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Halma MTJ, Tuszynski JA, Marik PE. Cancer Metabolism as a Therapeutic Target and Review of Interventions. Nutrients 2023; 15:4245. [PMID: 37836529 PMCID: PMC10574675 DOI: 10.3390/nu15194245] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Cancer is amenable to low-cost treatments, given that it has a significant metabolic component, which can be affected through diet and lifestyle change at minimal cost. The Warburg hypothesis states that cancer cells have an altered cell metabolism towards anaerobic glycolysis. Given this metabolic reprogramming in cancer cells, it is possible to target cancers metabolically by depriving them of glucose. In addition to dietary and lifestyle modifications which work on tumors metabolically, there are a panoply of nutritional supplements and repurposed drugs associated with cancer prevention and better treatment outcomes. These interventions and their evidentiary basis are covered in the latter half of this review to guide future cancer treatment.
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Affiliation(s)
- Matthew T. J. Halma
- Department of Physics and Astronomy, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
- EbMC Squared CIC, Bath BA2 4BL, UK
| | - Jack A. Tuszynski
- Department of Physics, University of Alberta, 11335 Saskatchewan Dr NW, Edmonton, AB T6G 2M9, Canada
- Department of Data Science and Engineering, The Silesian University of Technology, 44-100 Gliwice, Poland
- DIMEAS, Politecnico di Torino, Corso Duca degli Abruzzi 24, I-1029 Turin, Italy
| | - Paul E. Marik
- Frontline COVID-19 Critical Care Alliance, Washington, DC 20036, USA
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2
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Kory P, Meduri GU, Iglesias J, Varon J, Cadegiani FA, Marik PE. "MATH+" Multi-Modal Hospital Treatment Protocol for COVID-19 Infection: Clinical and Scientific Rationale. J Clin Med Res 2022; 14:53-79. [PMID: 35317360 PMCID: PMC8912998 DOI: 10.14740/jocmr4658] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
In December 2019, coronavirus disease 2019 (COVID-19), a severe respiratory illness caused by the new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working", the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and non-antiviral co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically.
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Affiliation(s)
- Pierre Kory
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
| | | | - Jose Iglesias
- Jersey Shore University Medical Center, Hackensack School of Medicine at Seton Hall, NJ, USA
| | - Joseph Varon
- University of Texas Health Science Center, Houston, TX, USA
| | | | - Paul E. Marik
- Front Line Critical Care Consortium (FLCCC.org), Washington DC, USA
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3
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Araiza A, Duran M, Patiño C, Marik PE, Varon J. The Ichikado CT score as a prognostic tool for coronavirus disease 2019 pneumonia: a retrospective cohort study. J Intensive Care 2021; 9:51. [PMID: 34419163 PMCID: PMC8379600 DOI: 10.1186/s40560-021-00566-4] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/08/2021] [Indexed: 01/08/2023] Open
Abstract
Background The relationship between computed tomography (CT) and prognosis of patients with COVID-19 pneumonia remains unclear. We hypothesized that the Ichikado CT score, obtained in the first 24 h of hospital admission, is an independent predictor for all-cause mortality during hospitalization in patients with COVID-19 pneumonia. Methods Single-center retrospective cohort study of patients with confirmed COVID-19 pneumonia admitted at our institution between March 20th, 2020 and October 31st, 2020. Patients were enrolled if, within 24 h of admission, a chest CT scan, an arterial blood gas, a complete blood count, and a basic metabolic panel were performed. Two independent radiologists, who were blinded to clinical data, retrospectively evaluated the chest CT scans following a previously described qualitative and quantitative CT scoring system. The primary outcome was all-cause in-hospital mortality or survival to hospital discharge. Secondary outcomes were new requirements for invasive mechanical ventilation and hospital length of stay. Cox regression models were used to test the association between potential independent predictors and all-cause mortality. Results Two hundred thirty-five patients, 197 survivors and 38 nonsurvivors, were studied. The median Ichikado CT score for nonsurvivors was significantly higher than survivors (P < 0.001). An Ichikado CT score of more than 172 enabled prediction of mortality, with a sensitivity of 84.2% and a specificity of 79.7%. Multivariate analysis identified Ichikado CT score (HR, 7.772; 95% CI, 3.164–19.095; P < 0.001), together with age (HR, 1.030; 95% CI, 1.030–1.060; P = 0.043), as independent predictors of all-cause in-hospital mortality. Conclusions Ichikado CT score is an independent predictor of both requiring invasive mechanical ventilation and all-cause mortality in patients hospitalized with COVID-19 pneumonia. Further prospective evaluation is necessary to confirm these findings. Trial registration: The WCG institutional review board approved this retrospective study and patient consent was waived due to its non-interventional nature (Identifier: 20210799).
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Affiliation(s)
- Alan Araiza
- United Memorial Medical Center, Houston, TX, USA.,Universidad Autónoma de Baja California, Tijuana, México
| | - Melanie Duran
- United Memorial Medical Center, Houston, TX, USA.,Universidad Xochicalco, Ensenada, México
| | - Cesar Patiño
- United Memorial Medical Center, Houston, TX, USA.,Benemérita Universidad Autónoma de Puebla, Puebla, México
| | - Paul E Marik
- United Memorial Medical Center, Houston, TX, USA
| | - Joseph Varon
- United Memorial Medical Center, Houston, TX, USA. .,University of Texas Health Science Center at Houston, Houston, TX, USA.
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4
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Colunga Biancatelli RML, Solopov PA, Sharlow ER, Lazo JS, Marik PE, Catravas JD. The SARS-CoV-2 spike protein subunit S1 induces COVID-19-like acute lung injury in Κ18-hACE2 transgenic mice and barrier dysfunction in human endothelial cells. Am J Physiol Lung Cell Mol Physiol 2021; 321:L477-L484. [PMID: 34156871 PMCID: PMC8384477 DOI: 10.1152/ajplung.00223.2021] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acute lung injury (ALI) leading to acute respiratory distress syndrome is the major cause of COVID-19 lethality. Cell entry of SARS-CoV-2 occurs via the interaction between its surface spike protein (SP) and angiotensin-converting enzyme-2 (ACE2). It is unknown if the viral spike protein alone is capable of altering lung vascular permeability in the lungs or producing lung injury in vivo. To that end, we intratracheally instilled the S1 subunit of SARS-CoV-2 spike protein (S1SP) in K18-hACE2 transgenic mice that overexpress human ACE2 and examined signs of COVID-19-associated lung injury 72 h later. Controls included K18-hACE2 mice that received saline or the intact SP and wild-type (WT) mice that received S1SP. K18-hACE2 mice instilled with S1SP exhibited a decline in body weight, dramatically increased white blood cells and protein concentrations in bronchoalveolar lavage fluid (BALF), upregulation of multiple inflammatory cytokines in BALF and serum, histological evidence of lung injury, and activation of signal transducer and activator of transcription 3 (STAT3) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathways in the lung. K18-hACE2 mice that received either saline or SP exhibited little or no evidence of lung injury. WT mice that received S1SP exhibited a milder form of COVID-19 symptoms, compared with the K18-hACE2 mice. Furthermore, S1SP, but not SP, decreased cultured human pulmonary microvascular transendothelial resistance (TER) and barrier function. This is the first demonstration of a COVID-19-like response by an essential virus-encoded protein by SARS-CoV-2 in vivo. This model of COVID-19-induced ALI may assist in the investigation of new therapeutic approaches for the management of COVID-19 and other coronaviruses.
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Affiliation(s)
| | - Pavel A Solopov
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, Virginia
| | - Elizabeth R Sharlow
- Department of Pharmacology, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - John S Lazo
- Department of Pharmacology, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Paul E Marik
- Division of Pulmonary Disease and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia
| | - John D Catravas
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, Virginia.,Division of Pulmonary Disease and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia.,School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, Virginia
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Abstract
BACKGROUND After COVID-19 emerged on U.S shores, providers began reviewing the emerging basic science, translational, and clinical data to identify potentially effective treatment options. In addition, a multitude of both novel and repurposed therapeutic agents were used empirically and studied within clinical trials. AREAS OF UNCERTAINTY The majority of trialed agents have failed to provide reproducible, definitive proof of efficacy in reducing the mortality of COVID-19 with the exception of corticosteroids in moderate to severe disease. Recently, evidence has emerged that the oral antiparasitic agent ivermectin exhibits numerous antiviral and anti-inflammatory mechanisms with trial results reporting significant outcome benefits. Given some have not passed peer review, several expert groups including Unitaid/World Health Organization have undertaken a systematic global effort to contact all active trial investigators to rapidly gather the data needed to grade and perform meta-analyses. DATA SOURCES Data were sourced from published peer-reviewed studies, manuscripts posted to preprint servers, expert meta-analyses, and numerous epidemiological analyses of regions with ivermectin distribution campaigns. THERAPEUTIC ADVANCES A large majority of randomized and observational controlled trials of ivermectin are reporting repeated, large magnitude improvements in clinical outcomes. Numerous prophylaxis trials demonstrate that regular ivermectin use leads to large reductions in transmission. Multiple, large "natural experiments" occurred in regions that initiated "ivermectin distribution" campaigns followed by tight, reproducible, temporally associated decreases in case counts and case fatality rates compared with nearby regions without such campaigns. CONCLUSIONS Meta-analyses based on 18 randomized controlled treatment trials of ivermectin in COVID-19 have found large, statistically significant reductions in mortality, time to clinical recovery, and time to viral clearance. Furthermore, results from numerous controlled prophylaxis trials report significantly reduced risks of contracting COVID-19 with the regular use of ivermectin. Finally, the many examples of ivermectin distribution campaigns leading to rapid population-wide decreases in morbidity and mortality indicate that an oral agent effective in all phases of COVID-19 has been identified.
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Affiliation(s)
- Pierre Kory
- Front-Line Covid-19 Critical Care Alliance, Madison, WI
| | - Gianfranco Umberto Meduri
- Memphis VA Medical Center—University of Tennessee Health Science Center, Pulmonary, Critical Care, and Research Services, Memphis, TN
| | - Joseph Varon
- University of Texas Health Science Center, Critical Care Service, Houston, TX
| | - Jose Iglesias
- Department of Medicine, Hackensack School of Medicine, Seton Hall, NJ; and
| | - Paul E. Marik
- Eastern Virginia Medical School, Division of Pulmonary and Critical Care, Norfolk, VA
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6
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Abstract
COVID-19 is a highly heterogeneous and complex medical disorder; indeed, severe COVID-19 is probably amongst the most complex of medical conditions known to medical science. While enormous strides have been made in understanding the molecular pathways involved in patients infected with coronaviruses an overarching and comprehensive understanding of the pathogenesis of COVID-19 is lacking. Such an understanding is essential in the formulation of effective prophylactic and treatment strategies. Based on clinical, proteomic, and genomic studies as well as autopsy data severe COVID-19 disease can be considered to be the connection of three basic pathologic processes, namely a pulmonary macrophage activation syndrome with uncontrolled inflammation, a complement-mediated endothelialitis together with a procoagulant state with a thrombotic microangiopathy. In addition, platelet activation with the release of serotonin and the activation and degranulation of mast cells contributes to the hyper-inflammatory state. Auto-antibodies have been demonstrated in a large number of hospitalized patients which adds to the end-organ damage and pro-thrombotic state. This paper provides a clinical overview of the major pathogenetic mechanism leading to severe COVID-19 disease.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
- Front Line Covid-19 Critical Care Alliance
| | - Jose Iglesias
- Department of Nephrology, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, USA
- Front Line Covid-19 Critical Care Alliance
| | - Joseph Varon
- Department of Critical Care Medicine, United Memorial Medical Center, Houston, TX, USA
- Front Line Covid-19 Critical Care Alliance
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7
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Kory P, Meduri GU, Iglesias J, Varon J, Marik PE. Clinical and Scientific Rationale for the "MATH+" Hospital Treatment Protocol for COVID-19. J Intensive Care Med 2020; 36:135-156. [PMID: 33317385 DOI: 10.1177/0885066620973585] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 12/12/2022]
Abstract
In December 2019, COVID-19, a severe respiratory illness caused by the new coronavirus SARS-CoV-2 (COVID-19) emerged in Wuhan, China. The greatest impact that COVID-19 had was on intensive care units (ICUs), given that approximately 20% of hospitalized cases developed acute respiratory failure (ARF) requiring ICU admission. Based on the assumption that COVID-19 represented a viral pneumonia and no anti-coronaviral therapy existed, nearly all national and international health care societies' recommended "supportive care only" avoiding other therapies outside of randomized controlled trials, with a specific prohibition against the use of corticosteroids in treatment. However, early studies of COVID-19-associated ARF reported inexplicably high mortality rates, with frequent prolonged durations of mechanical ventilation (MV), even from centers expert in such supportive care strategies. These reports led the authors to form a clinical expert panel called the Front-Line COVID-19 Critical Care Alliance (www.flccc.net). The panel collaboratively reviewed the emerging clinical, radiographic, and pathological reports of COVID-19 while initiating multiple discussions among a wide clinical network of front-line clinical ICU experts from initial outbreak areas in China, Italy, and New York. Based on the shared early impressions of "what was working and what wasn't working," the increasing medical journal publications and the rapidly accumulating personal clinical experiences with COVID-19 patients, a treatment protocol was created for the hospitalized patients based on the core therapies of methylprednisolone, ascorbic acid, thiamine, heparin and co-interventions (MATH+). This manuscript reviews the scientific and clinical rationale behind MATH+ based on published in-vitro, pre-clinical, and clinical data in support of each medicine, with a special emphasis of studies supporting their use in the treatment of patients with viral syndromes and COVID-19 specifically. The review concludes with a comparison of published multi-national mortality data with MATH+ center outcomes.
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Affiliation(s)
- Pierre Kory
- 22392Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - G Umberto Meduri
- Memphis VA Medical Center, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jose Iglesias
- Jersey Shore University Medical Center, Hackensack School of Medicine at Seton Hall, NJ, USA
| | - Joseph Varon
- 12340University of Texas Health Science Center, Houston, TX, USA
| | - Paul E Marik
- 6040Eastern Virginia Medical School, Norfolk, VA, USA
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8
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Holford P, Carr AC, Jovic TH, Ali SR, Whitaker IS, Marik PE, Smith AD. Vitamin C-An Adjunctive Therapy for Respiratory Infection, Sepsis and COVID-19. Nutrients 2020; 12:E3760. [PMID: 33297491 PMCID: PMC7762433 DOI: 10.3390/nu12123760] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 12/15/2022] Open
Abstract
There are limited proven therapies for COVID-19. Vitamin C's antioxidant, anti-inflammatory and immunomodulating effects make it a potential therapeutic candidate, both for the prevention and amelioration of COVID-19 infection, and as an adjunctive therapy in the critical care of COVID-19. This literature review focuses on vitamin C deficiency in respiratory infections, including COVID-19, and the mechanisms of action in infectious disease, including support of the stress response, its role in preventing and treating colds and pneumonia, and its role in treating sepsis and COVID-19. The evidence to date indicates that oral vitamin C (2-8 g/day) may reduce the incidence and duration of respiratory infections and intravenous vitamin C (6-24 g/day) has been shown to reduce mortality, intensive care unit (ICU) and hospital stays, and time on mechanical ventilation for severe respiratory infections. Further trials are urgently warranted. Given the favourable safety profile and low cost of vitamin C, and the frequency of vitamin C deficiency in respiratory infections, it may be worthwhile testing patients' vitamin C status and treating them accordingly with intravenous administration within ICUs and oral administration in hospitalised persons with COVID-19.
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Affiliation(s)
- Patrick Holford
- Institute for Optimum Nutrition, Ambassador House, Richmond TW9 1SQ, UK
| | - Anitra C. Carr
- Nutrition in Medicine Research Group, Department of Pathology & Biomedical Science, University of Otago, Christchurch 8140, New Zealand;
| | - Thomas H. Jovic
- Reconstructive Surgery & Regenerative Medicine Research Group, Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea SA2 8PY, UK; (T.H.J.); (S.R.A.); (I.S.W.)
- Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, UK
| | - Stephen R. Ali
- Reconstructive Surgery & Regenerative Medicine Research Group, Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea SA2 8PY, UK; (T.H.J.); (S.R.A.); (I.S.W.)
- Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, UK
| | - Iain S. Whitaker
- Reconstructive Surgery & Regenerative Medicine Research Group, Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea SA2 8PY, UK; (T.H.J.); (S.R.A.); (I.S.W.)
- Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea SA6 6NL, UK
| | - Paul E. Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA;
| | - A. David Smith
- Department of Pharmacology, University of Oxford, Oxford OX1 3QT, UK;
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9
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Arvinte C, Singh M, Marik PE. Serum Levels of Vitamin C and Vitamin D in a Cohort of Critically Ill COVID-19 Patients of a North American Community Hospital Intensive Care Unit in May 2020: A Pilot Study. Med Drug Discov 2020; 8:100064. [PMID: 32964205 PMCID: PMC7499070 DOI: 10.1016/j.medidd.2020.100064] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [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: 08/11/2020] [Revised: 08/29/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background The COVID-19 pandemic has placed an enormous and growing burden on the population and health infrastructure, warranting innovative ways to mitigate risk of contracting and developing severe forms of this disease. A growing body of literature raises the issue of vitamin C and vitamin D as a risk-assessment tool, and therapeutic option, in COVID-19. Objective The objective of this pilot study was to measure serum vitamin C and vitamin D levels in a cohort of patients with critical COVID-19 illness in our community hospital ICU, correlate with other illness risk factors (age, BMI, HgbA1c, smoking status), generate hypotheses, and suggest further therapeutic intervention studies. Method This pilot study included all 21 critically ill COVID-19 patients hospitalized in May 2020 in the ICU of North Suburban Medical Center, Thornton, Colorado, in whose care the principal investigator (C.A.) was involved. We measured patients' serum vitamin C and vitamin D levels, and standard risk factors like age, BMI, HbA1c, and smoking status. Variables in this study were gauged using descriptive statistics. Results Of 21 critically ill COVID-19 patients (15 males and 6 females, 17 Hispanic and 4 Caucasian, of median age 61 years, range 20-94), there were 11 survivors.Serum levels of vitamin C and vitamin D were low in most of our critically ill COVID-19 ICU patients.Older age and low vitamin C level appeared co-dependent risk factors for mortality from COVID-19 in our sample.Insulin resistance and obesity were prevalent in our small cohort, but smoking was not. Conclusion Our pilot study found low serum levels of vitamin C and vitamin D in most of our critically ill COVID-19 ICU patients. Older age and low vitamin C level appeared co-dependent risk factors for mortality. Many were also insulin-resistant or diabetic, overweight or obese, known as independent risk factors for low vitamin C and vitamin D levels, and for COVID-19.These findings suggest the need to further explore whether caring for COVID-19 patients ought to routinely include measuring and correcting serum vitamin C and vitamin D levels, and whether treating critically ill COVID-19 warrants acute parenteral vitamin C and vitamin D replacement.
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Affiliation(s)
- Cristian Arvinte
- Intensivist & Pulmonologist, North Suburban Medical Center, Thornton, Colorado 80229, USA
| | - Maharaj Singh
- Research Assistant Professor, Biostatistics, Research and Graduate Studies, Marquette University, School of Dentistry, Milwaukee, Wisconsin 53201, USA.,Biostatistician Senior, Advocate Aurora Research Institute, Advocate Aurora Health Care, Milwaukee, Wisconsin, 53233, USA
| | - Paul E Marik
- Chief, Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia 23507, USA
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10
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Marik PE, Kory P, Varon J, Iglesias J, Meduri GU. MATH+ protocol for the treatment of SARS-CoV-2 infection: the scientific rationale. Expert Rev Anti Infect Ther 2020; 19:129-135. [PMID: 32809870 DOI: 10.1080/14787210.2020.1808462] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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]
Abstract
INTRODUCTION COVID-19 disease progresses through a number of distinct phases. The management of each phase is unique and specific. The pulmonary phase of COVID-19 is characterized by an organizing pneumonia with profound immune dysregulation, activation of clotting, and a severe microvascular injury culminating in severe hypoxemia. The core treatment strategy to manage the pulmonary phase includes the combination of methylprednisolone, ascorbic acid, thiamine, and heparin (MATH+ protocol). The rationale for the MATH+ protocol is reviewed in this paper. AREAS COVERED We provide an overview on the pathophysiological changes occurring in patients with COVID-19 respiratory failure and a treatment strategy to reverse these changes thereby preventing progressive lung injury and death. EXPERT OPINION While there is no single 'Silver Bullet' to cure COVID-19, we believe that the severely disturbed pathological processes leading to respiratory failure in patients with COVID-19 organizing pneumonia will respond to the combination of Methylprednisone, Ascorbic acid, Thiamine, and full anticoagulation with Heparin (MATH+ protocol).We believe that it is no longer ethically acceptable to limit management to 'supportive care' alone, in the face of effective, safe, and inexpensive medications that can effectively treat this disease and thereby reduce the risk of complications and death.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School , Norfolk, VA, USA
| | - Pierre Kory
- Trauma and Life Support Center, Critical Care Service, University of Wisconsin School of Medicine and Public Health , Madison, WI, USA
| | - Joseph Varon
- Department of Critical Care Medicine, United Memorial, Medical Center , Houston, TX, USA
| | - Jose Iglesias
- Department of Nephrology and Critical Care, Hackensack Meridian School of Medicine at Seton Hall University , Nutley, NJ, USA.,Department of Nephrology and Critical Care, Community Medical Center , Toms River, NJ, USA
| | - G Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Tennessee Health Science Center , Memphis, TN, USA.,Memphis Veterans Affairs Medical Center , Memphis, TN, USA
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11
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Marik PE, Stephenson E. The ability of Procalcitonin, lactate, white blood cell count and neutrophil-lymphocyte count ratio to predict blood stream infection. Analysis of a large database. J Crit Care 2020; 60:135-139. [PMID: 32799183 DOI: 10.1016/j.jcrc.2020.07.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 06/08/2020] [Revised: 07/15/2020] [Accepted: 07/26/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The global burden of death due to sepsis is considerable. Early diagnosis is essential to improve the outcome of this deadly syndrome. Yet, the diagnosis of sepsis is fraught with difficulties. Patients with blood stream infection (BSI) are at an increased risk of complications and death. The aim of this study was to determine the diagnostic accuracy of four readily available biomarkers to diagnose BSI in patients with suspected sepsis. METHODS In this retrospective, observational, Electronic Medical Record based study we compared the accuracy of procalcitonin (PCT), serum lactate concentration, total white blood cell (WBC) count and the neutrophil-lymphocyte count ratio (NLCR) to diagnose BSI in adult patients presenting to hospital with suspected sepsis. Based on the blood culture results patients were classified into 1 of the following 5 groups: i) negative blood cultures, ii) positive for a bacterial pathogen, iii) positive for a potential pathogen, iv) fungal pathogen and v) potential contaminant. Group 2 was further divided into Gram -ve and Gram +ve pathogens. Receiver operating characteristic (ROC) curves were constructed to compare the diagnostic performance of the biomarkers. RESULTS There were 1767 discreet patient admissions. The median PCT concentration differed significantly across blood culture groups (p < 0.0001). The highest median PCT concentration was observed in patients with a Gram-negative pathogen (17.1 ng/mL; IQR 3.6-49.7) and the lowest PCT in patients with negative blood cultures (0.6 ng/mL; IQR 0.2-2.8). The AUROC was 0.83 (0.79-0.86) for PCT, 0.68 (0.64-0.72) for the NLCR, 0.55 (0.51-0.60) for lactate concentration and 0.52 (0.48-0.57) for the WBC count. The AUROC for PCT was significantly greater than that of the NLCR (p < 0.0001). A PCT less than 0.5 ng/mL had a negative predictive value of 95% for excluding BSI. The best cut-off value of PCT for predicting BSI was 1.5 ng/ml. CONCLUSION Our results suggest that PCT of less than 0.5 ng/mL may be an effective screening tool to exclude BSI as the cause of sepsis, while the diagnosis of BSI should be considered in patients with a PCT above this threshold. The total WBC count and blood lactate concentration may not be reliable biomarkers for the diagnosis of BSI. The NLCR may be a useful screening test for BSI when PCT assays are not available.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Elise Stephenson
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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12
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Domínguez-Rodríguez A, Reiter RJ, Abreu-González P, Marik PE. [Melatonin, coronavirus, cardiovascular disease, and the geriatric emergency: let's use everything we have!]. Rev Esp Cardiol 2020; 73:1081-1082. [PMID: 32836663 PMCID: PMC7332906 DOI: 10.1016/j.recesp.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alberto Domínguez-Rodríguez
- Departamento de Cardiología, Hospital Universitario de Canarias San Cristóbal de La Laguna, Santa Cruz de Tenerife, España
- Facultad de Ciencias de la Salud, Universidad Europea de Canarias, La Orotava, Santa Cruz de Tenerife, España
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, CIBERCV, Madrid, España
| | - Russel J Reiter
- Department of Cell Systems and Anatomy, UT Health San Antonio, San Antonio, Texas, Estados Unidos
| | - Pedro Abreu-González
- Departamento de Fisiología, Facultad de Medicina, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, Estados Unidos
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13
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Colunga Biancatelli RML, Berrill M, Catravas JD, Marik PE. Quercetin and Vitamin C: An Experimental, Synergistic Therapy for the Prevention and Treatment of SARS-CoV-2 Related Disease (COVID-19). Front Immunol 2020; 11:1451. [PMID: 32636851 PMCID: PMC7318306 DOI: 10.3389/fimmu.2020.01451] [Citation(s) in RCA: 267] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/04/2020] [Indexed: 12/25/2022] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) represents an emergent global threat which is straining worldwide healthcare capacity. As of May 27th, the disease caused by SARS-CoV-2 (COVID-19) has resulted in more than 340,000 deaths worldwide, with 100,000 deaths in the US alone. It is imperative to study and develop pharmacological treatments suitable for the prevention and treatment of COVID-19. Ascorbic acid is a crucial vitamin necessary for the correct functioning of the immune system. It plays a role in stress response and has shown promising results when administered to the critically ill. Quercetin is a well-known flavonoid whose antiviral properties have been investigated in numerous studies. There is evidence that vitamin C and quercetin co-administration exerts a synergistic antiviral action due to overlapping antiviral and immunomodulatory properties and the capacity of ascorbate to recycle quercetin, increasing its efficacy. Safe, cheap interventions which have a sound biological rationale should be prioritized for experimental use in the current context of a global health pandemic. We present the current evidence for the use of vitamin C and quercetin both for prophylaxis in high-risk populations and for the treatment of COVID-19 patients as an adjunct to promising pharmacological agents such as Remdesivir or convalescent plasma.
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Affiliation(s)
- Ruben Manuel Luciano Colunga Biancatelli
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, United States.,Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA, United States.,Policlinico Umberto I, La Sapienza University of Rome, Rome, Italy
| | - Max Berrill
- Department of Respiratory Medicine, St. Peter's Hospital, Surrey, United Kingdom
| | - John D Catravas
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, United States.,Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA, United States.,School of Medical Diagnostic & Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA, United States
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
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14
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Reiter RJ, Abreu-Gonzalez P, Marik PE, Dominguez-Rodriguez A. Therapeutic Algorithm for Use of Melatonin in Patients With COVID-19. Front Med (Lausanne) 2020; 7:226. [PMID: 32574327 PMCID: PMC7242729 DOI: 10.3389/fmed.2020.00226] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/04/2020] [Indexed: 01/08/2023] Open
Abstract
The coronavirus, COVID-19, has infected hundreds of thousands and killed tens of thousands of individuals worldwide. This highly infectious condition continues to ravage the world population and has yet to reach it peak infective rate in some countries. Many conventional drugs including hydroxychloroquine/chloroquine, lopinavir, remdesivir, etc., have been repurposed as treatments for this often deadly disease, but there is no specifically-designed effective drug available; also, the drugs mentioned have significant side effects and their efficacy is unknown. New drugs and vaccines are being designed as COVID-19 treatment, but their development and testing will require months to years. Time is not a luxury that this crisis has. Thus, there is a serious unmet need for the identification of currently-available and safe molecules which can be used to slow or treat COVID-19 disease. Here, we suggest melatonin be given consideration for prophylactic use or treatment alone or in combination with other drugs. Melatonin's multiple actions as an anti-inflammatory, anti-oxidant, and anti-viral (against other viruses) make it a reasonable choice for use. Melatonin is readily available, can be easily synthesized in large quantities, is inexpensive, has a very high safety profile and can be easily self-administered. Melatonin is endogenously-produced molecule in small amounts with its production diminishing with increased age. Under the current critical conditions, large doses of melatonin alone or in combination with currently-recommended drugs, e.g., hydroxychloroquine/chloroquine, to resist COVID-19 infection would seem judicious.
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Affiliation(s)
- Russel J Reiter
- Department of Cell Systems and Anatomy, UT Health San Antonio, San Antonio, TX, United States
| | - Pedro Abreu-Gonzalez
- Department of Physiology, Faculty of Medicine, University of La Laguna, San Cristóbal de La Laguna, Spain
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Alberto Dominguez-Rodriguez
- Department of Cardiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.,Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Santa Cruz de Tenerife, Spain.,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
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15
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Reiter RJ, Sharma R, Ma Q, Dominquez-Rodriguez A, Marik PE, Abreu-Gonzalez P. Melatonin Inhibits COVID-19-induced Cytokine Storm by Reversing Aerobic Glycolysis in Immune Cells: A Mechanistic Analysis. Med Drug Discov 2020; 6:100044. [PMID: 32395713 PMCID: PMC7211589 DOI: 10.1016/j.medidd.2020.100044] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Russel J. Reiter
- Department of Cell Systems and Anatomy, UT Health San Antonio, San Antonio, TX, United States of America
- Corresponding author:
| | - Ramaswamy Sharma
- Department of Cell Systems and Anatomy, UT Health San Antonio, San Antonio, TX, United States of America
| | - Qiang Ma
- Department of Cell Systems and Anatomy, UT Health San Antonio, San Antonio, TX, United States of America
| | | | - Paul E. Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Pedro Abreu-Gonzalez
- Department of Physiology, Faculty of Medicine, University of La Laguna, Tenerife, Spain
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16
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Martin GS, Kaufman DA, Marik PE, Shapiro NI, Levett DZH, Whittle J, MacLeod DB, Chappell D, Lacey J, Woodcock T, Mitchell K, Malbrain MLNG, Woodcock TM, Martin D, Imray CHE, Manning MW, Howe H, Grocott MPW, Mythen MG, Gan TJ, Miller TE. Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance. Perioper Med (Lond) 2020; 9:12. [PMID: 32337020 PMCID: PMC7171743 DOI: 10.1186/s13741-020-00142-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 09/30/2019] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background Optimal fluid therapy in the perioperative and critical care settings depends on understanding the underlying cardiovascular physiology and individualizing assessment of the dynamic patient state. Methods The Perioperative Quality Initiative (POQI-5) consensus conference brought together an international team of multidisciplinary experts to survey and evaluate the literature on the physiology of volume responsiveness and perioperative fluid management. The group used a modified Delphi method to develop consensus statements applicable to the physiologically based management of intravenous fluid therapy in the perioperative setting. Discussion We discussed the clinical and physiological evidence underlying fluid responsiveness and venous capacitance as relevant factors in fluid management and developed consensus statements with clinical implications for a broad group of clinicians involved in intravenous fluid therapy. Two key concepts emerged as follows: (1) The ultimate goal of fluid therapy and hemodynamic management is to support the conditions that enable normal cellular metabolic function in order to produce optimal patient outcomes, and (2) optimal fluid and hemodynamic management is dependent on an understanding of the relationship between pressure, volume, and flow in a dynamic system which is distensible with variable elastance and capacitance properties.
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Affiliation(s)
- Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory Critical Care Center, Emory University School of Medicine, Grady Health System, Atlanta, GA USA
| | - David A Kaufman
- 2Division of Pulmonary, Critical Care, and Sleep Medicine, NYU School of Medicine, New York, NY USA
| | - Paul E Marik
- 3Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA USA
| | - Nathan I Shapiro
- 4Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Denny Z H Levett
- 5Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,17Department of Anesthesiology and Critical Care, Stony Brook University, Stony Brook, New York, USA
| | - John Whittle
- 6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA
| | - David B MacLeod
- 6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA
| | - Desiree Chappell
- TopMedTalk, London, UK.,Private address: Louisville, Kentucky, USA
| | - Jonathan Lacey
- 8Institute of Sport Exercise & Health, University College London, London, UK
| | - Tom Woodcock
- 9University Hospitals Southampton, Southampton, UK
| | - Kay Mitchell
- 10Respiratory Biomedical Research Unit, University of Southampton, Southampton, England
| | - Manu L N G Malbrain
- 11Department of Intensive Care, University Hospital Brussels, Jette, Belgium and Facultyof Medicine and Pharmacy, Vrije Universiteit Brussels, Brussels, Belgium
| | - Tom M Woodcock
- Elsevier R&D Solutions, 1600 JFK Blvd, Philadelphia, PA 19103 USA
| | - Daniel Martin
- 13Intensive Care Unit and Division of Surgery and Interventional Science, Royal Free Hospital, London, UK
| | - Chris H E Imray
- Vascular and Renal Tranplant Surgeon, National Institute of Health Research Clinical Research Facility, Coventry, UK
| | - Michael W Manning
- 6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA
| | | | - Michael P W Grocott
- 5Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,17Department of Anesthesiology and Critical Care, Stony Brook University, Stony Brook, New York, USA
| | - Monty G Mythen
- 15UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Tong J Gan
- 16Department of Anesthesiology, Stony Brook University, Stony Brook, NY USA
| | - Timothy E Miller
- 6Department of Anesthesiology, Division of General, Vascular and Transplant Anesthesia, Duke University School of Medicine, Duke University Medical Center, Durham, NC USA
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17
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fair Suite 410, Norfolk, VA 23507, UK.
| | - Didier Payen
- University Paris 7 Denis Diderot, Cité Sorbonne, Paris, France
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18
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Marik PE, Shankaran S, King L. The effect of copper-oxide-treated soft and hard surfaces on the incidence of healthcare-associated infections: a two-phase study. J Hosp Infect 2020; 105:265-271. [PMID: 32068014 DOI: 10.1016/j.jhin.2020.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Copper-oxide-impregnated linens and hard surfaces within the hospital environment have emerged as a novel technology to reduce environmental contamination and thereby potentially reduce the risk of healthcare-associated infections (HCAIs). METHODS This was a two-phase study. Phase 1 was a prospective, cluster-randomized, cross-over clinical trial in which one pod (eight beds) of our general ICU (GICU) utilized copper-oxide-impregnated linens whereas the other pod (eight beds) used standard hospital linens. Phase 2 was a two-year before-after study, following the relocation of three ICUs into a new ICU tower in which all the hard surfaces were treated with copper oxide (in addition to copper-impregnated linens). HCAIs were recorded using the National Healthcare Safety Network definitions. FINDINGS A total of 1282 patients were enrolled in phase 1. There was no difference in the rate of HCAI between the patients who received standard compared with copper oxide linen. In phase 2 there was a significant reduction in the number of infections due to Clostridioides difficile (2.4 per 1000 vs 0.7 per 1000 patient-days; incidence rate ratio: 3.3; 95% confidence interval: 1.4-8.7; P = 0.002) but no difference in the rate of central-line-associated bloodstream infections nor of catheter-associated urinary tract infections. CONCLUSION Copper-oxide-impregnated linens alone had no effect on the rate of HCAI. Our data suggest that copper-oxide-treated hard surfaces reduced the rate of infections due to C. difficile; however, important confounders cannot be excluded.
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Affiliation(s)
- P E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.
| | - S Shankaran
- Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk, VA, USA; Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - L King
- Infection Prevention and Control Coordinator, Sentara Norfolk General Hospital, Norfolk, VA, USA
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19
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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20
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Abstract
The stress response is a preserved evolutionary response that functions to enhance the survival of the species. In mammals, the stress response is characterized by activation of the HPA axis and sympathoadrenal system (SAS) as well as the increased synthesis and secretion of vitamin C. Cortisol, catecholamines, and vitamin C act synergistically to increase hemodynamic reserve, maintain immune function and protect the host against excessive oxidant injury. Humans (and anthropoid apes) have lost the ability to synthesize vitamin C and therefore have an impaired stress response. The inability to produce vitamin C has serious implications in septic humans. Treatment with vitamin C appears to restore the stress response and improve the survival of stressed humans.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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21
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Abstract
Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation.
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Affiliation(s)
- Paul E Marik
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Liam Byrne
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia
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22
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Abstract
Sepsis affects 30 million people worldwide, leading to 6 million deaths every year (WHO), and despite decades of research, novel initiatives are drastically needed. According to the current literature, oxidative imbalance and mitochondrial dysfunction are common features of septic patients that can cause multiorgan failure and death. Melatonin, alongside its traditionally accepted role as the master hormonal regulator of the circadian rhythm, is a promising adjunctive drug for sepsis through its anti-inflammatory, antiapoptotic and powerful antioxidant properties. Several animal models of sepsis have demonstrated that melatonin can prevent multiorgan dysfunction and improve survival through restoring mitochondrial electron transport chain (ETC) function, inhibiting nitric oxide synthesis and reducing cytokine production. The purpose of this article is to review the current evidence for the role of melatonin in sepsis, review its pharmacokinetic profile and virtual absence of side effects. While clinical data is limited, we propose the adjunctive use of melatonin is patients with severe sepsis and septic shock.
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Affiliation(s)
- Ruben Manuel Luciano Colunga Biancatelli
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.,Policlinico Umberto I, La Sapienza University of Rome, Rome, Italy
| | - Max Berrill
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.,St. Peter's Hospital, Department of Respiratory Medicine, London, UK
| | - Yassen H Mohammed
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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23
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Abstract
The use of lactate as a marker of the severity of circulatory shock was popularized by Dr. Weil in the 1970's. Dr. Weil promoted the idea that blood lactate concentration increased in circulatory shock due to anaerobic metabolism following decreased oxygen delivery. This concept becomes entrenched with 1992 ACCP/SCCM consensus conference definition of sepsis. Since then, the central role of lactate in the definition and management of septic shock has only been expanded and become more ingrained. This review will discuss the wisdom of such an approach, an updated model describing the origins of hyperlactatemia in sepsis, and how such improvements in our knowledge of the underlying physiology should change our approach to resuscitation in patients presenting with septic shock.
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Affiliation(s)
- Rory Spiegel
- Department of Critical Care and Department of Emergency Medicine, Georgetown University Medstar Washington Hospital Center, Washington, DC, USA
| | - David Gordon
- Department of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD, USA
| | - Paul E Marik
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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24
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Affiliation(s)
- Ruben Manuel Luciano Colunga Biancatelli
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.,Policlinico Umberto I, La Sapienza University of Rome, Rome, Italy
| | - Max Berrill
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.,Department of Medicine, Queen Mary University of London, London, UK
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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25
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Marik PE, Varon J. Predatory Journals: Beware on Who You Trust. CRMR 2019. [DOI: 10.2174/1573398x1502191014113701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Paul E. Marik
- Department of Internal Medicine and Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, United States
| | - Joseph Varon
- Department of Critical Care, United General Hospital Houston, Texas, United States
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26
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk
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27
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Marik PE, Farkas JD, Spiegel R, Weingart S. POINT: Should the Surviving Sepsis Campaign Guidelines Be Retired? Yes. Chest 2019; 155:12-14. [PMID: 30616719 DOI: 10.1016/j.chest.2018.10.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/29/2023] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington VT
| | - Rory Spiegel
- Department Emergency Medicine, Critical Care Fellow Division of Pulmonary Critical Care University of Maryland Medical Center, Baltimore, MD
| | - Scott Weingart
- Department Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
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28
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Marik PE, Farkas JD, Spiegel R, Weingart S. Rebuttal From Drs Marik, Farkas, Spiegel et al. Chest 2019; 155:17-18. [PMID: 30616721 DOI: 10.1016/j.chest.2018.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington VT
| | - Rory Spiegel
- Department Emergency Medicine, Critical Care Fellow Division of Pulmonary Critical Care University of Maryland Medical Center, Baltimore, MD
| | - Scott Weingart
- Department Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
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29
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Marik PE. Response. Chest 2019; 154:229. [PMID: 30044742 DOI: 10.1016/j.chest.2018.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 03/14/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, East Virginia Medical School, Norfolk, VA.
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30
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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31
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Marik PE, Hooper MH, Khangoora V, Rivera R, Catravas J. Response. Chest 2019; 152:690-691. [PMID: 28889895 DOI: 10.1016/j.chest.2017.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, VA
| | - John Catravas
- Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA; School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA
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32
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Marik PE, Rivera R, Hooper MH, Khangoora V, Catravas J. Response. Chest 2019; 152:677. [PMID: 28889882 DOI: 10.1016/j.chest.2017.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital; and the School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John Catravas
- Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA
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33
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Marik PE, Liggett A. Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders. Crit Care 2019; 23:165. [PMID: 31077227 PMCID: PMC6511125 DOI: 10.1186/s13054-019-2435-4] [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] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND At least a third of the world's population consumes alcohol regularly. Patients with alcohol use disorders (AUDs) are frequently hospitalized for both alcohol-related and unrelated medical conditions. It is well recognized that patients with an AUD are thiamine deficient with thiamine replacement therapy being considered the standard of care. However, the incidence of vitamin C deficiency in this patient population has been poorly defined. METHODS In this retrospective, observational study, we recorded the admission vitamin C level in patients with an AUD admitted to our medical intensive care unit (MICU) over a 1-year period. In addition, we recorded relevant clinical and laboratory data including the day 2 and day 3 vitamin C level following empiric treatment with vitamin C. Septic patients were excluded from this study. RESULTS Sixty-nine patients met the inclusion criteria for this study. The patients' mean age was 53 ± 14 years; 52 patients (75%) were males. Severe alcohol withdrawal syndrome was the commonest admitting diagnosis (46%). Eighteen patients (26%) had cirrhosis as the admitting diagnosis with 18 (13%) patients admitted due to alcohol/drug intoxication. Forty-six patients (67%) had evidence of acute alcoholic hepatitis. The mean admission vitamin C level was 17.0 ± 18.1 μmol/l (normal 40-60 μmol/l). Sixty-one (88%) patients had a level less than 40 μmol/l (subnormal) while 52 patients (75%) had hypovitaminosis C (level < 23 μmol/l). None of the variables recorded predicted the vitamin C level. Various vitamin C replacement dosing strategies were used. A 1.5-g loading dose, followed by 500-mg PO q 6, was effective in restoring blood levels to normal by day 2. CONCLUSION Our results suggest that hypovitaminosis C is exceedingly common in patients with an AUD admitted to an intensive care unit and that all such patients should receive supplementation with vitamin C in addition to thiamine. Additional studies are required to confirm the findings of our observational study and to determine the optimal vitamin C dosing strategy.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 721 Fairfax Ave, Suite 423, Norfolk, VA, 23507, USA.
| | - Amanda Liggett
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 721 Fairfax Ave, Suite 423, Norfolk, VA, 23507, USA. .,Department of Medicine, Eastern Virginia Medical School, 721 Fairfax ave, Norfolk, VA, 23507, USA.
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Marik PE. Procalcitonin is an essential biomarker for hydrocortisone, ascorbic acid, and thiamine (HAT) therapy in patients with sepsis. Crit Care 2019; 23:151. [PMID: 31046800 PMCID: PMC6498640 DOI: 10.1186/s13054-019-2445-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/15/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
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Hooper MH, Carr A, Marik PE. The adrenal-vitamin C axis: from fish to guinea pigs and primates. Crit Care 2019; 23:29. [PMID: 30691525 PMCID: PMC6348603 DOI: 10.1186/s13054-019-2332-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/22/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA
| | - Anitra Carr
- Department of Pathology, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
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Marik PE, Hooper MH. Adjuvant Vitamin C in critically ill patients undergoing renal replacement therapy: What's the right dose? Crit Care 2018; 22:320. [PMID: 30466487 PMCID: PMC6249758 DOI: 10.1186/s13054-018-2190-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/12/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, United States of America.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, United States of America
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Marik PE. Hydrocortisone, Ascorbic Acid and Thiamine (HAT Therapy) for the Treatment of Sepsis. Focus on Ascorbic Acid. Nutrients 2018; 10:nu10111762. [PMID: 30441816 PMCID: PMC6265973 DOI: 10.3390/nu10111762] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a devastating disease that carries an enormous toll in terms of human suffering and lives lost. Over 100 novel pharmacologic agents that targeted specific molecules or pathways have failed to improve the outcome of sepsis. Preliminary data suggests that the combination of Hydrocortisone, Ascorbic Acid and Thiamine (HAT therapy) may reduce organ failure and mortality in patients with sepsis and septic shock. HAT therapy is based on the concept that a combination of readily available, safe and cheap agents, which target multiple components of the host’s response to an infectious agent, will synergistically restore the dysregulated immune response and thereby prevent organ failure and death. This paper reviews the rationale for HAT therapy with a focus on vitamin C.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Moskowitz A, Andersen LW, Huang DT, Berg KM, Grossestreuer AV, Marik PE, Sherwin RL, Hou PC, Becker LB, Cocchi MN, Doshi P, Gong J, Sen A, Donnino MW. Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation. Crit Care 2018; 22:283. [PMID: 30373647 PMCID: PMC6206928 DOI: 10.1186/s13054-018-2217-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [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: 08/09/2018] [Accepted: 10/03/2018] [Indexed: 12/12/2022] Open
Abstract
The combination of thiamine, ascorbic acid, and hydrocortisone has recently emerged as a potential adjunctive therapy to antibiotics, infectious source control, and supportive care for patients with sepsis and septic shock. In the present manuscript, we provide a comprehensive review of the pathophysiologic basis and supporting research for each element of the thiamine, ascorbic acid, and hydrocortisone drug combination in sepsis. In addition, we describe potential areas of synergy between these therapies and discuss the strengths/weaknesses of the two studies to date which have evaluated the drug combination in patients with severe infection. Finally, we describe the current state of current clinical practice as it relates to the thiamine, ascorbic acid, and hydrocortisone combination and present an overview of the randomized, placebo-controlled, multi-center Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial and other planned/ongoing randomized clinical trials.
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Affiliation(s)
- Ari Moskowitz
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA USA
| | - Lars W. Andersen
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - David T. Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Katherine M. Berg
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA USA
| | - Anne V. Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
| | - Paul E. Marik
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA USA
| | - Robert L. Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine/Detroit Receiving Hospital, Detroit, MI USA
| | - Peter C. Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Lance B. Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
- Feinstein Institute for Medical Research, Manhasset, NY USA
| | - Michael N. Cocchi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
- Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Pratik Doshi
- Department of Emergency Medicine and Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jonathan Gong
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ USA
| | - Michael W. Donnino
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA USA
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
- Beth Israel Deaconess Medical Center, Emergency Medicine, One Deaconess Rd, W/CC 2, Boston, MA 02215 USA
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Spiegel R, Farkas JD, Rola P, Kenny JE, Olusanya S, Marik PE, Weingart SD. The 2018 Surviving Sepsis Campaign's Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use. Ann Emerg Med 2018; 73:356-358. [PMID: 30193754 DOI: 10.1016/j.annemergmed.2018.06.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Rory Spiegel
- Department of Emergency Medicine and Division of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, Quebec, Canada
| | | | - Segun Olusanya
- Department of Perioperative Medicine, St Bartholomew's Hospital, London, UK
| | - Paul E Marik
- Department of Internal Medicine and Pulmonary and Critical Care Medicine, Eastern Virginia Medical School
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Marik PE. Patterns of Death in Patients with Sepsis and the Use of Hydrocortisone, Ascorbic Acid, and Thiamine to Prevent These Deaths. Surg Infect (Larchmt) 2018; 19:812-820. [PMID: 30040533 DOI: 10.1089/sur.2018.111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: In general, patients with sepsis die from the host response to the infecting pathogen rather than from the infecting pathogen itself. Four patterns of death have been identified in sepsis, namely vasoplegic shock, single-organ respiratory failure (acute respiratory distress syndrome [ARDS]), multi-system organ failure (MSOF), and persistent MSOF with ongoing inflammation and immunosuppression with recurrent infections (persistent inflammation-immunosuppression and catabolism syndrome [PICS]). To improve the outcome of sepsis adjunctive therapies that modulate the immune system have been tested; these therapies that have targeted specific molecules or pathways have universally failed. Conclusion: We propose that the combination of hydrocortisone, intravenous ascorbic acid, and thiamine (HAT therapy), which synergistically targets multiple pathways, restores the dysregulated immune system and organ injury, and reduces the risk of death and organ failure following sepsis.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School , Norfolk, Virginia
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Marik PE, Varon J. Critical Care for the Respiratory Specialist: Sepsis, Delirium and Long- Term Cognitive Dysfunction: Prevention with the Combination of Vitamin C, Hydrocortisone and Thiamine. CRMR 2018. [DOI: 10.2174/1573398x14666180430145142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Paul E. Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Joseph Varon
- Department of Critical Care Medicine, United Memorial Medical Center, Houston, TX, United States
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A, Briegel J, Carcillo J, Christ-Crain M, Cooper MS, Marik PE, Umberto Meduri G, Olsen KM, Rodgers S, Russell JA, Van den Berghe G. Correction to: Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med 2018; 44:401-402. [PMID: 29476199 DOI: 10.1007/s00134-018-5071-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.
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Affiliation(s)
- Djillali Annane
- General ICU Department, Raymond Poincaré Hospital (APHP), Helath Science Centre Simone Veil, Universite Versailles SQY-Paris Saclay, Garches, France.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-1179, New York, NY, 10065, USA.
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wiebke Arlt
- Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Institute of Metabolism and Systems Research (IMSR), University of Birmingham and Centre for Endocrinology, Birmingham, UK
| | - Robert A Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Josef Briegel
- Anesthesiology and Critical Care Medicine, Klinik für Anästhesiologie, Klinikum der Universität, Munich, Germany
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Mark S Cooper
- Department of Endocrinology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Gianfranco Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Keith M Olsen
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sophia Rodgers
- Clinical Adjunct Faculty, University of New Mexico and Sandoval Regional Medical Center, Albuquerque, NM, USA
| | - James A Russell
- Division of Critical Care Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University and Hospitals, Louvain, 3000, Belgium
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA.
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA
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Affiliation(s)
- Paul E Marik
- 1 Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk, Virginia and
| | - Todd W Rice
- 2 Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University School of Medicine Nashville, Tennessee
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Marik PE, Malbrain MLNG. The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid! Anaesthesiol Intensive Ther 2017; 49:323-328. [PMID: 29150996 DOI: 10.5603/ait.a2017.0056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/04/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, USA.
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Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A, Briegel J, Carcillo J, Christ-Crain M, Cooper MS, Marik PE, Umberto Meduri G, Olsen KM, Rodgers S, Russell JA, Van den Berghe G. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med 2017; 43:1751-1763. [PMID: 28940011 DOI: 10.1007/s00134-017-4919-5] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/19/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. PARTICIPANTS A multispecialty task force of 16 international experts in Critical Care Medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. DESIGN/METHODS The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members. RESULTS The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of <9 µg/dl) after cosyntropin (250 µg) administration and a random plasma cortisol of <10 µg/dl may be used by clinicians. We suggest against using plasma free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using intravenous (IV) hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence). CONCLUSIONS Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.
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Affiliation(s)
- Djillali Annane
- General ICU Department, Raymond Poincaré Hospital (APHP), Helath Science Centre Simone Veil, Universite Versailles SQY-Paris Saclay, Garches, France.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-1179, New York, NY, 10065, USA.
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wiebke Arlt
- Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Institute of Metabolism and Systems Research (IMSR), University of Birmingham and Centre for Endocrinology, Birmingham, UK
| | - Robert A Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Josef Briegel
- Anesthesiology and Critical Care Medicine, Klinik für Anästhesiologie, Klinikum der Universität, Munich, Germany
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Mark S Cooper
- Department of Endocrinology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Gianfranco Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Keith M Olsen
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sophia Rodgers
- Clinical Adjunct Faculty, University of New Mexico and Sandoval Regional Medical Center, Albuquerque, NM, USA
| | - James A Russell
- Division of Critical Care Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University and Hospitals, Louvain, 3000, Belgium
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Barabutis N, Khangoora V, Marik PE, Catravas JD. Hydrocortisone and Ascorbic Acid Synergistically Prevent and Repair Lipopolysaccharide-Induced Pulmonary Endothelial Barrier Dysfunction. Chest 2017; 152:954-962. [PMID: 28739448 DOI: 10.1016/j.chest.2017.07.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [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: 03/27/2017] [Revised: 06/20/2017] [Accepted: 07/12/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Sepsis refers to the dysregulated host immune response elicited by microbial infections resulting in life-threatening organ dysfunction. Sepsis represents a medical challenge, since it is associated with a rate of death as high as 60%. Septic shock is strongly associated with vascular dysfunction and elevated pulmonary capillary permeability. We recently reported that the combination of hydrocortisone (HC), ascorbic acid (vitC), and thiamine dramatically improves outcomes and reduces mortality in patients with sepsis. In the present study, we provide experimental evidence in support of the hypothesis that the combination of HC and vitC enhances endothelial barrier function. METHODS Human lung microvascular endothelial cells were exposed to lipopolysaccharide (LPS) in the absence or presence of HC and vitC. RESULTS LPS alone induced profound hyperpermeability, as reflected in decreased values of transendothelial electrical resistance. vitC alone did not exhibit barrier enhancement properties nor did it affect the LPS-induced hyperpermeability. Similarly, HC alone exhibited only a minor barrier-enhancing and protective effect. Conversely, the combination of HC and vitC, either as before or after treatment, dramatically reversed the LPS-induced barrier dysfunction. The barrier-protective effects of HC and vitC were associated with reversal of LPS-induced p53 and phosphorylated cofilin downregulation and LPS-induced RhoA activation and myosin light chain phosphorylation. CONCLUSIONS These data provide a novel mechanism of endothelial barrier protection and suggest one possible pathway that may contribute to the therapeutic effects of HC and vitC in patients with sepsis.
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Affiliation(s)
- Nektarios Barabutis
- Frank Reidy Research Center for Bioelectrics, College of Health Sciences, Old Dominion University, Norfolk, VA
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John D Catravas
- School of Medical Diagnostic and Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA; Departments of Medicine and Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA.
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