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Hoisington AJ, Choy K, Khair S, Dyamenahalli KU, Najarro KM, Wiktor AJ, Frank DN, Burnham EL, McMahan RH, Kovacs EJ. Recent alcohol intake impacts microbiota in adult burn patients. Alcohol 2024; 118:25-35. [PMID: 38604285 DOI: 10.1016/j.alcohol.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/26/2024] [Accepted: 04/04/2024] [Indexed: 04/13/2024]
Abstract
Alcohol use is associated with an increased incidence of negative health outcomes in burn patients due to biological mechanisms that include a dysregulated inflammatory response and increased intestinal permeability. This study used phosphatidylethanol (PEth) in blood, a direct biomarker of recent alcohol use, to investigate associations between a recent history of alcohol use and the fecal microbiota, short chain fatty acids, and inflammatory markers in the first week after a burn injury for nineteen participants. Burn patients were grouped according to PEth levels of low or high and differences in the overall fecal microbial community were observed between these cohorts. Two genera that contributed to the differences and had higher relative abundance in the low PEth burn patient group were Akkermansia, a mucin degrading bacteria that improves intestinal barrier function, and Bacteroides, a potentially anti-inflammatory bacteria. There was no statistically significant difference between levels of short chain fatty acids or intestinal permeability across the two groups. To our knowledge, this study represents the first report to evaluate the effects of burn injury and recent alcohol use on early post burn microbiota dysbiosis, inflammatory response, and levels of short chain fatty acids. Future studies in this field are warranted to better understand the factors associated with negative health outcomes and develop interventional trials.
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Affiliation(s)
- Andrew J Hoisington
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA; Department of Systems Engineering and Management, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA
| | - Kevin Choy
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Shanawaj Khair
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kiran U Dyamenahalli
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kevin M Najarro
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Veterans Health Administration, Eastern Colorado Health Care System, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA
| | - Arek J Wiktor
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel N Frank
- GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ellen L Burnham
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Alcohol Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rachel H McMahan
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Veterans Health Administration, Eastern Colorado Health Care System, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA
| | - Elizabeth J Kovacs
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Veterans Health Administration, Eastern Colorado Health Care System, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Alcohol Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Dunbar PJ, Peterson R, McGrath M, Pomponio R, Kiser TH, Ho PM, Vandivier RW, Burnham EL, Moss M, Sottile PD. Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure. Crit Care Med 2024:00003246-990000000-00310. [PMID: 38506571 DOI: 10.1097/ccm.0000000000006253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To describe U.S. practice regarding administration of sedation and analgesia to patients on noninvasive ventilation (NIV) for acute respiratory failure (ARF) and to determine the association of this practice with odds of intubation or death. DESIGN A retrospective multicenter cohort study. SETTING A total of 1017 hospitals contributed data between January 2010 and September 2020 to the Premier Healthcare Database, a nationally representative healthcare database in the United States. PATIENTS Adult (≥ 18 yr) patients admitted to U.S. hospitals requiring NIV for ARF. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 433,357 patients on NIV of whom (26.7% [95% CI] 26.3%-27.0%) received sedation or analgesia. A total of 50,589 patients (11.7%) received opioids only, 40,646 (9.4%) received benzodiazepines only, 20,146 (4.6%) received opioids and benzodiazepines, 1.573 (0.4%) received dexmedetomidine only, and 2,639 (0.6%) received dexmedetomidine in addition to opioid and/or benzodiazepine. Of 433,357 patients receiving NIV, 50,413 (11.6%; 95% CI, 11.5-11.7%) patients underwent invasive mechanical ventilation on hospital days 2-5 or died on hospital days 2-30. Intubation was used in 32,301 patients (7.4%; 95% CI, 7.3-7.6%). Further, death occurred in 24,140 (5.6%; 95% CI, 5.5-5.7%). In multivariable analysis adjusting for relevant covariates, receipt of any medication studied was associated with increased odds of intubation or death. In inverse probability weighting, receipt of any study medication was also associated with increased odds of intubation or death (average treatment effect odds ratio 1.38; 95% CI, 1.35-1.40). CONCLUSIONS The use of sedation and analgesia during NIV is common. Medication exposure was associated with increased odds of intubation or death. Further investigation is needed to confirm this finding and determine whether any subpopulations are especially harmed by this practice.
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Affiliation(s)
- Peter J Dunbar
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Max McGrath
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Raymond Pomponio
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
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Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, Dickson RP, Almonor F, Luo F, Madan K, Morales-Nebreda L, Mould KJ, Simpson AJ, Singer BD, Stapleton RD, Wendt CH, Files DC. Research Bronchoscopies in Critically Ill Research Participants: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:621-631. [PMID: 37125997 PMCID: PMC10174130 DOI: 10.1513/annalsats.202302-106st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Bronchoscopy for research purposes is a valuable tool to understand lung-specific biology in human participants. Despite published reports and active research protocols using this procedure in critically ill patients, no recent document encapsulates the important safety considerations and downstream applications of this procedure in this setting. The objectives were to identify safe practices for patient selection and protection of hospital staff, provide recommendations for sample procurement to standardize studies, and give guidance on sample preparation for novel research technologies. Seventeen international experts in the management of critically ill patients, bronchoscopy in clinical and research settings, and experience in patient-oriented clinical or translational research convened for a workshop. Review of relevant literature, expert presentations, and discussion generated the findings presented herein. The committee concludes that research bronchoscopy with bronchoalveolar lavage in critically ill patients on mechanical ventilation is valuable and safe in appropriately selected patients. This report includes recommendations on standardization of this procedure and prioritizes the reporting of sample management to produce more reproducible results between laboratories. This document serves as a resource to the community of researchers who endeavor to include bronchoscopy as part of their research protocols and highlights key considerations for the inclusion and safety of research participants.
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Reynolds PM, Afshar M, Wright GC, Ho PM, Kiser TH, Sottile PD, Althoff MD, Moss M, Jolley SE, Vandivier RW, Burnham EL. Association between Substance Misuse and Outcomes in Critically III Patients with Pneumonia. Ann Am Thorac Soc 2023; 20:556-565. [PMID: 37000145 PMCID: PMC10112399 DOI: 10.1513/annalsats.202206-532oc] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/23/2023] [Indexed: 01/24/2023] Open
Abstract
Rationale: In patients with pneumonia requiring intensive care unit (ICU) admission, alcohol misuse is associated with increased mortality, but the relationship between other commonly misused substances and mortality is unknown. Objectives: We sought to establish whether alcohol misuse, cannabis misuse, opioid misuse, stimulant misuse, or misuse of more than one of these substances was associated with differences in mortality among ICU patients with pneumonia. Methods: This was a retrospective cohort study of hospitals participating in the Premier Healthcare Database between 2010 and 2017. Patients were included if they had a primary or secondary diagnosis of pneumonia and received antibiotics or antivirals within 1 day of admission. Substance misuse related to alcohol, cannabis, stimulants, and opioids, or more than one substance, were identified from the International Classification of Diseases (Ninth and Tenth Editions). The associations between substance misuse and in-hospital mortality were the primary outcomes of interest. Secondary outcomes included the measured associations between substance misuse disorders and mechanical ventilation, as well as vasopressor and continuous paralytic administration. Analyses were conducted with multivariable mixed-effects logistic regression modeling adjusting for age, comorbidities, and hospital characteristics. Results: A total of 167,095 ICU patients met inclusion criteria for pneumonia. Misuse of alcohol was present in 5.0%, cannabis misuse in 0.6%, opioid misuse in 1.5%, stimulant misuse in 0.6%, and misuse of more than one substance in 1.2%. No evidence of substance misuse was found in 91.1% of patients. In unadjusted analyses, alcohol misuse was associated with increased in-hospital mortality (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.06-1.19), whereas opioid misuse was associated with decreased in-hospital mortality (OR, 0.46; 95% CI, 0.39-0.53) compared with no substance misuse. These findings persisted in adjusted analyses. Although cannabis, stimulant, and more than one substance misuse (a majority of which were alcohol in combination with another substance) were associated with lower odds for in-hospital mortality in unadjusted analyses, these relationships were not consistently present after adjustment. Conclusions: In this study of ICU patients hospitalized with severe pneumonia, substance misuse subtypes were associated with different effects on mortality. Although administrative data can provide epidemiologic insight regarding substance misuse and pneumonia outcomes, biases inherent to these data should be considered when interpreting results.
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Affiliation(s)
- Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
- Colorado Pulmonary Outcomes Research Group
- Department of Pharmacy, Rocky Mountain Regional VA Medical Center, Aurora, Colorado; and
| | - Majid Afshar
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Garth C. Wright
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - P. Michael Ho
- Colorado Pulmonary Outcomes Research Group
- Division of Cardiology, Department of Medicine, and
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
- Colorado Pulmonary Outcomes Research Group
| | - Peter D. Sottile
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Meghan D. Althoff
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marc Moss
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah E. Jolley
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - R. William Vandivier
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ellen L. Burnham
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Choy K, Dyamenahalli KU, Khair S, Colborn KL, Wiktor AJ, Idrovo JP, McMahan RH, Burnham EL, Kovacs EJ. Aberrant Inflammatory Responses in Intoxicated Burn Injured Patients Parallel Impaired Cognitive Function. Alcohol 2023; 109:35-41. [PMID: 36690221 PMCID: PMC10175175 DOI: 10.1016/j.alcohol.2023.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
Burn injured patients with alcohol use disorder (AUD) have increased morbidity and mortality compared to alcohol abstaining individuals with similar injuries. It is hypothesized that this is due, in part, to alcohol-induced dysregulation of the systemic inflammatory response, leading to worsened clinical outcomes, including increased susceptibility to infection, and heightened cognitive impairment. To examine the effects of alcohol on inflammatory markers after burn injury, we used multiplex assays to measure a panel of 48 cytokines, chemokines, and growth factors in the plasma of burn patents within 24 hours of admission to the University of Colorado Burn Center. Thirty patients were enrolled between July 2018 to February 2020 and were stratified based on presence of AUD and total body surface area (TBSA) burn of ≥20% into four groups: [AUD-, TBSA <20%, N=12], [AUD+, TBSA <20%, N=3], [AUD-, TBSA ≥20%, N=8], [AUD+, TBSA ≥20%, N=7]. In addition, Confusion Assessment Method (CAM) scores were collected to evaluate patient delirium during the course of hospitalization. Multivariate statistical analysis demonstrated a number of cytokines and other factors that were significantly different between the groups. For example, the anti-inflammatory cytokine interleukin 1 receptor antagonist (IL-1ra) was dampened in the AUD+, TBSA ≥20% cohort with a 75.2% decrease compared to AUD-, TBSA ≥20% and 83.9% decrease compared to AUD-, TBSA <20% (p=0.008). Additionally, plasma levels of the pro-inflammatory mediator CXCL12 (C-X-C motif chemokine ligand 12 also known as stromal cell-derived factor 1, SDF-1) was higher in the AUD+ groups (p=0.03) and similarly IL-18 levels were greater in AUD+, TBSA ≥20% (p=0.009). Eotaxin (also known as cytokine CC motif ligand 11, CCL11) was markedly elevated in the AUD+, TBSA ≥20% cohort with a 2.4-fold increase over the AUD-, TBSA ≥20% and a 1.7-fold rise compared to the AUD-, TBSA <20% cohorts (p=0.04). Interestingly, there was also a marked rise in CAM+ delirium scores (85.7%) among the AUD+ patients with TBSA ≥20% (p=0.02). Not surprisingly, we found that hospital stays increased with AUD+ and larger burns (p=0.0009). Our findings reveal that burn patients who misuse alcohol have aberrant inflammatory responses which may lead to greater immune dysregulation and worse clinical outcomes.
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Affiliation(s)
- Kevin Choy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kiran U Dyamenahalli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Shanawaj Khair
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Arek J Wiktor
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Juan-Pablo Idrovo
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Rachel H McMahan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA; Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Ellen L Burnham
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, USA; Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA; Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, USA.
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Zakrajsek JK, Min SJ, Ho PM, Kiser TH, Kannappan A, Sottile PD, Allen RR, Althoff MD, Reynolds PM, Moss M, Burnham EL, Mikkelsen ME, Vandivier RW. Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure. Chest 2023; 163:38-51. [PMID: 36191634 PMCID: PMC10354700 DOI: 10.1016/j.chest.2022.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7% to 15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed. RESEARCH QUESTION Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care? STUDY DESIGN AND METHODS This is a retrospective, epidemiologic, observational cohort study using a national, administrative data set from 2010 to 2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an asthma exacerbation, and were treated with short-acting bronchodilators, systemic corticosteroids, and invasive ventilation. People were excluded for age < 18 years, no ICU stay, nonasthma chronic lung disease, COVID-19, or multiple admissions. The main exposure was ECMO vs No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time receiving invasive ventilation, and total hospital costs. RESULTS The study analyzed 13,714 patients with AERF, including 127 with ECMO and 13,587 with No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR, 0.33; 95% CI, 0.17-0.64; P = .001), propensity score-adjusted (OR, 0.36; 95% CI, 0.16-0.81; P = .01), and propensity score-matched models (OR, 0.48; 95% CI, 0.24-0.98; P = .04) vs No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (P < .0001 for all) vs No ECMO, but not with decreased ICU LOS, hospital LOS, or time receiving invasive ventilation. INTERPRETATION ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.
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Affiliation(s)
- Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sung-Joon Min
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tyree H Kiser
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Arun Kannappan
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Meghan D Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Medepalli K, Purdon S, Bade RM, Glassberg MK, Burnham EL, Gershengorn HB. Association of Women Leaders with Women Program Director and Trainee Representation Across US Academic Internal Medicine. J Gen Intern Med 2023; 38:57-66. [PMID: 35604632 PMCID: PMC9126637 DOI: 10.1007/s11606-022-07635-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/21/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Women are underrepresented within internal medicine (IM). Whether women leaders attract women trainees is not well explored. OBJECTIVE To characterize leader and trainee gender across US academic IM and to investigate the association of leader gender with trainee gender. DESIGN Cross-sectional study. PARTICIPANTS Leaders (chairs, chiefs, program directors (PDs)) in 2018 and trainees (residents, fellows) in 2012-2016 at medical school-affiliated IM and seven IM fellowship programs. EXPOSURE Leadership (chair/chief and program director; and, for resident analyses, fellow) gender. MAIN MEASURES Our primary outcome was percent women trainees (IM residents and, separately, subspecialty fellows). We used standard statistics to describe leadership and trainee gender. We created separate multivariable linear regressions to evaluate associations of leader gender and percent women fellows with percent women IM residents. We then created separate multivariable multilevel models (site as a random effect) to evaluate associations of leader gender with percent women subspecialty fellows. KEY RESULTS Our cohort consisted of 940 programs. Women were 13.4% of IM chairs and <25% of chiefs in each fellowship subspecialty (cardiology: 2.6%; gastroenterology: 6.6%; pulmonary and critical care: 10.7%; nephrology: 14.4%; endocrinology: 20.6%; hematology-oncology: 23.2%; infectious diseases: 24.3%). IM PDs were 39.7% women; fellowship PDs ranged from nearly 25% (cardiology and gastroenterology) to nearly 50% (endocrinology and infectious disease) women. Having more women fellows (but not chairs or PDs) was associated with having more women residents (0.3% (95% CI: 0.2-0.5%) increase per 1% fellow increase, p<0.001); this association remained after adjustment (0.3% (0.1%, 0.4%), p=0.001). In unadjusted analyses, having a woman PD (increase of 7.7% (4.7%, 10.6%), p<0.001) or chief (increase of 8.9% (4.6%, 13.1%), p<0.001) was associated with an increase in women fellows; after adjustment, these associations were lost. CONCLUSIONS Women held a minority of leadership positions in academic IM. Having women leaders was not independently associated with having more women trainees.
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Affiliation(s)
- Kantha Medepalli
- Division of Pulmonary, and Sleep Medicine, Kaiser Permanente Washington, Seattle, WA, USA
| | - Stefanie Purdon
- Division of Pulmonary and Critical Care Medicine, Beaumont Hospital, Troy, MI, USA.
| | - Rebecca M Bade
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - M K Glassberg
- Division of Pulmonary Medicine, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Burns KEA, Moss M, Lorens E, Jose EKA, Martin CM, Viglianti EM, Fox-Robichaud A, Mathews KS, Akgun K, Jain S, Gershengorn H, Mehta S, Han JE, Martin GS, Liebler JM, Stapleton RD, Trachuk P, Vranas KC, Chua A, Herridge MS, Tsang JLY, Biehl M, Burnham EL, Chen JT, Attia EF, Mohamed A, Harkins MS, Soriano SM, Maddux A, West JC, Badke AR, Bagshaw SM, Binnie A, Carlos WG, Çoruh B, Crothers K, D'Aragon F, Denson JL, Drover JW, Eschun G, Geagea A, Griesdale D, Hadler R, Hancock J, Hasmatali J, Kaul B, Kerlin MP, Kohn R, Kutsogiannis DJ, Matson SM, Morris PE, Paunovic B, Peltan ID, Piquette D, Pirzadeh M, Pulchan K, Schnapp LM, Sessler CN, Smith H, Sy E, Thirugnanam S, McDonald RK, McPherson KA, Kraft M, Spiegel M, Dodek PM. Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. Crit Care Med 2022; 50:1689-1700. [PMID: 36300945 PMCID: PMC9668381 DOI: 10.1097/ccm.0000000000005674] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN Cross-sectional survey using four validated instruments. SETTING Sixty-two sites in Canada and the United States. SUBJECTS Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.
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Affiliation(s)
- Karen E A Burns
- Unity Health Toronto - St. Michaels Hospital, Toronto, ON, Canada
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marc Moss
- University of Colorado - Anschutz Medical Campus and Children's Hospital of Colorado, Aurora, CO
| | - Edmund Lorens
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Claudio M Martin
- Division of Critical Care, London Health Sciences, London Health Sciences Centre, London, ON, Canada
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Alison Fox-Robichaud
- Division of Critical Care, McMaster University, Department of Medicine, Hamilton, ON, Canada
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kathleen Akgun
- Section of Pulmonary, Critical Care & Sleep Medicine, VA Connecticut Healthcare System, West Haven, CT
| | - Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Hayley Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Sangeeta Mehta
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Sinai Health, Toronto, ON, Canada
| | - Jenny E Han
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Gregory S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA
| | - Janice M Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Polina Trachuk
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, New York University Langone Health, New York, NY
| | - Kelly C Vranas
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | | | - Margaret S Herridge
- Department of Medicine and the Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | | | - Michelle Biehl
- Departments of Critical Care Medicine and Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Bronx, NY
| | - Jen-Ting Chen
- Harborview Medical Center, University of Washington, Seattle, WA
| | - Engi F Attia
- Division of Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Amira Mohamed
- Division of Pulmonary, Critical Care and Sleep, Department of Internal Medicine, Montefiore Medical Center, Bronx, NY
| | - Michelle S Harkins
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of New Mexico, Albuquerque, NM
| | - Sheryll M Soriano
- OSF Medical Group Pulmonary and Critical Care Division, Order of St Francis (OSF) Healthcare, Peoria, IL
| | - Aline Maddux
- University of Colorado - Anschutz Medical Campus and Children's Hospital of Colorado, Aurora, CO
| | - Julia C West
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andrew R Badke
- Pulmonary and Critical Care, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexandra Binnie
- Department of Critical Care Medicine at William Osler Health System, William Osler Health System, Toronto, ON, Canada
| | - W Graham Carlos
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Puget Sound Health Care, Seattle, WA
| | - Frederick D'Aragon
- Department of Anesthesia, University de Sherbrooke, Sherbrooke, QC, Canada
| | - Joshua Lee Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - John W Drover
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Gregg Eschun
- Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada
| | - Anna Geagea
- Division of Critical Care, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia. Vancouver, BC, Canada
| | - Rachel Hadler
- Department of Anesthesia, University of Iowa Hospital and Clinics, Iowa City, IA
| | | | - Jovan Hasmatali
- Department of Critical Care, Health Sciences Centre, Winnipeg, MB, Canada
| | - Bhavika Kaul
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Meeta Prasad Kerlin
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Rachel Kohn
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D James Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scott M Matson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Bojan Paunovic
- Department of Internal Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ithan D Peltan
- Division of Pulmonary/Critical Care Medicine, Department of Medicine, Intermountain Healthcare, Salt Lake City, UT
| | - Dominique Piquette
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mina Pirzadeh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Krishna Pulchan
- Division of Critical Care Medicine, Horizon Health Network, Fredericton, NB, Canada
| | - Lynn M Schnapp
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Curtis N Sessler
- Department of Medicine, Section of Critical Care, Virginia Commonwealth University Health System, Richmond, VA
| | | | - Eric Sy
- Regina General Hospital, Regina, SK, Canada
| | | | | | - Katie A McPherson
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Monica Kraft
- University of Arizona College of Medicine, Tucson, AZ
| | - Michelle Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC
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9
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Kim E, Mathai SK, Stancil IT, Ma X, Hernandez-Gutierrez A, Becerra JN, Marrero-Torres E, Hennessy CE, Hatakka K, Wartchow EP, Estrella A, Huber JP, Cardwell JH, Burnham EL, Zhang Y, Evans CM, Vladar EK, Schwartz DA, Dobrinskikh E, Yang IV. Aberrant Multiciliogenesis in Idiopathic Pulmonary Fibrosis. Am J Respir Cell Mol Biol 2022; 67:188-200. [PMID: 35608953 PMCID: PMC9348560 DOI: 10.1165/rcmb.2021-0554oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
We previously identified a novel molecular subtype of idiopathic pulmonary fibrosis (IPF) defined by increased expression of cilium-associated genes, airway mucin gene MUC5B, and KRT5 marker of basal cell airway progenitors. Here we show the association of MUC5B and cilia gene expression in human IPF airway epithelial cells, providing further rationale for examining the role of cilium genes in the pathogenesis of IPF. We demonstrate increased multiciliogenesis and changes in motile cilia structure of multiciliated cells both in IPF and bleomycin lung fibrosis models. Importantly, conditional deletion of a cilium gene, Ift88 (intraflagellar transport 88), in Krt5 basal cells reduces Krt5 pod formation and lung fibrosis, whereas no changes are observed in Ift88 conditional deletion in club cell progenitors. Our findings indicate that aberrant injury-activated primary ciliogenesis and Hedgehog signaling may play a causative role in Krt5 pod formation, which leads to aberrant multiciliogenesis and lung fibrosis. This implies that modulating cilium gene expression in Krt5 cell progenitors is a potential therapeutic target for IPF.
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Affiliation(s)
- Eunjoo Kim
- Department of Medicine, School of Medicine and
| | | | | | - Xiaoqian Ma
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Centre for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, China
| | | | | | - Emilette Marrero-Torres
- Department of Medicine-M.D. Program, San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | | | | | - Eric P. Wartchow
- Department of Pathology, Children's Hospital Colorado, Aurora, Colorado
| | | | | | | | | | - Yingze Zhang
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | | | | | | | - Evgenia Dobrinskikh
- Department of Medicine, School of Medicine and
- Department of Pediatrics, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Ivana V. Yang
- Department of Medicine, School of Medicine and
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
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10
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Aschner Y, Correll KA, Beke K, Foster DG, Roybal HM, Nelson MR, Meador CL, Strand M, Anderson KC, Moore CM, Reynolds PR, Kopf KW, Burnham EL, Downey GP. PTPα Promotes Fibroproliferative Responses After Acute Lung Injury. Am J Physiol Lung Cell Mol Physiol 2022; 323:L69-L83. [PMID: 35670474 DOI: 10.1152/ajplung.00436.2021] [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] [Indexed: 12/15/2022] Open
Abstract
The Acute Respiratory Distress Syndrome (ARDS) is a major healthcare problem, accounting for significant mortality and long-term disability. Approximately 25% of patients with ARDS will develop an over-exuberant fibrotic response, termed fibroproliferative ARDS (FP-ARDS) that portends a poor prognosis and increased mortality. The cellular pathologic processes that drive FP-ARDS remain incompletely understood. We have previously shown that the transmembrane receptor-type tyrosine phosphatase Protein Tyrosine Phosphatase-a (PTPa) promotes pulmonary fibrosis in preclinical murine models through regulation of TGF-b signaling. In this study, we examine the role of PTPa in the pathogenesis of FP-ARDS in a preclinical murine model of acid (HCl)-induced acute lung injury. We demonstrate that while mice genetically deficient in PTPa (Ptpra-/-) are susceptible to early HCl-induced lung injury, they exhibit markedly attenuated fibroproliferative responses. Additionally, early pro-fibrotic gene expression is reduced in lung tissue after acute lung injury in Ptpra-/- mice, and stimulation of naïve lung fibroblasts with the BAL fluid from these mice results in attenuated fibrotic outcomes compared to wild type littermate controls. Transcriptomic analyses demonstrates reduced Extracellular Matrix (ECM) deposition and remodeling in mice genetically deficient in PTPa. Importantly, human lung fibroblasts modified with a CRISPR-targeted deletion of PTPRA exhibit reduced expression of profibrotic genes in response to TGF-β stimulation, demonstrating the importance of PTPa in human lung fibroblasts. Together, these findings demonstrate that PTPa is a key regulator of fibroproliferative processes following acute lung injury and could serve as a therapeutic target for patients at risk for poor long-term outcomes in ARDS.
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Affiliation(s)
- Yael Aschner
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, CO, United States.,Department of Medicine, National Jewish Health, Denver, CO, United States
| | - Kelly A Correll
- Department of Medicine, National Jewish Health, Denver, CO, United States
| | - Keriann Beke
- Department of Medicine, National Jewish Health, Denver, CO, United States
| | - Daniel G Foster
- Department of Medicine, National Jewish Health, Denver, CO, United States.,Department of Pediatrics, National Jewish Health, Denver, CO, United States
| | - Helen M Roybal
- Department of Medicine, National Jewish Health, Denver, CO, United States
| | - Meghan R Nelson
- Department of Medicine, National Jewish Health, Denver, CO, United States
| | - Carly L Meador
- Department of Medicine, National Jewish Health, Denver, CO, United States
| | - Matthew Strand
- Division of Biostatistics, National Jewish Health, Denver, CO, United States
| | - Kelsey C Anderson
- Center for Genes, Environment and Health, National Jewish Health, Denver, CO, United States
| | - Camille M Moore
- Center for Genes, Environment and Health, National Jewish Health, Denver, CO, United States.,Department of Immunology and Genomic Medicine, National Jewish Health, Denver, CO, United States
| | - Paul R Reynolds
- Department of Medicine, National Jewish Health, Denver, CO, United States.,Department of Pediatrics, National Jewish Health, Denver, CO, United States
| | - Katrina W Kopf
- Office of Academic Affairs, National Jewish Health, Denver, CO, United States
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, CO, United States
| | - Gregory P Downey
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, CO, United States.,Department of Medicine, National Jewish Health, Denver, CO, United States.,Department of Immunology and Genomic Medicine, National Jewish Health, Denver, CO, United States.,Department of Pediatrics, National Jewish Health, Denver, CO, United States.,Office of Academic Affairs, National Jewish Health, Denver, CO, United States.,Department of Immunology and Microbiology, University of Colorado, Aurora, CO, United States
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11
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Files DC, Matthay MA, Calfee CS, Aggarwal NR, Asare AL, Beitler JR, Berger PA, Burnham EL, Cimino G, Coleman MH, Crippa A, Discacciati A, Gandotra S, Gibbs KW, Henderson PT, Ittner CAG, Jauregui A, Khan KT, Koff JL, Lang J, LaRose M, Levitt J, Lu R, McKeehan JD, Meyer NJ, Russell DW, Thomas KW, Eklund M, Esserman LJ, Liu KD. I-SPY COVID adaptive platform trial for COVID-19 acute respiratory failure: rationale, design and operations. BMJ Open 2022; 12:e060664. [PMID: 35667714 PMCID: PMC9170797 DOI: 10.1136/bmjopen-2021-060664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/16/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic brought an urgent need to discover novel effective therapeutics for patients hospitalised with severe COVID-19. The Investigation of Serial studies to Predict Your Therapeutic Response with Imaging And moLecular Analysis (ISPY COVID-19 trial) was designed and implemented in early 2020 to evaluate investigational agents rapidly and simultaneously on a phase 2 adaptive platform. This manuscript outlines the design, rationale, implementation and challenges of the ISPY COVID-19 trial during the first phase of trial activity from April 2020 until December 2021. METHODS AND ANALYSIS The ISPY COVID-19 Trial is a multicentre open-label phase 2 platform trial in the USA designed to evaluate therapeutics that may have a large effect on improving outcomes from severe COVID-19. The ISPY COVID-19 Trial network includes academic and community hospitals with significant geographical diversity across the country. Enrolled patients are randomised to receive one of up to four investigational agents or a control and are evaluated for a family of two primary outcomes-time to recovery and mortality. The statistical design uses a Bayesian model with 'stopping' and 'graduation' criteria designed to efficiently discard ineffective therapies and graduate promising agents for definitive efficacy trials. Each investigational agent arm enrols to a maximum of 125 patients per arm and is compared with concurrent controls. As of December 2021, 11 investigational agent arms had been activated, and 8 arms were complete. Enrolment and adaptation of the trial design are ongoing. ETHICS AND DISSEMINATION ISPY COVID-19 operates under a central institutional review board via Wake Forest School of Medicine IRB00066805. Data generated from this trial will be reported in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT04488081.
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Affiliation(s)
- Daniel Clark Files
- Pulmonary, Critical Care, Allergy and Immunology Division, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael A Matthay
- University of California San Francisco, San Francisco, California, USA
| | - Carolyn S Calfee
- University of California San Francisco, San Francisco, California, USA
| | - Neil R Aggarwal
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Adam L Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California, USA
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York City, New York, USA
| | - Paul A Berger
- Sanford USD Medical Center - Sioux Falls, Sioux Falls, South Dakota, USA
| | - Ellen L Burnham
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - George Cimino
- Quantum Leap Healthcare Collaborative, Fremont, California, USA
| | - Melissa H Coleman
- University of California San Francisco, San Francisco, California, USA
| | - Alessio Crippa
- Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Stockholm, Sweden
| | | | - Sheetal Gandotra
- Pulmonary, Allergy, Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kevin W Gibbs
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Paul T Henderson
- Quantum Leap Healthcare Collaborative, San Francisco, California, USA
| | - Caroline A G Ittner
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Kashif T Khan
- University of Southern California, Los Angeles, California, USA
| | | | - Julie Lang
- University of Southern California, Los Angeles, California, USA
| | - Mary LaRose
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Joe Levitt
- Stanford University, Stanford, California, USA
| | - Ruixiao Lu
- Quantum Leap Healthcare Collaborative, Fremont, California, USA
| | | | - Nuala J Meyer
- Medicine, Division of Pulmonary, Allergy, & Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek W Russell
- Division of Pulmonary, Allergy, & Critical Care Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Karl W Thomas
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Laura J Esserman
- University of California San Francisco, San Francisco, California, USA
| | - Kathleen D Liu
- Nephrology, University of California San Francisco, San Francisco, California, USA
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12
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Bailey KL, Sayles H, Campbell J, Khalid N, Anglim M, Ponce J, Wyatt TA, McClay JC, Burnham EL, Anzalone A, Hanson C. COVID-19 patients with documented alcohol use disorder or alcohol-related complications are more likely to be hospitalized and have higher all-cause mortality. Alcohol Clin Exp Res 2022; 46:1023-1035. [PMID: 35429004 PMCID: PMC9111368 DOI: 10.1111/acer.14838] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/25/2022] [Accepted: 04/07/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Coronavirus Disease 2019 (COVID-19) has affected every country globally, with hundreds of millions of people infected with the SARS-CoV-2 virus and over 6 million deaths to date. It is unknown how alcohol use disorder (AUD) affects the severity and mortality of COVID-19. AUD is known to increase the severity and mortality of bacterial pneumonia and the risk of developing acute respiratory distress syndrome. Our objective is to determine whether individuals with AUD have increased severity and mortality from COVID-19. METHODS We utilized a retrospective cohort study of inpatients and outpatients from 44 centers participating in the National COVID Cohort Collaborative. All were adult COVID-19 patients with and without documented AUDs. RESULTS We identified 25,583 COVID-19 patients with an AUD and 1,309,445 without. In unadjusted comparisons, those with AUD had higher odds of hospitalization (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.94 to 2.06, p < 0.001). After adjustment for age, sex, race/ethnicity, smoking, body mass index, and comorbidities, individuals with an AUD still had higher odds of requiring hospitalization (adjusted OR [aOR] 1.51, CI 1.46 to 1.56, p < 0.001). In unadjusted comparisons, individuals with AUD had higher odds of all-cause mortality (OR 2.18, CI 2.05 to 2.31, p < 0.001). After adjustment as above, individuals with an AUD still had higher odds of all-cause mortality (aOR 1.55, CI 1.46 to 1.65, p < 0.001). CONCLUSION This work suggests that AUD can increase the severity and mortality of COVID-19 infection. This reinforces the need for clinicians to obtain an accurate alcohol history from patients hospitalized with COVID-19. For this study, our results are limited by an inability to quantify the daily drinking habits of the participants. Studies are needed to determine the mechanisms by which AUD increases the severity and mortality of COVID-19.
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Affiliation(s)
- Kristina L. Bailey
- Division of PulmonaryCritical Care, and Sleep MedicineDepartment of Internal MedicineUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
- VA Nebraska‐Western Iowa Health SystemsOmahaNebraskaUSA
| | - Harlan Sayles
- Department of BiostatisticsUniversity of Nebraska Medical Center, College of Public HealthOmahaNebraskaUSA
| | - James Campbell
- Division of PulmonaryCritical Care, and Sleep MedicineDepartment of Internal MedicineUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
| | - Neha Khalid
- Division of PulmonaryCritical Care, and Sleep MedicineDepartment of Internal MedicineUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
| | - Madyson Anglim
- Division of PulmonaryCritical Care, and Sleep MedicineDepartment of Internal MedicineUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
| | - Jana Ponce
- University of Nebraska Medical Center, College of Allied HealthOmahaNebraskaUSA
| | - Todd A. Wyatt
- Division of PulmonaryCritical Care, and Sleep MedicineDepartment of Internal MedicineUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
- VA Nebraska‐Western Iowa Health SystemsOmahaNebraskaUSA
- Department of Environmental, Agricultural and Occupational HealthUniversity of Nebraska Medical Center, College of Public HealthOmahaNebraskaUSA
| | - James C. McClay
- Department of Emergency MedicineUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
| | - Ellen L. Burnham
- Division of Pulmonary Sciences and Critical Care MedicineDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Alfred Anzalone
- Department of Neurological SciencesUniversity of Nebraska Medical Center, College of MedicineOmahaNebraskaUSA
- Great Plains IDeA‐CTROmahaNebraskaUSA
| | - Corrine Hanson
- University of Nebraska Medical Center, College of Allied HealthOmahaNebraskaUSA
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13
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Chockalingam L, Burnham EL, Jolley SE. Medication prescribing for alcohol use disorders during alcohol-related encounters in a Colorado regional healthcare system. Alcohol Clin Exp Res 2022; 46:1094-1102. [PMID: 35723682 DOI: 10.1111/acer.14837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE Investigations show that medications for alcohol use disorders (MAUD) reduce heavy drinking and relapses. However, only 1.6% of individuals with alcohol use disorders (AUD) receive MAUD across care settings. The epidemiology of MAUD prescribing in the acute care setting is incompletely described. We hypothesized that MAUD would be under prescribed in inpatient acute care hospital settings compared to the outpatient, emergency department (ED), and inpatient substance use treatment settings. METHODS We evaluated electronic health record (EHR) data from adult patients with an International Classification of Diseases, 10th revision (ICD-10) alcohol-related diagnosis in the University of Colorado Health (UCHealth) system between January 1, 2016 and 31 December, 2019. Data from patients with an ICD-10 diagnosis code for opioid use disorder and those receiving MAUD prior to their first alcohol-related episode were excluded. The primary outcome was prescribing of MAUD, defined by prescription of naltrexone, acamprosate, and/or disulfiram. We performed bivariate and multivariate analyses to identify independent predictors of MAUD prescribing at UCHealth. RESULTS We identified 48,421 unique patients with 136,205 alcohol-related encounters at UCHealth. Encounters occurred in the ED (42%), inpatient acute care (17%), inpatient substance use treatment (18%), or outpatient primary care (12%) settings. Only 2270 (5%) patients received MAUD across all settings. Female sex and addiction medicine consults positively predicted MAUD prescribing. In contrast, encounters outside inpatient substance use treatment, Hispanic ethnicity, and black or non-white race were negative predictors of MAUD prescribing. Compared to inpatient substance use treatment, inpatient acute care hospitalizations for AUD was associated with a 93% reduced odds of receiving MAUD. CONCLUSIONS AUD-related ED and inpatient acute care hospital encounters in our healthcare system were common. Nevertheless, prescriptions for MAUD were infrequent in this population, particularly in inpatient settings. Our findings suggest that the initiation of MAUD for patients with alcohol-related diagnoses in acute care settings deserves additional evaluation.
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Affiliation(s)
| | - Ellen L Burnham
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
| | - Sarah E Jolley
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
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14
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Sacha GL, Kiser TH, Wright GC, Vandivier RW, Moss M, Burnham EL, Ho PM, Reynolds PM, Bauer SR. Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock. Crit Care Med 2022; 50:644-654. [PMID: 34605778 DOI: 10.1097/ccm.0000000000005305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Vasopressin is suggested as an adjunct to norepinephrine in patients with septic shock. However, after vasopressin was rebranded in November 2014, its cost exponentially increased. Utilization patterns of vasopressin after its rebranding are unclear. The objective of this study was to determine if there is an association between the rebranding of vasopressin in November 2014 and its utilization in vasopressor-dependent patients with severe sepsis or septic shock. DESIGN Retrospective, multicenter, database study between January 2010 and March 2017. SETTING Premier Healthcare Database hospitals. PATIENTS Adult patients admitted to an ICU with severe sepsis or septic shock, who received at least one vasoactive agent for two or more calendar days were included. INTERVENTIONS The proportion of patients who received vasopressin and vasopressin cost was assessed before and after rebranding, and evaluated with segmented regression. MEASUREMENTS AND MAIN RESULTS Among 294,733 patients (mean age, 66 ± 15 yr), 27.8% received vasopressin, and ICU mortality was 26.5%. The proportion of patients receiving vasopressin was higher after rebranding (31.2% postrebranding vs 25.8% prerebranding). Before vasopressin rebranding, the quarterly proportion of patients who received vasopressin had an increasing slope (prerebranding slope 0.41% [95% CI, 0.35-0.46%]), with no difference in slope detected after vasopressin rebranding (postrebranding slope, 0.47% [95% CI, 0.29-0.64%]). After vasopressin rebranding, mean vasopressin cost per patient was higher ($527 ± 1,130 vs $77 ± 160), and the quarterly slope of vasopressin cost was higher (change in slope $77.18 [95% CI, $75.73-78.61]). Total vasopressin billed cost postrebranding continually increased by ~$294,276 per quarter from less than $500,000 in Q4 2014 to over $3,000,000 in Q1 2017. CONCLUSIONS After vasopressin rebranding, utilization continued to increase quarterly despite a significant increase in vasopressin cost. Vasopressin appeared to have price inelastic demand in septic shock.
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Affiliation(s)
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Garth C Wright
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
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15
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Liu C, Gaydos J, Johnson-Paben R, Kechris K, Burnham EL, Sharma S. Chronic Marijuana Use Is Associated with Gene Expression Changes in BAL. Am J Respir Cell Mol Biol 2022; 66:238-239. [PMID: 35103554 PMCID: PMC8845134 DOI: 10.1165/rcmb.2021-0285le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Cuining Liu
- Colorado School of Public Health Aurora, Colorado.,University of Colorado School of Medicine Aurora, Colorado
| | | | | | | | | | - Sunita Sharma
- University of Colorado School of Medicine Aurora, Colorado
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16
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Dyamenahalli K, Choy K, Frank DN, Najarro K, Boe D, Colborn KL, Idrovo JP, Wagner AL, Wiktor AJ, Afshar M, Burnham EL, McMahan RH, Kovacs EJ. Age and Injury Size Influence the Magnitude of Fecal Dysbiosis in Adult Burn Patients. J Burn Care Res 2022; 43:1145-1153. [PMID: 35020913 PMCID: PMC9435505 DOI: 10.1093/jbcr/irac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Clinical studies have demonstrated that age 50 years or older is an independent risk factor associated with poor prognosis after burn injury, the second leading cause of traumatic injuries in the aged population. While mechanisms driving age-dependent postburn mortality are perplexing, changes in the intestinal microbiome, may contribute to the heightened, dysregulated systemic response seen in aging burn patients. The fecal microbiome from 22 patients admitted to a verified burn center from July 2018 to February 2019 was stratified based on the age of 50 years and total burn surface area (TBSA) size of ≥10%. Significant differences (P = .014) in overall microbiota community composition (ie, beta diversity) were measured across the four patient groups: young <10% TBSA, young ≥10% TBSA, older <10% TBSA, and older ≥10% TBSA. Differences in beta diversity were driven by %TBSA (P = .013) and trended with age (P = .087). Alpha diversity components, richness, evenness, and Shannon diversity were measured. We observed significant differences in bacterial species evenness (P = .0023) and Shannon diversity (P = .0033) between the groups. There were significant correlations between individual bacterial species and levels of short-chain fatty acids. Specifically, levels of fecal butyrate correlated with the presence of Enterobacteriaceae, an opportunistic gut pathogen, when elevated in burn patients lead to worsen outcomes. Overall, our findings reveal that age-specific changes in the fecal microbiome following burn injuries may contribute to immune system dysregulation in patients with varying TBSA burns and potentially lead to worsened clinical outcomes with heightened morbidity and mortality.
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Affiliation(s)
| | | | - Daniel N Frank
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, USA,Gastrointestinal and Liver and Innate Immunity Program, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kevin Najarro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA,Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Devin Boe
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Juan-Pablo Idrovo
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Anne L Wagner
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Arek J Wiktor
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Majid Afshar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Ellen L Burnham
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Rachel H McMahan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA,Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Elizabeth J Kovacs
- Address correspondence to Elizabeth J. Kovacs, PhD, Department of Surgery, GITES, University of Colorado Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, Aurora, CO 80045, USA.
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17
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Wyatt TA, Warren KJ, Wetzel TJ, Suwondo T, Rensch GP, DeVasure JM, Mosley DD, Kharbanda KK, Thiele GM, Burnham EL, Bailey KL, Yeligar SM. Malondialdehyde-Acetaldehyde Adduct Formation Decreases Immunoglobulin A Transport across Airway Epithelium in Smokers Who Abuse Alcohol. Am J Pathol 2021; 191:1732-1742. [PMID: 34186073 PMCID: PMC8485061 DOI: 10.1016/j.ajpath.2021.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 12/16/2022]
Abstract
Alcohol misuse and smoking are risk factors for pneumonia, yet the impact of combined cigarette smoke and alcohol on pneumonia remains understudied. Smokers who misuse alcohol form lung malondialdehyde-acetaldehyde (MAA) protein adducts and have decreased levels of anti-MAA secretory IgA (sIgA). Transforming growth factor-β (TGF-β) down-regulates polymeric Ig receptor (pIgR) on mucosal epithelium, resulting in decreased sIgA transcytosis to the mucosa. It is hypothesized that MAA-adducted lung protein increases TGF-β, preventing expression of epithelial cell pIgR and decreasing sIgA. Cigarette smoke and alcohol co-exposure on sIgA and TGF-β in human bronchoalveolar lavage fluid and in mice instilled with MAA-adducted surfactant protein D (SPD-MAA) were studied herein. Human bronchial epithelial cells (HBECs) and mouse tracheal epithelial cells were treated with SPD-MAA and sIgA and TGF-β was measured. Decreased sIgA and increased TGF-β were observed in bronchoalveolar lavage from combined alcohol and smoking groups in humans and mice. CD204 (MAA receptor) knockout mice showed no changes in sIgA. SPD-MAA decreased pIgR in HBECs. Conversely, SPD-MAA stimulated TGF-β release in both HBECs and mouse tracheal epithelial cells, but not in CD204 knockout mice. SPD-MAA stimulated TGF-β in alveolar macrophage cells. These data show that MAA-adducted surfactant protein stimulates lung epithelial cell TGF-β, down-regulates pIgR, and decreases sIgA transcytosis. These data provide a mechanism for the decreased levels of sIgA observed in smokers who misuse alcohol.
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Affiliation(s)
- Todd A Wyatt
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Environmental, Agricultural and Occupational Health, University of Nebraska Medical Center, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Kristi J Warren
- Department of Medicine-Pulmonary Division, University of Utah/VA Salt Lake Health Care System, Salt Lake City, Utah
| | - Tanner J Wetzel
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Troy Suwondo
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Gage P Rensch
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jane M DeVasure
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Deanna D Mosley
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kusum K Kharbanda
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Geoffrey M Thiele
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Kristina L Bailey
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Samantha M Yeligar
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, Georgia; Research Service, Atlanta VA Health Care System, Decatur, Georgia
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18
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Steel TL, Afshar M, Edwards S, Jolley SE, Timko C, Clark BJ, Douglas IS, Dzierba AL, Gershengorn HB, Gilpin NW, Godwin DW, Hough CL, Maldonado JR, Mehta AB, Nelson LS, Patel MB, Rastegar DA, Stollings JL, Tabakoff B, Tate JA, Wong A, Burnham EL. Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e61-e87. [PMID: 34609257 PMCID: PMC8528516 DOI: 10.1164/rccm.202108-1845st] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.
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19
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Tanabe J, Neff S, Sutton B, Ellis S, Patten L, Brown MS, Hoffman PL, Tabakoff B, Burnham EL. Effects of acetate on cerebral blood flow, systemic inflammation, and behavior in alcohol use disorder. Alcohol Clin Exp Res 2021; 45:922-933. [PMID: 33682145 PMCID: PMC8496991 DOI: 10.1111/acer.14588] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Alcohol use disorders (AUDs) are associated with altered regulation of physiological processes in the brain. Acetate, a metabolite of ethanol, has been implicated in several processes that are disrupted in AUDs including transcriptional regulation, metabolism, inflammation, and neurotransmission. To further understand the effects of acetate on brain function in AUDs, we investigated the effects of acetate on cerebral blood flow (CBF), systemic inflammatory cytokines, and behavior in AUD. METHODS Sixteen participants with AUD were recruited from a nonmedical, clinically managed detoxification center. Each participant received acetate and placebo in a randomly assigned order of infusion and underwent 3T MR scanning using quantitative pseudo-continuous arterial spin labeling. Participants and the study team were blinded to the infusion. CBF values (ml/100 g/min) extracted from thalamus were compared between placebo and acetate using a mixed effect linear regression model accounting for infusion order. Voxel-wise CBF comparisons were set at threshold of p < 0.05 cluster-corrected for multiple comparisons, voxel-level p < 0.0001. Plasma cytokine levels and behavior were also assessed between infusions. RESULTS Fifteen men and 1 woman were enrolled with Alcohol Use Disorders Identification Test (AUDIT) scores between 13 and 38 with a mean of 28.3 ± 9.1. Compared to placebo, acetate administration increased CBF in the thalamus bilaterally (Left: 51.2 vs. 68.8, p < 0.001; Right: 53.7 vs. 69.6, p = 0.001), as well as the cerebellum, brainstem, and cortex. Older age and higher AUDIT scores were associated with increases in acetate-induced thalamic blood flow. Cytokine levels and behavioral measures did not differ between placebo and acetate infusions. CONCLUSIONS This pilot study in AUD suggests that during the first week of abstinence from alcohol, the brain's response to acetate differs by brain region and this response may be associated with the severity of alcohol dependence.
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Affiliation(s)
- Jody Tanabe
- Department of Radiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
- Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Sarah Neff
- Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Brianne Sutton
- Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Sam Ellis
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Luke Patten
- Department of Biostatistics and Informatics, School of Public Health; University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Mark S. Brown
- Department of Radiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Paula L. Hoffman
- Department of Pharmacology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Boris Tabakoff
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
| | - Ellen L. Burnham
- Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045
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20
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Carmichael H, Wright FL, McIntyre RC, Vogler T, Urban S, Jolley SE, Burnham EL, Firth W, Velopulos CG, Idrovo JP. Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection. Trauma Surg Acute Care Open 2021; 6:e000591. [PMID: 34192162 PMCID: PMC7817387 DOI: 10.1136/tsaco-2020-000591] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/17/2020] [Accepted: 12/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background Since the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns about transmission of the infection to providers. It is unclear whether tracheostomy in patients with COVID-19 infection facilitates ventilator weaning, and long-term outcomes are not yet reported in the literature. Methods This is a retrospective study of tracheostomy outcomes in patients with COVID-19 infection at a single-center academic tertiary referral intensive care unit. Patients underwent percutaneous tracheostomy at the bedside; the procedure was performed with limited staffing to reduce risk of disease transmission. Results Between March 1 and June 30, 2020, a total of 206 patients with COVID-19 infection required mechanical ventilation and 26 underwent tracheostomy at a mean of 25±5 days after initial intubation. Overall, 81% of tracheostomy patients were liberated from the ventilator at a mean of 9±6 days postprocedure, and 54% were decannulated prior to hospital discharge at a mean of 21±10 days postprocedure. Sedation and pain medication requirements decreased significantly in the week after the procedure. In-hospital mortality was 15%. Among tracheostomy survivors, 68% were discharged to a facility. Discussion The management of patients with COVID-19 related respiratory failure can be challenging due to prolonged ventilator dependency. In our initial experience, outcomes post-tracheostomy in this population are encouraging, with short time to liberation from the ventilator, a high rate of decannulation prior to hospital discharge, and similar mortality to tracheostomy performed for other indications. Barriers to weaning ventilation in this cohort may be high sedation needs and ventilator dyssynchrony. Level of evidence Level V-Therapeutic/care management.
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Affiliation(s)
| | - Franklin L Wright
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
| | - Robert C McIntyre
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
| | - Thomas Vogler
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Shane Urban
- Trauma Program, University of Colorado Health, Aurora, Colorado, USA
| | - Sarah E Jolley
- Division of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
| | - Ellen L Burnham
- Division of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
| | - Whitney Firth
- Surgical/Trauma ICU, University of Colorado Health, Aurora, Colorado, USA
| | - Catherine G Velopulos
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
| | - Juan Pablo Idrovo
- Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
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21
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Althoff MD, Holguin F, Yang F, Grunwald GK, Moss M, Vandivier RW, Ho PM, Kiser TH, Burnham EL. Noninvasive Ventilation Use in Critically Ill Patients with Acute Asthma Exacerbations. Am J Respir Crit Care Med 2020; 202:1520-1530. [PMID: 32663410 PMCID: PMC7706169 DOI: 10.1164/rccm.201910-2021oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Rationale: Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been well studied in asthma.Objectives: To assess the association between noninvasive ventilation and subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted with asthma exacerbation to the ICU.Methods: We performed a retrospective cohort study using administrative data collected during 2010-2017 from 682 hospitals in the United States. Outcomes included receipt of invasive mechanical ventilation and in-hospital mortality. Generalized estimating equations, propensity-matched models, and marginal structural models were used to assess the association between noninvasive ventilation and outcomes.Measurements and Main Results: The study population included 53,654 participants with asthma exacerbation. During the study period, 13,540 patients received noninvasive ventilation (25.2%; 95% confidence interval [CI], 24.9-25.6%), 14,498 underwent invasive mechanical ventilation (27.0%; 95% CI, 26.7-27.4%), and 1,291 died (2.4%; 95% CI, 2.3-2.5%). Among those receiving noninvasive ventilation, 3,013 patients (22.3%; 95% CI, 21.6-23.0%) required invasive mechanical ventilation after first receiving noninvasive ventilation, 136 of whom died (4.5%; 95% CI, 3.8-5.3%). Across all models, the use of noninvasive ventilation was associated with a lower odds of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58). Those who received noninvasive ventilation before invasive mechanical ventilation were more likely to have comorbid pneumonia and severe sepsis.Conclusions: Noninvasive ventilation use during asthma exacerbation was associated with improved outcomes but should be used cautiously with acute comorbid conditions.
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Affiliation(s)
- Meghan D. Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - Fan Yang
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Gary K. Grunwald
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - R. William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
| | - P. Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
- Division of Cardiology, VA Eastern Colorado Health Care System, Aurora, Colorado; and
| | - Tyree H. Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Ellen L. Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado
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22
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Bowden K, Burnham EL, Keniston A, Levin D, Limes J, Persoff J, Thurman L, Burden M. Harnessing the Power of Hospitalists in Operational Disaster Planning: COVID-19. J Gen Intern Med 2020; 35:2732-2737. [PMID: 32661930 PMCID: PMC7358298 DOI: 10.1007/s11606-020-05952-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/29/2020] [Indexed: 12/02/2022]
Abstract
Hospitalists are well poised to serve in key leadership roles and in frontline care in particular when facing a pandemic such as the SARS-CoV-2 (COVID-19) infection. Much of the disaster planning in hospitals around the country addresses overcrowded emergency departments and decompressing these locations; however, in the case of COVID-19, intensive care units, emergency departments, and medical wards ran the risk of being overwhelmed by a large influx of patients needing high-level medical care. In a matter of days, our Division of Hospital Medicine, in partnership with our hospital, health system, and academic institution, was able to modify and deploy existing disaster plans to quickly care for an influx of medically complex patients. We describe a scaled approach to managing hospitalist clinical operations during the COVID-19 pandemic.
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Affiliation(s)
- Kasey Bowden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Ellen L Burnham
- University of Colorado School of Medicine, Aurora, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Aurora, CO, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Dimitriy Levin
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Julia Limes
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason Persoff
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Lindsay Thurman
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
- University of Colorado School of Medicine, Aurora, CO, USA.
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Bailey KL, Smith H, Mathai SK, Huber J, Yacoub M, Yang IV, Wyatt TA, Kechris K, Burnham EL. Alcohol Use Disorders Are Associated With a Unique Impact on Airway Epithelial Cell Gene Expression. Alcohol Clin Exp Res 2020; 44:1571-1584. [PMID: 32524622 PMCID: PMC7484391 DOI: 10.1111/acer.14395] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alcohol use disorders (AUDs) and cigarette smoking both increase risk for the development of community-acquired pneumonia (CAP), likely through adverse effects on proximal airway mucociliary clearance and pathogen recognition. Smoking-related alterations on airway gene expression are well described, but little is known about the impact of AUDs. We measured gene expression in human airway epithelial cells (AECs), hypothesizing that AUDs would be associated with novel differences in gene expression that could alter risk for CAP. METHODS Bronchoscopy with airway brushings was performed in participants with AUDs and controls to obtain AECs. An AUD Identification Test was used to define AUD. RNA was extracted from AECs, and mRNA expression data were collected on an Agilent micro-array. Differential expression analyses were performed on the filtered and normalized data with correction for multiple testing. Enrichment analyses were performed using clusterProfiler. RESULTS Expression data from 19 control and 18 AUD participants were evaluated. After adjustment for smoking, AUDs were associated with significant differential expression of 520 AEC genes, including genes for ribosomal proteins and genes involved in protein folding. Enrichment analyses indicated significant differential expression of 24 pathways in AUDs, including those implicated in protein targeting to membrane and viral gene expression. Smoking-associated AEC gene expression differences mirrored previous reports, but differed from those associated with AUDs. CONCLUSIONS AUDs have a distinct impact on AEC gene expression that may influence proximal airway function independent of smoking. Alcohol-associated alterations may influence risk for CAP through modifying key mechanisms important in protecting proximal airway integrity.
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Affiliation(s)
- Kristina L. Bailey
- University of Nebraska Medical Center, Department of Internal Medicine. Division of Pulmonary, Critical Care, Sleep and Allergy
- VA Nebraska-Western Iowa Health Care System
| | - Harry Smith
- University of Colorado Anschutz Medical Campus, Department of Biostatistics and Informatics, Colorado School of Public Health
| | - Susan K. Mathai
- Baylor University Medical Center, Center for Advanced Heart & Lung Disease
| | - Jonathan Huber
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Allergy & Clinical Immunology
| | - Mark Yacoub
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine
| | - Ivana V. Yang
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Biomedical Informatics and Personalized Medicine
| | - Todd A. Wyatt
- VA Nebraska-Western Iowa Health Care System
- University of Nebraska Medical Center, Department of Environmental, Agricultural, & Occupational Health
| | - Katerina Kechris
- University of Colorado Anschutz Medical Campus, Department of Biostatistics and Informatics, Colorado School of Public Health
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Biomedical Informatics and Personalized Medicine
| | - Ellen L. Burnham
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine
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24
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Hippensteel JA, Burnham EL, Jolley SE. Prevalence of venous thromboembolism in critically ill patients with COVID-19. Br J Haematol 2020; 190:e134-e137. [PMID: 32484907 PMCID: PMC7300700 DOI: 10.1111/bjh.16908] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Joseph A Hippensteel
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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25
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Hua JT, Afshar M, Clark BJ, Kovacs EJ, Burnham EL. The relationship of cannabis decriminalization in Colorado and cannabis use in individuals with alcohol use disorders. J Cannabis Res 2020; 2:13. [PMID: 33526125 PMCID: PMC7819320 DOI: 10.1186/s42238-020-00018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/18/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Over the past decade, cannabis use has become increasingly popular in states that include Colorado. During this time, alcohol use disorders (AUDs) and alcohol-related medical conditions have also been consistently recognized as public health problems with increasing prevalence in the state. Despite the widespread use of cannabis in Colorado, the epidemiology of cannabis use among those with AUDs has been poorly described. Therefore, we sought to examine cannabis use among individuals with likely AUDs and individuals with low-risk alcohol use during a time of major Colorado legislative changes before and after legalization of recreational cannabis in 2012. METHODS This study was a secondary data analysis conducted with information from 303 participants (80% male) in the Denver, CO metropolitan enrolled between August 2007 and April 2016 for studies related to alcohol and lung health. Of these participants, 188 (62%) were completing inpatient alcohol detoxification with likely AUDs. All participants completed the Alcohol Use Disorder Identification Test (AUDIT) to establish their likelihood of an AUD, and all had information on current cannabis use assessed by questionnaire and urine toxicology testing. RESULTS Individuals with likely AUDs more commonly used cannabis compared to control participants (42% vs 27%, p = 0.007). In multiple logistic regression analyses, participant type (likely AUD versus control), tobacco smoking, and age were significantly associated with cannabis smoking; however, the year of participant enrollment was not. Adjusted odds for cannabis use among participants with likely AUDs were 2.97 (1.51-5.82), p = 0.002, while odds for cannabis use among tobacco smokers were 3.67 (1.94-6.93), p < 0.0001. Among control participants, tobacco smoking increased odds of cannabis use seven-fold. CONCLUSIONS Our findings highlight the exceptionally high odds of cannabis use among individuals with likely AUDs undergoing alcohol detoxification at a Colorado treatment facility before and after legalization of recreational cannabis. Targeted investigations into the medical and psychiatric consequences of combined alcohol and cannabis use are urgently needed to define its health impact in these vulnerable individuals.
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Affiliation(s)
- Jeremy T Hua
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Majid Afshar
- Department of Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago Health Sciences Campus, Chicago, IL, USA
| | - Brendan J Clark
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, 12700 E. 19th St. C272, Aurora, CO, 80045, USA
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ellen L Burnham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, 12700 E. 19th St. C272, Aurora, CO, 80045, USA.
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26
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Gaydos J, McNally A, Burnham EL. The impact of alcohol use disorders on pulmonary immune cell inflammatory responses to Streptococcus pneumoniae. Alcohol 2019; 80:119-130. [PMID: 30195043 DOI: 10.1016/j.alcohol.2018.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 12/11/2022]
Abstract
Community-acquired pneumonia due to Streptococcus pneumoniae occurs commonly in alcohol use disorders (AUDs). Pneumonia in the AUD patient is associated with poorer outcomes, and specific therapies to mitigate disease severity in these patients do not exist. Numerous investigations have attributed increased severity of pneumonia in AUDs to aberrant function of the alveolar macrophage (AM), a lung immune cell critical in host defense initiation. No studies have examined the response of human AMs to S. pneumoniae in AUDs. We hypothesized that the inflammatory mediators released by AMs after S. pneumoniae stimulation would differ quantitatively in individuals with AUDs compared to non-AUD participants. We further postulated that AM inflammatory mediators would be diminished after exposure to the antioxidant, N-acetylcysteine (NAC). For comparison, responses of peripheral blood mononuclear cells (PBMCs) to pneumococcal protein were also examined. Otherwise healthy participants with AUDs and smoking-matched controls underwent bronchoalveolar lavage and peripheral blood sampling to obtain AMs and PBMCs, respectively. Freshly collected cells were cultured with increasing doses of heat-killed S. pneumoniae protein, with and without exposure to N-acetylcysteine. Cell culture supernatants were collected, and inflammatory mediators were measured, including interferon (IFN)-γ, interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α. IFN-γ and IL-6 were significantly higher in unstimulated AM cell culture supernatants from subjects with AUDs. After stimulation with pneumococcal protein, a dose-response and time-dependent increase in pro-inflammatory cytokine production by both AMs and PBMCs was also observed; differences were not observed between AUD and non-AUD subjects. Addition of NAC to pneumococcal-stimulated AMs and PBMCs was generally associated with diminished cytokine production, with the exception of IL-1β that was elevated in AM culture supernatants from subjects with AUDs. Our observations suggest that AUDs contribute to basal alterations in AM pro-inflammatory cytokine elaboration, but did not support consistent differences in pneumococcal-stimulated AM or PBMC inflammatory mediator secretion that were referable to AUDs.
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27
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Bailey KL, Wyatt TA, Katafiasz DM, Taylor KW, Heires AJ, Sisson JH, Romberger DJ, Burnham EL. Alcohol and cannabis use alter pulmonary innate immunity. Alcohol 2019; 80:131-138. [PMID: 30419300 DOI: 10.1016/j.alcohol.2018.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/19/2018] [Accepted: 11/03/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Cannabis use is increasing due to recent legislative changes. In addition, cannabis is often used in conjunction with alcohol. The airway epithelium is the first line of defense against infectious microbes. Toll-like receptors (TLR) recognize airborne microbes and initiate the inflammatory cytokine response. The mechanism by which cannabis use in conjunction with alcohol affects pulmonary innate immunity mediated by TLRs is unknown. METHODS Samples and data from an existing cohort of individuals with alcohol use disorders (AUDs), along with samples from additional participants with cannabis use alone and with AUD were utilized. Subjects were categorized into the following groups: no alcohol use disorder (AUD) or cannabis use (control) (n = 46), AUD only (n = 29), cannabis use-only (n = 39), and AUD and cannabis use (n = 29). The participants underwent bronchoscopy with bronchoalveolar lavage (BAL) and airway epithelial brushings. We measured IL-6, IL-8, TNF⍺, and IL-10 levels in BAL fluid, and performed real-time PCR for TLR1-9 on the airway epithelial brushings. RESULTS We found significant increases in TLR2 with AUD alone, cannabis use alone, and cannabis use with AUD, compared to control. TLR5 was increased in cannabis users compared to control, TLR6 was increased in cannabis users and cannabis users with AUD compared to control, TLR7 was increased in cannabis users compared to control, and TLR9 was increased in cannabis users compared to control. In terms of cytokine production, IL-6 was increased in cannabis users compared to control. IL-8 and IL-10 were increased in AUD only. CONCLUSIONS AUD and cannabis use have complex effects on pulmonary innate immunity that promote airway inflammation.
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Affiliation(s)
- Kristina L Bailey
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States; Veterans Affairs, Nebraska Western-Iowa Healthcare System, Omaha, NE 68105, United States.
| | - Todd A Wyatt
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States; Veterans Affairs, Nebraska Western-Iowa Healthcare System, Omaha, NE 68105, United States; Department of Environmental, Agricultural and Occupational Health, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Dawn M Katafiasz
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States
| | - Keenan W Taylor
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States
| | - Art J Heires
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States
| | - Joseph H Sisson
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States
| | - Debra J Romberger
- University of Nebraska Medical Center, Internal Medicine/Pulmonary, Critical Care Sleep and Allergy, Omaha, NE 68198, United States; Veterans Affairs, Nebraska Western-Iowa Healthcare System, Omaha, NE 68105, United States
| | - Ellen L Burnham
- University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, United States
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28
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Tanabe J, Yamamoto DJ, Sutton B, Brown MS, Hoffman PL, Burnham EL, Glueck DH, Tabakoff B. Effects of Alcohol and Acetate on Cerebral Blood Flow: A Pilot Study. Alcohol Clin Exp Res 2019; 43:2070-2078. [PMID: 31386214 PMCID: PMC7066986 DOI: 10.1111/acer.14173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute alcohol produces effects on cerebral metabolism and blood flow. Alcohol is converted to acetate, which serves as a source of energy for the brain and is an agonist at G protein-coupled receptors distributed in different cell types in the body including neurons. Acetate has been hypothesized to play a role in the cerebral blood flow (CBF) response after alcohol ingestion. We tested whether administration of acetate would alter CBF in a pattern similar to or different from that of alcohol ingestion in healthy individuals. METHODS Twenty-four healthy participants were assigned by convenience to receive either 0.6 g/kg alcohol orally (n = 12) or acetate intravenously (n = 12). For each participant, CBF maps were acquired using an arterial spin labeling sequence on a 3T magnetic resonance scanner after placebo and after drug administration. Whole-brain CBF maps were compared between placebo and drug using a paired t-test, and set at a threshold of p < 0.05 corrected for multiple comparisons (k ≥ 142 voxels, ≥3.78 cm3 ), voxel-level p < 0.005. Intoxication was measured after placebo and drug administration with a Subjective High Assessment Scale (SHAS-7). RESULTS Compared to placebo, alcohol and acetate were associated with increased CBF in the medial thalamus. Alcohol, but not acetate, was associated with increased CBF in the right orbitofrontal, medial prefrontal and cingulate cortex, and hippocampus. Plasma acetate levels increased following administration of alcohol and acetate and did not differ between the 2 arms. Alcohol, but not acetate, was associated with an increase in SHAS-7 scores (p < 0.001). CONCLUSIONS Increased thalamic CBF associated with either alcohol or acetate administration suggests that the thalamic CBF response after alcohol could be mediated by acetate. Compared to other brain regions, thalamus may differ in its ability to metabolize acetate or expression of receptors responsive to acetate. Increased prefrontal and limbic CBF associated with alcohol may be linked to alcohol's behavioral effects.
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Affiliation(s)
- Jody Tanabe
- Department of Radiology, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
- Department of Psychiatry, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Dorothy J. Yamamoto
- Department of Radiology, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Brianne Sutton
- Department of Radiology, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
- Department of Psychiatry, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Mark S. Brown
- Department of Radiology, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Paula L. Hoffman
- Department of Pharmacology, School of Medicine, University
of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Ellen L. Burnham
- Department of Medicine, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Deborah H. Glueck
- Department of Pediatrics, School of Medicine, University of
Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Boris Tabakoff
- Department of Pharmaceutical Sciences, School of Pharmacy,
University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
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29
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Sottile PD, Kiser TH, Burnham EL, Ho PM, Allen RR, Vandivier RW, Moss M. An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 197:897-904. [PMID: 29241014 DOI: 10.1164/rccm.201706-1132oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular blocking agents, such as vecuronium, are commonly used and have different mechanisms of action, side effects, cost, and availability in the setting of drug shortages. OBJECTIVES To determine whether cisatracurium is associated with improved outcomes when compared with vecuronium in patients at risk for and with ARDS. METHODS Using a nationally representative database, patients who were admitted to the ICU with a diagnosis of ARDS or an ARDS risk factor, received mechanical ventilation, and were treated with a continuous infusion of neuromuscular blocking agent for at least 2 days within 2 days of hospital admission were included. Patients were stratified into two groups: those who received cisatracurium or vecuronium. Propensity matching was used to balance both patient- and hospital-specific factors. Outcomes included hospital mortality, duration of mechanical ventilation, ICU and hospital duration, and discharge location. MEASUREMENTS AND MAIN RESULTS Propensity matching successfully balanced all covariates for 3,802 patients (1,901 per group). There was no significant difference in mortality (odds ratio, 0.932; P = 0.40) or hospital days (-0.66 d; P = 0.411) between groups. However, patients treated with cisatracurium had fewer ventilator days (-1.01 d; P = 0.005) and ICU days (-0.98 d; P = 0.028) but were equally likely to be discharged home (odds ratio, 1.19; P = 0.056). CONCLUSIONS When compared with vecuronium, cisatracurium was not associated with a difference in mortality but was associated with improvements in other clinically important outcomes. These data suggest that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.
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Affiliation(s)
- Peter D Sottile
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
| | - Tyree H Kiser
- 2 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora, Colorado; and
| | - Ellen L Burnham
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
| | - P Michael Ho
- 3 Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Marc Moss
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
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Burns KEA, Burnham EL, Dodek PM, Moss M. Unconscious bias in the selection and interpretation of data on sex and burnout - Authors' reply. Lancet Respir Med 2019; 7:e24. [PMID: 31342898 DOI: 10.1016/s2213-2600(19)30223-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Karen E A Burns
- Critical Care Medicine and the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Ellen L Burnham
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Peter M Dodek
- Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Marc Moss
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
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31
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Prohaska CC, Sottile PD, Nordon-Craft A, Gallagher MD, Burnham EL, Clark BJ, Ho M, Kiser TH, Vandivier RW, Liu W, Schenkman M, Moss M. Patterns of utilization and effects of hospital-specific factors on physical, occupational, and speech therapy for critically ill patients with acute respiratory failure in the USA: results of a 5-year sample. Crit Care 2019; 23:175. [PMID: 31097017 PMCID: PMC6524324 DOI: 10.1186/s13054-019-2467-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/05/2019] [Indexed: 05/30/2023]
Abstract
Background Timely initiation of physical, occupational, and speech therapy in critically ill patients is crucial to reduce morbidity and improve outcomes. Over a 5-year time interval, we sought to determine the utilization of these rehabilitation therapies in the USA. Methods We performed a retrospective cohort study utilizing a large, national administrative database including ICU patients from 591 hospitals. Patients over 18 years of age with acute respiratory failure requiring invasive mechanical ventilation within the first 2 days of hospitalization and for a duration of at least 48 h were included. Results A total of 264,137 patients received invasive mechanical ventilation for a median of 4.0 [2.0–8.0] days. Overall, patients spent a median of 5.0 [3.0–10.0] days in the ICU and 10.0 [7.0–16.0] days in the hospital. During their hospitalization, 66.5%, 41.0%, and 33.2% (95% CI = 66.3–66.7%, 40.8–41.2%, 33.0–33.4%, respectively) received physical, occupational, and speech therapy. While on mechanical ventilation, 36.2%, 29.7%, and 29.9% (95% CI = 36.0–36.4%, 29.5–29.9%, 29.7–30.1%) received physical, occupational, and speech therapy. In patients receiving therapy, their first physical therapy session occurred on hospital day 5 [3.0–8.0] and hospital day 6 [4.0–10.0] for occupational and speech therapy. Of all patients, 28.6% (95% CI = 28.4–28.8%) did not receive physical, occupational, or speech therapy during their hospitalization. In a multivariate analysis, patients cared for in the Midwest and at teaching hospitals were more likely to receive physical, occupational, and speech therapy (all P < 0.05). Of patients with identical covariates receiving therapy, there was a median of 61%, 187%, and 70% greater odds of receiving physical, occupational, and speech therapy, respectively, at one randomly selected hospital compared with another (median odds ratio 1.61, 2.87, 1.70, respectively). Conclusions Physical, occupational, and speech therapy are not routinely delivered to critically ill patients, particularly while on mechanical ventilation in the USA. The utilization of these therapies varies according to insurance coverage, geography, and hospital teaching status, and at a hospital level. Electronic supplementary material The online version of this article (10.1186/s13054-019-2467-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clare C Prohaska
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA.
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Amy Nordon-Craft
- Department of Physical Therapy, University of Colorado Hospital, Aurora, CO, 80045, USA
| | | | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, 80045, USA
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Wenhui Liu
- VA Eastern Colorado Health Care System, Aurora, CO, 80045, USA
| | - Margaret Schenkman
- Department of Physical Therapy, University of Colorado Hospital, Aurora, CO, 80045, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
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Burnham EL, Burns KEA, Moss M, Dodek PM. Burnout in women intensivists: a hidden epidemic? Lancet Respir Med 2019; 7:292-294. [PMID: 30744938 DOI: 10.1016/s2213-2600(19)30029-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Ellen L Burnham
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045 USA.
| | - Karen E A Burns
- Critical Care Medicine and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Marc Moss
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045 USA
| | - Peter M Dodek
- Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
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Reynolds PM, Van Matre ET, Wright GC, McQueen RB, Burnham EL, Ho PJM, Moss M, Vandivier RW, Kiser TH. Evaluation of Prophylactic Heparin Dosage Strategies and Risk Factors for Venous Thromboembolism in the Critically Ill Patient. Pharmacotherapy 2019; 39:232-241. [PMID: 30592541 DOI: 10.1002/phar.2212] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) occurs frequently in critically ill patients without heparin prophylaxis. Although heparin prevents VTE, VTEs occur frequently despite prophylaxis. A higher heparin dosage may be more effective for preventing VTE. METHODS A retrospective study was conducted using the Premier Incorporated Perspective Database to evaluate comparatively the effects of different heparin prophylaxis dosing strategies in the critically ill patient. Critically ill adult patients who were mechanically ventilated for at least 1 day and had an intensive care unit (ICU) length of stay of at least 2 days were included. Patients received 5000 units of heparin either twice/day or 3 times/day. The primary outcome was development of a new VTE. Key secondary outcomes included clinically important bleeding, thrombocytopenia, and mortality. Patients were propensity matched to control for confounding. Multivariable analysis was conducted for VTE risk factors. RESULTS The study included 30,800 patients from 374 hospitals who were propensity matched by heparin dosage. New VTE occurred in 6.16% of patients treated with 3 times/day heparin versus 6.23% with twice/day heparin (p=0.8). No significant differences in the incidence of pulmonary embolism (0.91% vs 0.8%, p=0.29) or deep vein thrombosis (5.56% vs 5.70% p=0.59) were observed between the two types of heparin dosing. No differences were observed between the two types of heparin dosing in in-hospital mortality (15.8% vs 15.15%), bleeding (0.23% vs 0.33%), or thrombocytopenia (5.19% vs 5.34%, p>0.08 for all), respectively. Risk factors associated with VTE included intraabdominal and urinary tract infections, loop diuretics, malnutrition, obesity, thrombocytopenia, paralytics, vasopressors, female sex, peripheral vascular disease, sepsis, neutropenia, and end-stage renal disease. Antiplatelet therapy, heart failure, diabetes, and substance abuse were associated with reduced VTE (p<0.05 for all). CONCLUSIONS In critically ill patients, prophylactic dosing of heparin 3 times/day versus twice/day was not associated with differences in new VTE or safety outcomes. Several modifiable VTE risk factors were identified.
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Affiliation(s)
- Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Edward T Van Matre
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Garth C Wright
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Robert Brett McQueen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Ellen L Burnham
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - Pei Jai Michael Ho
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Health Care System, Denver, Colorado
| | - Marc Moss
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - Robert William Vandivier
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
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Kiser TH, Reynolds PM, Moss M, Burnham EL, Ho PM, Vandivier RW. Impact of Macrolide Antibiotics on Hospital Readmissions and Other Clinically Important Outcomes in Critically Ill Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Propensity Score-Matched Cohort Study. Pharmacotherapy 2019; 39:242-252. [PMID: 30663791 PMCID: PMC6445270 DOI: 10.1002/phar.2221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To assess whether a macrolide-based antibiotic treatment strategy reduces in-hospital mortality, decreases hospital readmissions, or improves other clinically important outcomes compared with a non-macrolide antibiotic treatment strategy in critically ill patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). DESIGN Propensity score-matched pharmacoepidemiologic cohort study. DATA SOURCE Premier's Perspective Hospital Database. PATIENTS A total of 28,700 adults aged 40 years or older who were admitted to one of 566 United States intensive care units and had the primary diagnosis of AECOPD between January 2010 and December 2014 and received antibiotic treatment within 2 days of hospital admission were included. Patients were divided into macrolide (11,602 patients [40%]) or non-macrolide (17,098 patients [60%]) antibiotic treatment groups. Propensity score analysis successfully matched 8660 patients in each treatment group. MEASUREMENTS AND MAIN RESULTS In the matched cohort, the macrolide treatment group was not associated with decreased hospital mortality after day 2 (3.0% vs 3.3%, p=0.28), intensive care unit length of stay (2 days vs 2 days, p=0.12), hospital length of stay (6 days vs 6 days, p=0.86), or length of assisted ventilation (3 days vs 3 days, p=0.71), compared with the non-macrolide treatment group. However, a macrolide-based antibiotic regimen was associated with an overall reduction in 30-day hospital readmissions (7.3% vs 8.8%, p<0.01), increased time to next all-cause (159 vs 130 days, p<0.01) or AECOPD (200 vs 175 days, p=0.03) readmission, and decreased hospital costs ($32,730 vs $34,021, p<0.01). CONCLUSION The results of this study suggest that inclusion of a macrolide antibiotic in the treatment regimen may have both acute and sustained benefits in critically ill patients admitted to the intensive care unit with an AECOPD, including reductions in hospital readmissions and improvements in time to next readmission.
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Affiliation(s)
- Tyree H. Kiser
- Department of Clinical Pharmacy, University of Colorado Denver, Skaggs School of Pharmacy and Pharmaceutical
Sciences, Aurora, Colorado
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado, Anschutz Medical Campus, Aurora,
Colorado
| | - Paul M. Reynolds
- Department of Clinical Pharmacy, University of Colorado Denver, Skaggs School of Pharmacy and Pharmaceutical
Sciences, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado,
Anschutz Medical Campus, Aurora, Colorado
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado, Anschutz Medical Campus, Aurora,
Colorado
| | - Ellen L. Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado,
Anschutz Medical Campus, Aurora, Colorado
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado, Anschutz Medical Campus, Aurora,
Colorado
| | - P. Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora,
Colorado
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado, Anschutz Medical Campus, Aurora,
Colorado
| | - R. William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado,
Anschutz Medical Campus, Aurora, Colorado
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado, Anschutz Medical Campus, Aurora,
Colorado
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Burnham EL, Eakin MN, Pakhale S. Ethics of Health Research Supported by For-Profit Cannabis Companies: What Have We Learned from Big Tobacco? Ann Am Thorac Soc 2019; 16:396-397. [PMID: 30712358 DOI: 10.1513/annalsats.201811-764le] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ellen L Burnham
- 1 University of Colorado School of Medicine Aurora, Colorado
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36
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Van Matre ET, Reynolds PM, MacLaren R, Mueller SW, Wright GC, Moss M, Burnham EL, Ho PM, Vandivier RW, Kiser TH. Evaluation of unfractionated heparin versus low-molecular-weight heparin and fondaparinux for pharmacologic venous thromboembolic prophylaxis in critically ill patients with cancer. J Thromb Haemost 2018; 16:2492-2500. [PMID: 30347498 DOI: 10.1111/jth.14317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 07/17/2018] [Indexed: 11/27/2022]
Abstract
Essentials Critically ill cancer patients require pharmacologic prophylaxis for venous thromboembolism (VTE). Patients from 566 hospitals in the United States between 2010 and 2014 were included. Low-molecular-weight heparin (LMWH) prophylaxis was not associated in a reduction of VTE rates. LMWH prophylaxis was associated with a reduction in bleeding and heparin induced thrombocytopenia. SUMMARY: Background Critically ill patients with cancer are at increased risk of venous thromboembolism (VTE) from physical and cellular factors, requiring pharmacologic prophylaxis to reduce the risk of VTE. Objectives To assess whether low-molecular-weight heparin (LMWH) prophylaxis reduces in-hospital rates of VTE or improves clinical outcomes compared with unfractionated heparin (UFH) prophylaxis in critically ill patients with cancer. Methods We used a propensity-matched comparative-effectiveness cohort from the Premier Database. Patients aged 18 years or older with a primary diagnosis of cancer, intensive care unit admission and VTE prophylaxis within 2 days of admission between 1 January 2010 and 31 December 2014 were included. Patients were divided into LMWH or UFH prophylaxis groups. Results A total of 103 798 patients were included; 75 321 (72.6%) patients received LMWH and 28 477 (27.4%) patients received UFH. Propensity analysis matched (2 : 1) 42 343 LMWH patients and 21 218 UFH patients. Overall, LMWH was not associated with a decreased incidence of VTE (5.32% vs. 5.50%). LMWH prophylaxis was associated with a reduction in pulmonary embolism (0.70% vs. 0.99%), significant bleeding (13.3% vs. 14.8%) and heparin-induced thrombocytopenia (HIT) (0.06% vs. 0.19%). In non-metastatic solid disease, LMWH was associated with decreased VTE (4.27% vs. 4.84%) and PE (0.47% vs. 0.95%). Conclusions The use of an LMWH for VTE prophylaxis was not associated with a reduction in the incidence of in-hospital VTE as compared with UFH, but was associated with significant reductions in PE, clinically important bleeding events, and incidence of HIT in critically ill patients with cancer.
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Affiliation(s)
- E T Van Matre
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - P M Reynolds
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
| | - R MacLaren
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
| | - S W Mueller
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
| | - G C Wright
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
| | - M Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - E L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - P M Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado, Anschutz Medical Campus, Aurora
- Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO, USA
| | - R W Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - T H Kiser
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
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Afshar M, Burnham EL, Joyce C, Kovacs EJ, Lowery EM. Optimal Cut-Points for Phosphatidylethanol Vary by Clinical Setting: Response to Nguyen and Seth's (2018) Letter to the Editor. Alcohol Clin Exp Res 2018; 42:2064-2065. [PMID: 30059162 DOI: 10.1111/acer.13853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Majid Afshar
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Cara Joyce
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Erin M Lowery
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
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38
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Neudecker V, Brodsky KS, Clambey ET, Schmidt EP, Packard TA, Davenport B, Standiford TJ, Weng T, Fletcher AA, Barthel L, Masterson JC, Furuta GT, Cai C, Blackburn MR, Ginde AA, Graner MW, Janssen WJ, Zemans RL, Evans CM, Burnham EL, Homann D, Moss M, Kreth S, Zacharowski K, Henson PM, Eltzschig HK. Neutrophil transfer of miR-223 to lung epithelial cells dampens acute lung injury in mice. Sci Transl Med 2018; 9:9/408/eaah5360. [PMID: 28931657 DOI: 10.1126/scitranslmed.aah5360] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 05/23/2017] [Indexed: 12/11/2022]
Abstract
Intercellular transfer of microRNAs can mediate communication between critical effector cells. We hypothesized that transfer of neutrophil-derived microRNAs to pulmonary epithelial cells could alter mucosal gene expression during acute lung injury. Pulmonary-epithelial microRNA profiling during coculture of alveolar epithelial cells with polymorphonuclear neutrophils (PMNs) revealed a selective increase in lung epithelial cell expression of microRNA-223 (miR-223). Analysis of PMN-derived supernatants showed activation-dependent release of miR-223 and subsequent transfer to alveolar epithelial cells during coculture in vitro or after ventilator-induced acute lung injury in mice. Genetic studies indicated that miR-223 deficiency was associated with severe lung inflammation, whereas pulmonary overexpression of miR-223 in mice resulted in protection during acute lung injury induced by mechanical ventilation or by infection with Staphylococcus aureus Studies of putative miR-223 gene targets implicated repression of poly(adenosine diphosphate-ribose) polymerase-1 (PARP-1) in the miR-223-dependent attenuation of lung inflammation. Together, these findings suggest that intercellular transfer of miR-223 from neutrophils to pulmonary epithelial cells may dampen acute lung injury through repression of PARP-1.
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Affiliation(s)
- Viola Neudecker
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA. .,Department of Anesthesiology, University Hospital, Ludwig-Maximilian University of Munich, 81377 Munich, Germany
| | - Kelley S Brodsky
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Eric T Clambey
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Eric P Schmidt
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA.,Program in Translational Lung Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Thomas A Packard
- Department of Immunology and Microbiology, University of Colorado Denver School of Medicine and National Jewish Health, Denver, CO 80206, USA
| | - Bennett Davenport
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Theodore J Standiford
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Tingting Weng
- Department of Biochemistry and Molecular Biology, University of Texas-Houston Medical School, Houston, TX 77030, USA
| | - Ashley A Fletcher
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Lea Barthel
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Joanne C Masterson
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado; Mucosal Inflammation Program, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado; Mucosal Inflammation Program, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Chunyan Cai
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Michael R Blackburn
- Department of Biochemistry and Molecular Biology, University of Texas-Houston Medical School, Houston, TX 77030, USA
| | - Adit A Ginde
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Michael W Graner
- Department of Neurosurgery, University of Colorado Denver, Aurora, CO 80045, USA
| | - William J Janssen
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA.,Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Rachel L Zemans
- Department of Medicine, National Jewish Health, Denver, CO 80206, USA
| | - Christopher M Evans
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA.,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Dirk Homann
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Simone Kreth
- Department of Anesthesiology, University Hospital, Ludwig-Maximilian University of Munich, 81377 Munich, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | - Peter M Henson
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA.,Department of Immunology and Microbiology, University of Colorado Denver School of Medicine and National Jewish Health, Denver, CO 80206, USA
| | - Holger K Eltzschig
- Organ Protection Program, Department of Anesthesiology, University of Colorado Denver, Aurora, CO 80045, USA.,Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Samuelson DR, Burnham EL, Maffei VJ, Vandivier RW, Blanchard EE, Shellito JE, Luo M, Taylor CM, Welsh DA. The respiratory tract microbial biogeography in alcohol use disorder. Am J Physiol Lung Cell Mol Physiol 2018; 314:L107-L117. [PMID: 28860145 PMCID: PMC5866426 DOI: 10.1152/ajplung.00277.2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/24/2017] [Accepted: 08/24/2017] [Indexed: 11/22/2022] Open
Abstract
Individuals with alcohol use disorders (AUDs) are at an increased risk of pneumonia and acute respiratory distress syndrome. Data of the lung microbiome in the setting of AUDs are lacking. The objective of this study was to determine the microbial biogeography of the upper and lower respiratory tract in individuals with AUDs compared with non-AUD subjects. Gargle, protected bronchial brush, and bronchoalveolar lavage specimens were collected during research bronchoscopies. Bacterial 16S gene sequencing and phylogenetic analysis was performed, and the alterations to the respiratory tract microbiota and changes in microbial biogeography were determined. The microbial structure of the upper and lower respiratory tract was significantly altered in subjects with AUDs compared with controls. Subjects with AUD have greater microbial diversity [ P < 0.0001, effect size = 16 ± 1.7 observed taxa] and changes in microbial species relative abundances. Furthermore, microbial communities in the upper and lower respiratory tract displayed greater similarity in subjects with AUDs. Alcohol use is associated with an altered composition of the respiratory tract microbiota. Subjects with AUDs demonstrate convergence of the microbial phylogeny and taxonomic communities between distinct biogeographical sites within the respiratory tract. These results support a mechanistic pathway potentially explaining the increased incidence of pneumonia and lung diseases in patients with AUDs.
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Affiliation(s)
- Derrick R. Samuelson
- Department of Medicine, Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Ellen L. Burnham
- Department of Medicine, Division of Pulmonary Sciences & Critical Care, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Vincent J. Maffei
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - R. William Vandivier
- Department of Medicine, Division of Pulmonary Sciences & Critical Care, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Eugene E. Blanchard
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Judd E. Shellito
- Department of Medicine, Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Meng Luo
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Christopher M. Taylor
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - David A. Welsh
- Department of Medicine, Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Department of Microbiology, Immunology and Parasitology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Fini MA, Gaydos J, McNally A, Karoor V, Burnham EL. Alcohol abuse is associated with enhanced pulmonary and systemic xanthine oxidoreductase activity. Am J Physiol Lung Cell Mol Physiol 2017; 313:L1047-L1057. [PMID: 28839105 PMCID: PMC5814699 DOI: 10.1152/ajplung.00570.2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 01/05/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common and devastating disorder. Alcohol use disorders (AUDs) increase ARDS risk and worsen outcomes through mechanisms that may include enhancement of pulmonary oxidative stress. Alcohol consumption increases activity of the enzyme xanthine oxidoreductase (XOR) that contributes to production of both reactive oxygen species (ROS) and uric acid, a damage-associated molecular pattern. These by-products have the potential to modulate proinflammatory pathways, such as those involving cyclooxygenase (COX)-2, and to activate the nucleotide-binding domain, leucine-rich-containing family, pyrin-domain containing-3 (NLRP3) inflammasome. We sought to determine if pulmonary and systemic XOR activity was altered by AUDs. Bronchoscopy with bronchoalveolar lavage (BAL) and blood sampling was performed in otherwise healthy human subjects with AUDs and controls. Uric acid in epithelial-lining fluid, derived from BAL, was substantially higher among individuals with AUDs and did not normalize after 7 days of abstinence; serum uric acid did not differ across groups. XOR enzyme activity in fresh BAL cells and serum was significantly increased in subjects with AUDs. XOR protein in BAL cells from AUD subjects was increased in parallel with COX-2 expression, and furthermore, mRNA expression of NLRP3 inflammasome components was sustained in LPS-stimulated BAL cells from AUD subjects in conjunction with increased IL-1β. Our data suggest that AUDs augment pulmonary and systemic XOR activity that may contribute to ROS and uric acid generation, promoting inflammation. Further investigations will be necessary to determine if XOR inhibition can mitigate alcohol-associated pulmonary oxidative stress, diminish inflammation, and improve ARDS outcomes.
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Affiliation(s)
- Mehdi A Fini
- Cardiovascular Pulmonary Research Laboratory, University of Colorado School of Medicine, Denver, Colorado; and
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Jeanette Gaydos
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Alicia McNally
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Vijaya Karoor
- Cardiovascular Pulmonary Research Laboratory, University of Colorado School of Medicine, Denver, Colorado; and
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
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Sapkota M, Burnham EL, DeVasure JM, Sweeter JM, Hunter C, Duryee MJ, Klassen LW, Kharbanda KK, Sisson JH, Thiele GM, Wyatt TA. Malondialdehyde-Acetaldehyde (MAA) Protein Adducts Are Found Exclusively in the Lungs of Smokers with Alcohol Use Disorders and Are Associated with Systemic Anti-MAA Antibodies. Alcohol Clin Exp Res 2017; 41:2093-2099. [PMID: 28941289 PMCID: PMC5711572 DOI: 10.1111/acer.13509] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malondialdehyde (MDA) and acetaldehyde (AA) exist following ethanol metabolism and tobacco pyrolysis. As such, lungs of individuals with alcohol use disorders (AUDs) are a target for the effects of combined alcohol and cigarette smoke metabolites. MDA and AA form a stable protein adduct, malondialdehyde-acetaldehyde (MAA) adduct, known to be immunogenic, profibrotic, and proinflammatory. MAA adduct is the dominant epitope in anti-MAA antibody formation. We hypothesized that MAA-adducted protein forms in lungs of those who both abuse alcohol and smoke cigarettes, and that this would be associated with systemically elevated anti-MAA antibodies. METHODS Four groups were established: AUD subjects who smoked cigarettes (+AUD/+smoke), smokers without AUD (-AUD/+smoke), AUD without smoke (+AUD/-smoke), and non-AUD/nonsmokers (-AUD/-smoke). RESULTS We observed a significant increase in MAA adducts in lung cells of +AUD/+smoke versus -AUD/-smoke. No significant increase in MAA adducts was observed in -AUD/+smoke or in +AUD/-smoke compared to -AUD/-smoke. Serum from +AUD/+smoke had significantly increased levels of circulating anti-MAA IgA antibodies. After 1 week of alcohol that MAA-adducted protein is formed in the lungs of those who smoke cigarettes and abuse alcohol, leading to a subsequent increase in serum IgA antibodies. CONCLUSIONS MAA-adducted proteins could play a role in pneumonia and other diseases of the lung in the setting of AUD and smoking.
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Affiliation(s)
- Muna Sapkota
- Department of Environmental, Agricultural and Occupational Health, University of Nebraska Medical Center, Omaha, NE
| | - Ellen L. Burnham
- University of Colorado School of Medicine, Anschutz Medical Campus, Denver, CO
| | - Jane M. DeVasure
- Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center
| | - Jenea M. Sweeter
- Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center
| | - C.D. Hunter
- Department of Internal Medicine, Division of Rheumatology and Immunology, University of Nebraska Medical Center
| | - Michael J. Duryee
- Department of Internal Medicine, Division of Rheumatology and Immunology, University of Nebraska Medical Center
| | - Lynell W. Klassen
- Department of Internal Medicine, Division of Rheumatology and Immunology, University of Nebraska Medical Center
| | | | - Joseph H. Sisson
- Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center
| | - Geoffrey M. Thiele
- Department of Internal Medicine, Division of Rheumatology and Immunology, University of Nebraska Medical Center
| | - Todd A. Wyatt
- Department of Environmental, Agricultural and Occupational Health, University of Nebraska Medical Center, Omaha, NE
- Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
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Frankel JH, Boe DM, Albright JM, O'Halloran EB, Carter SR, Davis CS, Ramirez L, Burnham EL, Gamelli RL, Afshar M, Kovacs EJ. Age-related immune responses after burn and inhalation injury are associated with altered clinical outcomes. Exp Gerontol 2017; 105:78-86. [PMID: 29080833 DOI: 10.1016/j.exger.2017.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 12/20/2022]
Abstract
This prospective study aimed to address changes in inflammatory response between different aged populations of patients who sustained burn and inhalation injury. Plasma and bronchoalveolar lavage (BAL) samples were collected from 104 patients within 15h of their estimated time of burn injury. Clinical variables, laboratory parameters, and immune mediator profiles were examined in association with clinical outcomes. Older patients were at higher odds for death after burn injury (odds ratio (OR)=7.37 per 10years, p=0.004). In plasma collected within 15h after burn injury, significant increases in the concentrations of interleukin 1 receptor antagonist (IL-1RA), interleukin 2 (IL-2), interleukin 4 (IL-4), interleukin 6 (IL-6), granulocyte colony-stimulating factor (G-CSF), interferon-gamma-induced protein 10 (IP-10) and monocyte chemoattractant protein 1 (MCP-1) (p<0.05 for all) were observed in the ≥65 group. In the BAL fluid, MCP-1 was increased three-fold in the ≥65 group. This study suggests that changes in certain immune mediators were present in the older cohort, in association with in-hospital mortality.
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Affiliation(s)
- John H Frankel
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Devin M Boe
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Joslyn M Albright
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Eileen B O'Halloran
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Stewart R Carter
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Christopher S Davis
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Luis Ramirez
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Ellen L Burnham
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Colorado Alcohol Pulmonary Research Collaborative, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | | | - Majid Afshar
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA; Division of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - Elizabeth J Kovacs
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Colorado Alcohol Pulmonary Research Collaborative, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA.
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Holloway AS, Ferguson J, Landale S, Cariola L, Newbury-Birch D, Flynn A, Knight JR, Sherritt L, Harris SK, O’Donnell AJ, Kaner E, Hanratty B, Loree AM, Yonkers KA, Ondersma SJ, Gilstead-Hayden K, Martino S, Adam A, Schwartz RP, Wu LT, Subramaniam G, Sharma G, McNeely J, Berman AH, Kolaas K, Petersén E, Bendtsen P, Hedman E, Linderoth C, Müssener U, Sinadinovic K, Spak F, Gremyr I, Thurang A, Mitchell AM, Finnell D, Savage CL, Mahmoud KF, Riordan BC, Conner TS, Flett JAM, Scarf D, McRee B, Vendetti J, Gallucci KS, Robaina K, Clark BJ, Jones J, Reed KD, Hodapp RM, Douglas I, Burnham EL, Aagaard L, Cook PF, Harris BR, Yu J, Wolff M, Rogers M, Barbosa C, Wedehase BJ, Dunlap LJ, Mitchell SG, Dusek KA, Gryczynski J, Kirk AS, Oros MT, Hosler C, O’Grady KE, Brown BS, Angus C, Sherborne S, Gillespie D, Meier P, Brennan A, de Vargas D, Soares J, Castelblanco D, Doran KM, Wittman I, Shelley D, Rotrosen J, Gelberg L, Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Deng Y, Dziura J, Fiellin LE, O’Connor PG, Bedimo R, Gibert C, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Justice AC, Bryant KJ, Fiellin DA, Giles EL, Coulton S, Deluca P, Drummond C, Howel D, McColl E, McGovern R, Scott S, Stamp E, Sumnall H, Vale L, Alabani V, Atkinson A, Boniface S, Frankham J, Gilvarry E, Hendrie N, Howe N, McGeechan GJ, Ramsey A, Stanley G, Clephane J, Gardiner D, Holmes J, Martin N, Shevills C, Soutar M, Chi FW, Weisner C, Ross TB, Mertens J, Sterling SA, Shorter GW, Heather N, Bray J, Cohen HA, McPherson TL, Adam C, López-Pelayo H, Gual A, Segura-Garcia L, Colom J, Ornelas IJ, Doyle S, Donovan D, Duran B, Torres V, Gaume J, Grazioli V, Fortini C, Paroz S, Bertholet N, Daeppen JB, Satterfield JM, Gregorich S, Alvarado NJ, Muñoz R, Kulieva G, Vijayaraghavan M, Adam A, Cunningham JA, Díaz E, Palacio-Vieira J, Godinho A, Kushir V, O’Brien KHM, Aguinaldo LD, Sellers CM, Spirito A, Chang G, Blake-Lamb T, LaFave LRA, Thies KM, Pepin AL, Sprangers KE, Bradley M, Jorgensen S, Catano NA, Murray AR, Schachter D, Andersen RM, Rey GN, Vahidi M, Rico MW, Baumeister SE, Johansson M, Sinadinovic C, Hermansson U, Andreasson S, O’Grady MA, Kapoor S, Akkari C, Bernal C, Pappacena K, Morley J, Auerbach M, Neighbors CJ, Kwon N, Conigliaro J, Morgenstern J, Magill M, Apodaca TR, Borsari B, Hoadley A, Scott Tonigan J, Moyers T, Fitzgerald NM, Schölin L, Barticevic N, Zuzulich S, Poblete F, Norambuena P, Sacco P, Ting L, Beaulieu M, Wallace PG, Andrews M, Daley K, Shenker D, Gallagher L, Watson R, Weaver T, Bruguera P, Oliveras C, Gavotti C, Barrio P, Braddick F, Miquel L, Suárez M, Bruguera C, Brown RL, Capell JW, Paul Moberg D, Maslowsky J, Saunders LA, McCormack RP, Scheidell J, Gonzalez M, Bauroth S, Liu W, Lindsay DL, Lincoln P, Hagle H, Wallhed Finn S, Hammarberg A, Andréasson S, King SE, Vargo R, Kameg BN, Acquavita SP, Van Loon RA, Smith R, Brehm BJ, Diers T, Kim K, Barker A, Jones AL, Skinner AC, Hinman A, Svikis DS, Thacker CL, Resnicow K, Beatty JR, Janisse J, Puder K, Bakshi AS, Milward JM, Kimergard A, Garnett CV, Crane D, Brown J, West R, Michie S, Rosendahl I, Andersson C, Gajecki M, Blankers M, Donoghue K, Lynch E, Maconochie I, Phillips C, Pockett R, Phillips T, Patton R, Russell I, Strang J, Stewart MT, Quinn AE, Brolin M, Evans B, Horgan CM, Liu J, McCree F, Kanovsky D, Oberlander T, Zhang H, Hamlin B, Saunders R, Barton MB, Scholle SH, Santora P, Bhatt C, Ahmed K, Hodgkin D, Gao W, Merrick EL, Drebing CE, Larson MJ, Sharma M, Petry NM, Saitz R, Weisner CM, Young-Wolff KC, Lu WY, Blosnich JR, Lehavot K, Glass JE, Williams EC, Bensley KM, Chan G, Dombrowski J, Fortney J, Rubinsky AD, Lapham GT, Forray A, Olmstead TA, Gilstad-Hayden K, Kershaw T, Dillon P, Weaver MF, Grekin ER, Ellis JD, McGoron L, McGoron L. Proceedings of the 14th annual conference of INEBRIA. Addict Sci Clin Pract 2017. [PMCID: PMC5606215 DOI: 10.1186/s13722-017-0087-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Afshar M, Burnham EL, Joyce C, Clark BJ, Yong M, Gaydos J, Cooper RS, Smith GS, Kovacs EJ, Lowery EM. Cut-Point Levels of Phosphatidylethanol to Identify Alcohol Misuse in a Mixed Cohort Including Critically Ill Patients. Alcohol Clin Exp Res 2017; 41:1745-1753. [PMID: 28792620 DOI: 10.1111/acer.13471] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 03/20/2017] [Accepted: 08/02/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although alcohol misuse is associated with deleterious outcomes in critically ill patients, its detection by either self-report or examination of biomarkers is difficult to obtain consistently. Phosphatidylethanol (PEth) is a direct alcohol biomarker that can characterize alcohol consumption patterns; however, its diagnostic accuracy in identifying misuse in critically ill patients is unknown. METHODS PEth values were obtained in a mixed cohort comprising 122 individuals from medical and burn intensive care units (n = 33), alcohol detoxification unit (n = 51), and healthy volunteers (n = 38). Any alcohol misuse and severe misuse were referenced by Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C scores separately. Mixed-effects logistic regression analysis was performed, and the discrimination of PEth was evaluated using the area under the receiver-operating characteristic (ROC) curve. RESULTS The area under the ROC curve for PEth was 0.927 (95% CI: 0.877, 0.977) for any misuse and 0.906 (95% CI: 0.850, 0.962) for severe misuse defined by AUDIT. By AUDIT-C, the area under the ROC curves was 0.948 (95% CI: 0.910, 0.956) for any misuse and 0.913 (95% CI: 0.856, 0.971) for severe misuse. The PEth cut-points of ≥250 and ≥400 ng/ml provided optimal discrimination for any misuse and severe misuse, respectively. The positive predictive value for ≥250 ng/ml was 88.7% (95% CI: 77.5, 95.0), and the negative predictive value was 86.7% (95% CI: 74.9, 93.7). PEth ≥ 400 ng/ml achieved similar values, and similar results were shown for AUDIT-C. In a subgroup analysis of critically ill patients only, test characteristics were similar to the mixed cohort. CONCLUSIONS PEth is a strong predictor and has good discrimination for any and severe alcohol misuse in a mixed cohort that includes critically ill patients. Cut-points at 250 ng/ml for any, and 400 ng/ml for severe, are favorable. External validation will be required to establish these cut-points in critically ill patients.
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Affiliation(s)
- Majid Afshar
- Stritch School of Medicine , Burn and Shock Trauma Research Institute, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program , Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Department of Public Health Sciences , Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Ellen L Burnham
- Department of Medicine , Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Cara Joyce
- Department of Public Health Sciences , Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Brendan J Clark
- Department of Medicine , Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Meagan Yong
- Stritch School of Medicine , Burn and Shock Trauma Research Institute, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program , Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Jeannette Gaydos
- Department of Medicine , Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Richard S Cooper
- Department of Public Health Sciences , Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Gordon S Smith
- Shock Trauma and Anesthesiology Research (STAR) - Organized Research Center , Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Elizabeth J Kovacs
- Department of Surgery , University of Colorado School of Medicine, Aurora, Colorado
| | - Erin M Lowery
- Stritch School of Medicine , Burn and Shock Trauma Research Institute, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program , Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
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45
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Afshar M, Netzer G, Mosier MJ, Cooper RS, Adams W, Burnham EL, Kovacs EJ, Durazo-Arvizu R, Kliethermes S. The Contributing Risk of Tobacco Use for ARDS Development in Burn-Injured Adults With Inhalation Injury. Respir Care 2017; 62:1456-1465. [PMID: 28900039 DOI: 10.4187/respcare.05560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aims to determine the relationship between tobacco use, inhalation injury, and ARDS in burn-injured adults. METHODS This study was an observational cohort of 2,485 primary burn admissions to a referral burn center between January 1, 2008 and March 15, 2015. Subjects were evaluated by methods used to account for mediation and traditional approaches (multivariable logistic regression and propensity score analysis). Mediation analysis examined both the (1) indirect effect of tobacco use via inhalation injury as the mediator on ARDS development and (2) the direct effect of tobacco use alone on ARDS development. RESULTS ARDS development occurred in 6.8% (n = 170) of the cohort. Inhalation injury occurred in 5.0% (n = 125) of the cohort, and ARDS developed in 48.8% (n = 83) of the subjects with inhalation injury. Tobacco use was 2-fold more common in subjects with ARDS. In the mediated model, the direct effect of tobacco use on ARDS, including interaction between tobacco use and inhalation injury, was not significant (odds ratio [OR] 1.63, 95% CI 0.91-2.92, P = .10). However, the indirect effect of tobacco use via inhalation injury as the mediator was significant (OR 1.61, 95% CI 1.25-2.07, P < .001), and the proportion of the total effect of tobacco use operating through the mediator was 55.6%. In the non-mediation models (multivariable logistic regression and propensity score analysis), which controlled for inhalation injury and other covariables, the OR for the association between tobacco use and ARDS was 1.84 (95% CI 1.22-2.81, P < .001) and 1.69 (95% CI 1.04-2.75, P = .03), respectively. CONCLUSIONS In mediation analysis, inhalation injury was the overwhelming predictor for ARDS development, whereas tobacco use has its strongest effect indirectly through inhalation injury. Patients with at least moderate inhalation injury are at greatest risk for ARDS development despite baseline risk factors like tobacco use.
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Affiliation(s)
- Majid Afshar
- Burn and Shock Trauma Research Institute .,Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, Illinois
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore Maryland
| | | | - Richard S Cooper
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - William Adams
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ramon Durazo-Arvizu
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Stephanie Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
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Mehta S, Burns KEA, Machado FR, Fox-Robichaud AE, Cook DJ, Calfee CS, Ware LB, Burnham EL, Kissoon N, Marshall JC, Mancebo J, Finfer S, Hartog C, Reinhart K, Maitland K, Stapleton RD, Kwizera A, Amin P, Abroug F, Smith O, Laake JH, Shrestha GS, Herridge MS. Gender Parity in Critical Care Medicine. Am J Respir Crit Care Med 2017; 196:425-429. [PMID: 28240961 DOI: 10.1164/rccm.201701-0076cp] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These documents inform and shape patient care around the world. In this Perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government. We propose five strategies to ensure gender parity within critical care medicine.
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Affiliation(s)
- Sangeeta Mehta
- 1 Department of Medicine.,2 Interdepartmental Division of Critical Care Medicine.,3 Sinai Health System
| | - Karen E A Burns
- 4 Canadian Critical Care Society, Markham, Ontario, Canada.,5 Interdepartmental Division of Critical Care Medicine and.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Flavia R Machado
- 7 Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Alison E Fox-Robichaud
- 4 Canadian Critical Care Society, Markham, Ontario, Canada.,8 Hamilton Health Sciences, Thrombosis and Atherosclerosis Research Institute.,9 Department of Medicine
| | - Deborah J Cook
- 10 Clinical Epidemiology and Biostatistics, and.,11 Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carolyn S Calfee
- 12 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine and.,13 Cardiovascular Research Institute, University of California, San Francisco, California
| | - Lorraine B Ware
- 14 Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ellen L Burnham
- 15 Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Niranjan Kissoon
- 16 Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John C Marshall
- 5 Interdepartmental Division of Critical Care Medicine and.,17 Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jordi Mancebo
- 18 University of Montreal Hospital Center and.,19 Division of Intensive Care, University of Montreal, Montreal, Quebec, Canada
| | - Simon Finfer
- 20 Division of Critical Care and Trauma, The George Institute for Global Health, Sydney, Australia.,21 University of Sydney, Sydney, Australia
| | - Christiane Hartog
- 22 Department of Anesthesiology and Intensive Care, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- 22 Department of Anesthesiology and Intensive Care, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,23 Global Sepsis Alliance, Jena, Germany
| | - Kathryn Maitland
- 24 Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Renee D Stapleton
- 25 Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington, Vermont
| | - Arthur Kwizera
- 26 Department of Anesthesia and Critical Care, Makerere University, Kampala, Uganda
| | - Pravin Amin
- 27 Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Fekri Abroug
- 28 Centre Hospitalo-Universitaire Fattouma Bourguiba, Monastir, Tunisia
| | - Orla Smith
- 29 Lawrence S. Bloomberg Faculty of Nursing, and.,5 Interdepartmental Division of Critical Care Medicine and.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jon H Laake
- 30 Scandinavian Society of Anaesthesiology and Intensive Care Medicine.,31 Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; and
| | - Gentle S Shrestha
- 32 Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Margaret S Herridge
- 1 Department of Medicine.,2 Interdepartmental Division of Critical Care Medicine.,33 University Health Network, University of Toronto, Toronto, Ontario, Canada
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Nedumaran B, Rudra P, Gaydos J, Kumar S, Meacham RB, Burnham EL, Malykhina AP. Impact of Regular Cannabis Use on Biomarkers of Lower Urinary Tract Function. Urology 2017; 109:223.e9-223.e16. [PMID: 28827195 DOI: 10.1016/j.urology.2017.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/31/2017] [Accepted: 08/07/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the differences in the composition and quantities of urine peptides in regular cannabis users and nonusers by liquid chromatography tandem mass spectrometry analysis. MATERIALS AND METHODS Urine specimens from healthy control subjects and cannabis users were utilized to identify the differences in the number and quantity of urine proteins by liquid chromatography tandem mass spectrometry analysis. Significantly altered proteins were determined by a permutation testing statistical method. Heat map, dendrogram, pathway, and network analyses were performed to assess the degree of expression and the potential relationships between proteins in both groups. RESULTS A total of 1337 proteins were detected in both groups with 19 proteins being significantly altered in cannabis users. Innate immunity and carbohydrate metabolic pathways were highly linked with upregulated proteins in the cannabis group. Additionally, 91 proteins were present and 46 proteins were absent only in cannabis users in comparison with the control cohort. Our results suggest that regular use of cannabis is associated with significant alterations in a number of urinary peptides, with a large number of proteins present or absent only in cannabis users. Pathway analyses demonstrated an increased immune response in cannabis users compared with controls. CONCLUSION Our observations potentially indicate activation (or inhibition) of specific signaling pathways in the lower urinary tract during chronic exposure to exogenous cannabinoids. Our study provides initial proteomic knowledge for future investigations on the potential role of exocannabinoids in the development of intravesical therapies to treat lower urinary tract disorders.
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Affiliation(s)
- Balachandar Nedumaran
- Division of Urology, Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Pratyaydipta Rudra
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Jeanette Gaydos
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Sushil Kumar
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics and Medicine, University of Colorado Denver, Aurora, CO
| | - Randall B Meacham
- Division of Urology, Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Anna P Malykhina
- Division of Urology, Department of Surgery, University of Colorado Denver, Aurora, CO.
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Blumhagen RZ, Hedin BR, Malcolm KC, Burnham EL, Moss M, Abraham E, Huie TJ, Nick JA, Fingerlin TE, Alper S. Alternative pre-mRNA splicing of Toll-like receptor signaling components in peripheral blood mononuclear cells from patients with ARDS. Am J Physiol Lung Cell Mol Physiol 2017; 313:L930-L939. [PMID: 28775099 DOI: 10.1152/ajplung.00247.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/28/2017] [Accepted: 07/30/2017] [Indexed: 12/14/2022] Open
Abstract
A key physiological feature of acute respiratory distress syndrome (ARDS) is inflammation. Toll-like receptor (TLR) signaling is required to combat the infection that underlies many ARDS cases but also contributes to pathological inflammation. Several TLR signaling pathway genes encoding positive effectors of inflammation also produce alternatively spliced mRNAs encoding negative regulators of inflammation. An imbalance between these isoforms could contribute to pathological inflammation and disease severity. To determine whether splicing in TLR pathways is altered in patients with ARDS, we monitored alternative splicing of MyD88 and IRAK1, two genes that function in multiple TLR pathways. The MyD88 and IRAK1 genes produce long proinflammatory mRNAs (MyD88L and IRAK1) and shorter anti-inflammatory mRNAs (MyD88S and IRAK1c). We quantified mRNA encoding inflammatory cytokines and MyD88 and IRAK1 isoforms in peripheral blood mononuclear cells (PBMCs) from 104 patients with ARDS and 30 healthy control subjects. We found that MyD88 pre-mRNA splicing is altered in patients with ARDS in a proinflammatory direction. We also observed altered MyD88 isoform levels in a second critically ill patient cohort, suggesting that these changes may not be unique to ARDS. Early in ARDS, PBMC IRAK1c levels were associated with patient survival. Despite the similarities in MyD88 and IRAK1 alternative splicing observed in previous in vitro studies, there were differences in how MyD88 and IRAK1 alternative splicing was altered in patients with ARDS. We conclude that pre-mRNA splicing of TLR signaling genes is altered in patients with ARDS, and further investigation of altered splicing may lead to novel prognostic and therapeutic approaches.
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Affiliation(s)
- Rachel Z Blumhagen
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado.,Department of Biomedical Research, National Jewish Health, Denver, Colorado
| | - Brenna R Hedin
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado.,Department of Biomedical Research, National Jewish Health, Denver, Colorado
| | - Kenneth C Malcolm
- Department of Medicine, National Jewish Health, Denver, Colorado.,Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Ellen L Burnham
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Edward Abraham
- Office of the Dean, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tristan J Huie
- Department of Medicine, National Jewish Health, Denver, Colorado.,Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, Colorado.,Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Tasha E Fingerlin
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado.,Department of Biomedical Research, National Jewish Health, Denver, Colorado.,Department of Biostatistics and Bioinformatics, Colorado School of Public Health, Aurora, Colorado
| | - Scott Alper
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado; .,Department of Biomedical Research, National Jewish Health, Denver, Colorado.,Program in Mucosal Inflammation and Immunity, National Jewish Health, Denver, Colorado; and.,Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado
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49
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Burnham EL, McNally A, Gaydos J, Brown LAS. The Relationship Between Airway Antioxidant Levels, Alcohol Use Disorders, and Cigarette Smoking. Alcohol Clin Exp Res 2016; 40:2147-2160. [PMID: 27627733 DOI: 10.1111/acer.13201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 04/03/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Alcohol use disorders (AUDs) and cigarette smoking are associated with pulmonary oxidative stress, likely related to antioxidant depletion. Pulmonary oxidative stress may adversely affect innate immunity, leading to increased pneumonia susceptibility and severity, including development of the acute respiratory distress syndrome. In people with AUDs, most of whom smoke, antioxidant therapy can potentially restore immune cell function and attenuate pneumonia development. Challenges to human investigations of antioxidant therapies include an inability to identify pulmonary oxidative stress noninvasively and the optimal route to deliver pulmonary antioxidants. We sought to determine whether bronchoalveolar lavage (BAL) measures of thiol antioxidants from a 50-ml upper airway aliquot approximated those in the alveolar space and to determine whether AUDs and/or smoking affected these relationships. METHODS Healthy human subjects with and without AUDs, including smokers and nonsmokers, underwent BAL. Samples obtained after the first 50-ml normal saline aliquot were analyzed as representing bronchial airways; subsequent 50-ml aliquots were analyzed as representative of the alveolar space. Reduced and oxidized (GSSG) glutathione, cysteine (Cys), and its oxidized species, cystine, along with mixed disulfides (MDs) were quantified using high-performance liquid chromatography. The percent of total thiols present in their oxidized forms, and thiol redox potentials, were calculated. RESULTS Positive correlations between upper and lower BAL fluid thiol species were observed that were most robust for GSSG (ρ = 0.85), Cys (ρ = 0.83), and MDs (ρ = 0.69), but poor for thiol redox potential measures. In contrast to nonsmokers (either with or without AUDs), in subjects with AUDs who smoked, upper BAL fluid %GSSG, Cys, and MD measures were relatively increased compared to lower. CONCLUSIONS A small volume BAL procedure may be suitable to assess intrapulmonary oxidative stress related to thiol depletion. Factors including AUDs and smoking may disproportionately increase upper airways oxidative stress that could be relevant for therapeutic interventions.
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Affiliation(s)
- Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.
| | - Alicia McNally
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeanette Gaydos
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Lou Ann S Brown
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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50
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Nick JA, Caceres SM, Kret JE, Poch KR, Strand M, Faino AV, Nichols DP, Saavedra MT, Taylor-Cousar JL, Geraci MW, Burnham EL, Fessler MB, Suratt BT, Abraham E, Moss M, Malcolm KC. Extremes of Interferon-Stimulated Gene Expression Associate with Worse Outcomes in the Acute Respiratory Distress Syndrome. PLoS One 2016; 11:e0162490. [PMID: 27606687 PMCID: PMC5015849 DOI: 10.1371/journal.pone.0162490] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/01/2016] [Indexed: 01/11/2023] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) severity may be influenced by heterogeneity of neutrophil activation. Interferon-stimulated genes (ISG) are a broad gene family induced by Type I interferons, often as a response to viral infections, which evokes extensive immunomodulation. We tested the hypothesis that over- or under-expression of immunomodulatory ISG by neutrophils is associated with worse clinical outcomes in patients with ARDS. Genome-wide transcriptional profiles of circulating neutrophils isolated from patients with sepsis-induced ARDS (n = 31) and healthy controls (n = 19) were used to characterize ISG expression. Hierarchical clustering of expression identified 3 distinct subject groups with Low, Mid and High ISG expression. ISG accounting for the greatest variability in expression were identified (MX1, IFIT1, and ISG15) and used to analyze a prospective cohort at the Colorado ARDS Network site. One hundred twenty ARDS patients from four urban hospitals were enrolled within 72 hours of initiation of mechanical ventilation. Circulating neutrophils were isolated from patients and expression of ISG determined by PCR. Samples were stratified by standard deviation from the mean into High (n = 21), Mid, (n = 82) or Low (n = 17) ISG expression. Clinical outcomes were compared between patients with High or Low ISG expression to those with Mid-range expression. At enrollment, there were no differences in age, gender, co-existing medical conditions, or type of physiologic injury between cohorts. After adjusting for age, race, gender and BMI, patients with either High or Low ISG expression had significantly worse clinical outcomes than those in the Mid for number of 28-day ventilator- and ICU-free days (P = 0.0006 and 0.0004), as well as 90-day mortality and 90-day home with unassisted breathing (P = 0.02 and 0.004). These findings suggest extremes of ISG expression by circulating neutrophils from ARDS patients recovered early in the syndrome are associated with poorer clinical outcomes.
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Affiliation(s)
- Jerry A. Nick
- Department of Medicine, National Jewish Health, Denver, Colorado, United States of America
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
| | - Silvia M. Caceres
- Department of Medicine, National Jewish Health, Denver, Colorado, United States of America
| | - Jennifer E. Kret
- St Louis County Department of Public Health, Berkeley, Missouri, United States of America
| | - Katie R. Poch
- Department of Medicine, National Jewish Health, Denver, Colorado, United States of America
| | - Matthew Strand
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, United States of America
| | - Anna V. Faino
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, United States of America
| | - David P. Nichols
- Department of Pediatrics, National Jewish Health, Denver, Colorado, United States of America
| | - Milene T. Saavedra
- Department of Medicine, National Jewish Health, Denver, Colorado, United States of America
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
| | - Jennifer L. Taylor-Cousar
- Department of Medicine, National Jewish Health, Denver, Colorado, United States of America
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
| | - Mark W. Geraci
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
| | - Ellen L. Burnham
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
| | - Michael B. Fessler
- Immunity, Inflammation, and Disease Laboratory, National Institute of Environmental Health Sciences, NIH, Research Triangle Park, North Carolina, United States of America
| | - Benjamin T. Suratt
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Edward Abraham
- Office of the Dean, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Marc Moss
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
| | - Kenneth C. Malcolm
- Department of Medicine, National Jewish Health, Denver, Colorado, United States of America
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, United States of America
- * E-mail:
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