points were not statistically significant for canakinumab versus placebo across groups. ISR (relative to glucose) at 0-0.5 h (first-phase insulin secretion) numerically favoured canakinumab versus placebo in insulin-treated patients {difference in mean change from baseline [point estimate (PE)] 3.81 pmol/min/m(2)/mmol/l; p = 0.0525} and in the IGT group (PE 3.92 pmol/min/m(2)/mmol/l; p = 0.1729). Mean change from baseline in fasting plasma glucose favoured canakinumab in the type 2 diabetes/metformin group and the IGT group; however, differences were not statistically significant. Mean change from baseline in peak insulin level and insulin AUC 0-4 h were statistically significantly higher in the canakinumab group in IGT patients. Canakinumab was well tolerated and consistent with known safety experience. CONCLUSIONS The trend towards improving ISR relative to glucose 0-0.5 h in patients treated with insulin supports the hypothesis that insulin secretion can be improved by blocking IL-1β.
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Affiliation(s)
- A Rissanen
- Obesity Research Unit, Helsinki University Central Hospital, Helsinki, Finland
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Florescu DF, Langnas AN, Grant W, Mercer DF, Botha J, Qiu F, Shafer L, Kalil AC. Incidence, risk factors, and outcomes associated with cytomegalovirus disease in small bowel transplant recipients. Pediatr Transplant 2012; 16:294-301. [PMID: 22212495 DOI: 10.1111/j.1399-3046.2011.01628.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite improved prophylaxis, monitoring, and more efficient immunosuppression, CMV infection remains a common opportunistic infection in transplant recipients. We assessed the incidence of CMV disease in pediatric SBT recipients, the timing of CMV disease after transplantation, and its impact on patient outcome. The medical records of 98 SBT recipients were reviewed. We performed descriptive analysis, regression analysis, and Kaplan-Meier curves to determine the time-to-event after transplantation. Fifty-three percent patients were male and 47% female, with a mean age of 38.3 months. Thirty-five percent of patients received prophylactic VGC, 55% GCV, 10% a combination of GCV/VGC, and 99% CMV immunoglobulins. A total of 24.5% recipients were CMV D+/R- (CMV serostatus donor positive/recipient negative). Seven (c. 7%) patients developed CMV disease. CMV disease was associated with 2.5 times (0.52-12.1; p = 0.25) higher rate of CMV mismatch and 11.1 times (1.3-95.9; p = 0.03) higher risk of death. CMV prophylaxis increased time-to-death (p = 0.074). Time-to-CMV disease was shorter in patients with enteritis (p < 0.0001), and CMV disease was associated with shorter time-to-death after transplantation (p = 0.001). CMV disease in SBT recipients was associated with an 11-fold mortality increase and a fourfold faster time-to-death. Time-to-death was significantly shorter with CMV enteritis.
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Affiliation(s)
- D F Florescu
- Infectious Diseases Division, Transplant Infectious Diseases Program, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198-5400, USA.
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Tiruvoipati R, Chiezey B, Lewis D, Ong K, Villanueva E, Haji K, Botha J. Stress hyperglycemia may not be harmful in critically ill patients with sepsis. J Crit Care 2012; 27:153-8. [PMID: 21855283 DOI: 10.1016/j.jcrc.2011.06.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [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: 03/03/2011] [Revised: 06/13/2011] [Accepted: 06/18/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Stress hyperglycemia (SH) is commonly seen in critically ill patients. It has been shown to be associated with adverse outcomes in some groups of patients. The effects of SH on critically ill patients with sepsis have not been well studied. We aimed to evaluate the effects of SH in critically ill patients with sepsis. METHODS In this retrospective study, patients with sepsis admitted to intensive care unit (ICU) over a 5-year period were included. RESULTS Of 297 patients, 204 (68.7%) had SH during the study period. The mean blood glucose level in patients with SH was 8.7 mmol/L compared with 5.9 mmol/L in those without SH (P < .05). There were no statistically significant differences in age; sex; sepsis severity; cardiovascular, respiratory, and renal comorbidities; requirement of mechanical ventilation; inotropes; and Acute Physiology, Age, and Chronic Health Evaluation III and Simplified Acute Physiology 2 scores on ICU admission. Intensive care unit mortality was significantly lower in patients who had SH. The median duration of ICU and hospital length of stay was longer in patients with SH. On logistic regression analysis, the presence of SH was associated with reduced ICU mortality. Subgroup analysis revealed SH to be protective in patients with septic shock. CONCLUSION Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Patients with SH had lower ICU mortality.
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Tiruvoipati R, Botha J, Peek G. Effectiveness of extracorporeal membrane oxygenation when conventional ventilation fails: valuable option or vague remedy? J Crit Care 2012; 27:192-8. [PMID: 21703814 DOI: 10.1016/j.jcrc.2011.04.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [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: 02/01/2011] [Revised: 03/22/2011] [Accepted: 04/23/2011] [Indexed: 02/08/2023]
Abstract
The mortality and morbidity of patients with severe acute respiratory distress syndrome (ARDS) remains high despite the advances in intensive care practice. The low-tidal-volume ventilation strategy (ARDS net protocol) has been shown to be effective in improving survival. Unfortunately, however, some patients have such severe ARDS that they cannot be managed with the ARDS net strategy. In these patients, rescue therapies such as high-frequency ventilation, prone ventilation, nitric oxide, and extracorporeal membrane oxygenation (ECMO) are considered. The CESAR trial has shown that an ECMO-based protocol improved survival without severe disability as compared with conventional ventilation. The recent increased incidence of severe respiratory failure due to H1N1 influenza pandemic has led to an increased use of ECMO. Although several reports showed ECMO use to be encouraging, some scepticism remains. In this article, we reviewed the usefulness of ECMO in patients with severe ARDS in the light of current evidence.
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Loveland JA, Govender T, Botha J, Britz R. Paediatric liver transplantation in Johannesburg: initial 29 cases and prospects for the future. S Afr Med J 2012; 102:233-236. [PMID: 22464505] [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] [Received: 07/30/2011] [Accepted: 08/22/2011] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND The Wits Donald Gordon Medical Centre paediatric liver transplant programme is the second such unit in sub-Saharan Africa. Initiated in November 2005, it forms part of the centre's solid organ transplant unit, comprising kidney, liver and simultaneous kidney-pancreas arms. Initially established in the private sector, we recently received government approval to expand our programme into the provincial sector and have performed transplants on several provincial-sector patients. Current challenges relate to the lack of appropriately trained paediatric sub-specialists, specifically critical care practitioners and hepatologists. METHODS Subsequent to institutional approval, a retrospective chart analysis of all paediatric liver transplants performed at our facility to date was conducted. RESULTS Defining children as those under 18 years of age, 29 patients have received a cadaveric liver transplant since 2005, using 16 whole livers, 10 reduced-size grafts, and 3 split segments; 13 were transplanted with biliary atresia, 3 hyperoxalurea, 3 autosomal recessive polycystic disease, 2 alpha-1 antitrypsin deficiency, and 2 idiopathic, with the remainder for a wide spectrum of other pathologies. Seven patients received combined liver-kidney transplants. There were 3 in-hospital mortalities. The remaining 26 patients are all long-term survivors. We describe 7 acute surgical morbidities in 6 patients, and 8 long-term surgical morbidities. One patient was subsequently re-transplanted in Cape Town. CONCLUSIONS Despite a shortage of organs, we have overcome a steep learning curve, with results comparable with other early series. The current threat to the continued viability of our unit is the lack of appropriately trained paediatric hepatologists and intensivists.
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Affiliation(s)
- J A Loveland
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
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Florescu DF, McCartney AM, Qiu F, Langnas AN, Botha J, Mercer DF, Grant W, Kalil AC. Staphylococcus aureus infections after liver transplantation. Infection 2011; 40:263-9. [PMID: 22124952 DOI: 10.1007/s15010-011-0224-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 11/08/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND More data on the risk factors and outcomes after Staphylococcus aureus infections in liver transplantation are needed. METHODS Liver recipients with S. aureus infections (cases) were retrospectively identified and compared to gender-, age-, and transplant type-matched (1:2) non-S. aureus-infected controls. Risk factors associated with S. aureus infections were identified by conditional logistic regression analysis. RESULTS We evaluated 51 patients (median age 52 years). First S. aureus infections developed at a median time of 29 days after transplantation, with 52.94% of them in the first month; 88.24% were nosocomial, 41.18% were polymicrobial, and 47.06% were caused by methicillin-resistant S. aureus (MRSA). Surgical site infections represented 58.82% and bacteremia 23.53%. By univariate analysis, patients with S. aureus infections were intubated more frequently (odds ratio [OR] 26.92, 95% confidence interval [CI] 3.23-3,504.15, p = 0.0006), had a central line (OR 11.69, 95% CI 1.42-95.9, p = 0.02), or recent surgery (OR 26.92, 95% CI 3.23-3,504.15, p = 0.0006) compared with controls. By multivariate analysis, subjects who underwent surgery within 2 weeks prior to infection had a 26.9 times higher risk of developing S. aureus infection (95% CI 3.23-3,504.15, p = 0.0006); these results were adjusted for matched criteria. S. aureus infections did not affect graft or patient survival, but the study was not powered for such outcomes. CONCLUSION Only recent surgical procedure was found to be a significant independent risk factor for S. aureus infections after liver transplantation.
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Affiliation(s)
- D F Florescu
- Infectious Diseases Section, University of Nebraska Medical Center, Omaha, USA.
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