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Bradley J, Xu Q, Touloumes N, Lusciks E, Ali T, Huang EC, Chen J, Ghafghazi S, Arnold FW, Kong M, Huang J, Cavallazzi R. Association of pulmonary function test abnormalities and quality-of-life measures after COVID-19 infection. Am J Med Sci 2024:S0002-9629(24)01170-4. [PMID: 38636655 DOI: 10.1016/j.amjms.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/29/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Long-COVID is a multisystem disease that can lead to significant impairments in health-related quality of life (HRQoL). Following COVID-19 infection, abnormalities on pulmonary function tests (PFT) are common. The primary aim of this study is to evaluate for any correlation between PFT abnormalities and impairment in HRQoL scores following COVID-19 infection. METHODS This is an analysis of a prospective cohort of patients in Louisville, KY who were infected with COVID-19. Data collected included demographics, past medical history, laboratory tests, PFTs, and several HRQoL questionnaires such as the EuroQol 5 Dimension HRQoL questionnaire (EQ-5D-5 L), Generalized Anxiety Disorder 7 (GAD-7), Patient Health Questionnaire (PHQ-9), and Posttraumatic stress disorder checklist for DSM-5 (PCL-5). Descriptive statistics were performed, comparing PFTs (normal vs abnormal) and time since COVID-19 infection (3- vs 6- vs ≥ 12 months). RESULTS There were no significant differences in FEV1, FVC, or the percentage of patients with abnormal PFTs over time after COVID-19 infection. Following COVID-19, patients with normal PFTs had worse impairment in mobility HRQoL scores and change in GAD-7 scores over time. There were no differences over time in any of the HRQoL scores among patients with abnormal PFTs. CONCLUSIONS Among patients with an abnormal PFT, there was no temporal association with HRQoL scores as measured by EQ-5D-5 L, GAD-7, PHQ-9, and PCL-5. Among patients with a normal PFT, mobility impairment and anxiety may be associated with COVID-19 infection. Following COVID-19 infection, impairment in HRQoL scores is not completely explained by the presence of abnormalities on spirometry.
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Affiliation(s)
- James Bradley
- Division of Pulmonary, Critical Care Medicine and Sleep Disorders, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Qian Xu
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA; Biometrics and Data Science, Fosun Pharma, Beijing, 100026, PR China
| | - Nikolas Touloumes
- Division of General Internal Medicine, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Eugene Lusciks
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - T'shura Ali
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA; Department of Epidemiology and Population Health, School of Public Health and Information Sciences, University of Louisville, Louisville, KY, USA
| | - Emma C Huang
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - James Chen
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Forest W Arnold
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Maiying Kong
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine and Sleep Disorders, Department of Medicine, University of Louisville, Louisville, KY, USA.
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Cavallazzi R, Ramirez JA. Definition, Epidemiology, and Pathogenesis of Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:143-157. [PMID: 38330995 DOI: 10.1055/s-0044-1779016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
The clinical presentation of community-acquired pneumonia (CAP) can vary widely among patients. While many individuals with mild symptoms can be managed as outpatients with excellent outcomes, there is a distinct subgroup of patients who present with severe CAP. In these cases, the mortality rate can reach approximately 25% within 30 days and even up to 50% within a year. It is crucial to focus attention on these patients who are at higher risk. Among the various definitions of severe CAP found in the literature, one commonly used criterion is the requirement for admission to intensive care unit. Notable epidemiological characteristics of these patients include the impact of acute cardiovascular diseases on clinical outcomes and the enduring, independent effect of pneumonia on long-term outcomes. Factors such as pathogen virulence, the presence of comorbidities, and the host response are important contributors to the pathogenesis of severe CAP. In these patients, the host response may be dysregulated and compartmentalized. Gaining a better understanding of the epidemiology and pathogenesis of severe CAP will provide a foundation for the development of new therapies for this condition. This manuscript aims to review the definition, epidemiology, and pathogenesis of severe CAP, shedding light on important aspects that can aid in the improvement of patient care and outcomes.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, Kentucky
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
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3
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Cavallazzi R, Ramirez JA. Influenza and Viral Pneumonia. Infect Dis Clin North Am 2024; 38:183-212. [PMID: 38280763 DOI: 10.1016/j.idc.2023.12.010] [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] [Indexed: 01/29/2024]
Abstract
Influenza and other respiratory viruses are commonly identified in patients with community-acquired pneumonia, hospital-acquired pneumonia, and in immunocompromised patients with pneumonia. Clinically, it is difficult to differentiate viral from bacterial pneumonia. Similarly, the radiological findings of viral infection are in general nonspecific. The advent of polymerase chain reaction testing has enormously facilitated the identification of respiratory viruses, which has important implications for infection control measures and treatment. Currently, treatment options for patients with viral infection are limited but there is ongoing research on the development and clinical testing of new treatment regimens and strategies.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders, University of Louisville, Louisville, KY, USA.
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
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Ramirez J, Furmanek S, Chandler TR, Wiemken T, Peyrani P, Arnold F, Mattingly W, Wilde A, Bordon J, Fernandez-Botran R, Carrico R, Cavallazzi R, Group TUOLPS. Epidemiology of Pneumococcal Pneumonia in Louisville, Kentucky, and Its Estimated Burden of Disease in the United States. Microorganisms 2023; 11:2813. [PMID: 38004825 PMCID: PMC10673027 DOI: 10.3390/microorganisms11112813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Streptococcus pneumoniae remains a primary pathogen in hospitalized patients with community-acquired pneumonia (CAP). The objective of this study was to define the epidemiology of pneumococcal pneumonia in Louisville, Kentucky, and to estimate the burden of pneumococcal pneumonia in the United States (US). This study was nested in a prospective population-based cohort study of all adult residents in Louisville, Kentucky, who were hospitalized with CAP from 1 June 2014 to 31 May 2016. In hospitalized patients with CAP, urinary antigen detection of 24 S. pneumoniae serotypes (UAD-24) was performed. The annual population-based pneumococcal pneumonia incidence was calculated. The distribution of S. pneumoniae serotypes was characterized. Ecological associations between pneumococcal pneumonia and income level, race, and age were defined. Mortality was evaluated during hospitalization and at 30 days, 6 months, and 1 year after hospitalization. Among the 5402 CAP patients with a UAD-24 test performed, 708 (13%) patients had pneumococcal pneumonia. The annual cumulative incidence was 93 pneumococcal pneumonia hospitalizations per 100,000 adults (95% CI = 91-95), corresponding to an estimated 226,696 annual pneumococcal pneumonia hospitalizations in the US. The most frequent serotypes were 19A (12%), 3 (11%), and 22F (11%). Clusters of cases were found in areas with low incomes and a higher proportion of Black or African American population. Pneumococcal pneumonia mortality was 3.7% during hospitalization, 8.2% at 30 days, 17.6% at 6 months, and 25.4% at 1 year after hospitalization. The burden of pneumococcal pneumonia in the US remains significant, with an estimate of more than 225,000 adults hospitalized annually, and approximately 1 out of 4 hospitalized adult patients dies within 1 year after hospitalization.
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Affiliation(s)
- Julio Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
- School of Medicine, University of Louisville, Louisville, KY 40290, USA
| | - Stephen Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Thomas R. Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Timothy Wiemken
- School of Medicine, University of Louisville, Louisville, KY 40290, USA
| | - Paula Peyrani
- School of Medicine, University of Louisville, Louisville, KY 40290, USA
| | - Forest Arnold
- School of Medicine, University of Louisville, Louisville, KY 40290, USA
| | - William Mattingly
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Ashley Wilde
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Jose Bordon
- Washington Health Institute, Washington, DC 20017, USA
| | | | - Ruth Carrico
- School of Medicine, University of Louisville, Louisville, KY 40290, USA
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Ramirez JA, Chandler TR, Furmanek SP, Carrico R, Wilde AM, Sheikh D, Ambadapoodi R, Salunkhe V, Tahboub M, Arnold FW, Bordon J, Cavallazzi R. Community-Acquired Pneumonia in the Immunocompromised Host: Epidemiology and Outcomes. Open Forum Infect Dis 2023; 10:ofad565. [PMID: 38023559 PMCID: PMC10676121 DOI: 10.1093/ofid/ofad565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 12/01/2023] Open
Abstract
Background The epidemiology and outcomes of community-acquired pneumonia (CAP) in immunocompromised hosts (ICHs) are not well defined. The objective of this study was to define the epidemiology and outcomes of CAP in ICHs as compared with non-ICHs. Methods This ancillary study included a prospective cohort of hospitalized adult Louisville residents with CAP from 1 June 2014 to 31 May 2016. An ICH was defined per the criteria of the Centers for Disease Control and Prevention. Geospatial epidemiology explored associations between ICHs hospitalized with CAP and income level, race, and age. Mortality for ICHs and non-ICHs was evaluated during hospitalization and 30 days, 6 months, and 1 year after hospitalization. Results A total of 761 (10%) ICHs were identified among 7449 patients hospitalized with CAP. The most common immunocompromising medical conditions or treatments were advanced-stage cancer (53%), cancer chemotherapy (23%), and corticosteroid use (20%). Clusters of ICHs hospitalized with CAP were found in areas associated with low-income and Black or African American populations. Mortality by time point for ICHs vs non-ICHs was as follows: hospitalization, 9% vs 5%; 30 days, 24% vs 11%; 6 months, 44% vs 21%; and 1 year, 53% vs 27%, respectively. Conclusions Approximately 1 in 10 hospitalized patients with CAP is immunocompromised, with advanced-stage cancer being the most frequent immunocompromising condition, as seen in half of all patients who are immunocompromised. Risk for hospitalization may be influenced by socioeconomic disparities and/or race. ICHs have a 2-fold increase in mortality as compared with non-ICHs.
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Affiliation(s)
- Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky, USA
- Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Thomas R Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Stephen P Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Ruth Carrico
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Ashley M Wilde
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky, USA
| | - Daniya Sheikh
- Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Raghava Ambadapoodi
- Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Vidyulata Salunkhe
- Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Mohammad Tahboub
- Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Forest W Arnold
- Division of Infectious Diseases, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Jose Bordon
- Washington Health Institute, Washington, DC, USA
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care and Sleep Disorders, School of Medicine, University of Louisville, Louisville, Kentucky, USA
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Bradley J, Khurana S, Cavallazzi R. Adjunctive immunomodulation in severe community-acquired pneumonia. J Bras Pneumol 2023; 49:e20230248. [PMID: 37729338 PMCID: PMC10578938 DOI: 10.36416/1806-3756/e20230248] [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: 09/22/2023] Open
Affiliation(s)
- James Bradley
- . Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville (KY) USA
| | - Shriya Khurana
- . Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville (KY) USA
| | - Rodrigo Cavallazzi
- . Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville (KY) USA
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7
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Salmon C, Khurana S, Cavallazzi R. A 79-Year-Old Woman With Shock. Chest 2023; 164:e15-e17. [PMID: 37423701 DOI: 10.1016/j.chest.2022.10.042] [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: 07/02/2022] [Revised: 09/25/2022] [Accepted: 10/12/2022] [Indexed: 07/11/2023] Open
Affiliation(s)
- Cristina Salmon
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville School of Medicine, Louisville, KY.
| | - Shriya Khurana
- Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville School of Medicine, Louisville, KY
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Ali AS, Sheikh D, Chandler TR, Furmanek S, Huang J, Ramirez JA, Arnold F, Cavallazzi R. Cardiovascular Complications Are the Primary Drivers of Mortality in Hospitalized Patients With SARS-CoV-2 Community-Acquired Pneumonia. Chest 2023; 163:1051-1060. [PMID: 36410493 PMCID: PMC9674393 DOI: 10.1016/j.chest.2022.11.013] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Hospitalized patients with SARS-CoV-2 community-acquired pneumonia (CAP) and associated comorbidities are at increased risk of cardiovascular complications. The magnitude of effect of cardiovascular complications and the role of prior comorbidities on clinical outcomes are not well defined. RESEARCH QUESTION What is the impact of cardiovascular complications on mortality in hospitalized patients with SARS-CoV-2 CAP? What is the impact of comorbidities and other risk factors on the risk of developing cardiovascular complications and mortality in these patients? STUDY DESIGN AND METHODS This cohort study included 1,645 hospitalized patients with SARS-CoV-2 CAP. Cardiovascular complications were evaluated. The clinical course during hospitalization was described by using a multistate model with four states: (1) hospitalized with no cardiovascular complications; (2) hospitalized with cardiovascular complications; (3) discharged alive; (4) and dead. Cox proportional hazards regression was used to analyze the impact of prior comorbid conditions on transitions between these states. Hazard ratios (HRs) and 95% CIs are reported. RESULTS Cardiovascular complications occurred in 18% of patients hospitalized with SARS-CoV-2 CAP. The mortality rate in this group was 45% vs 13% in patients without cardiovascular complications. Male subjects (HR, 1.32; 95% CI, 1.03-1.68), older adults (HR, 1.34; 95% CI, 1.03-1.75), and patients with congestive heart failure (HR, 1.59; 95% CI, 1.18-2.15), coronary artery disease (HR, 1.34; 95% CI, 1.00-1.79), atrial fibrillation (HR, 1.43; 95% CI, 1.06-1.95), direct admissions to the ICU (HR, 1.77; 95% CI, 1.36-2.32), and Pao2/Fio2 < 200 (HR, 1.46; 95% CI, 1.11-1.92) were more likely to develop cardiovascular complications following hospitalization for SARS-CoV-2 CAP; however, these factors are not associated with increased risk of death following a cardiovascular complication. INTERPRETATION Prior comorbidities, older age, male sex, severity of illness, and hypoxemia are associated with increased risk of cardiovascular complications. Once patients develop cardiovascular complications, the risk of death is extremely high. Cardiovascular complications are the primary drivers of mortality in hospitalized patients with SARS-CoV-2 CAP.
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Affiliation(s)
- Ahmed Shebl Ali
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Daniya Sheikh
- Division of Infectious Diseases, University of Louisville, Louisville, KY.
| | - Thomas R Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Stephen Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Forest Arnold
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY
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Spindel J, Furmanek S, Chandler T, Ramirez JA, Cavallazzi R. In Patients Hospitalized for Community-Acquired Pneumonia, SARS-CoV-2 Is Associated with Worse Clinical Outcomes When Compared to Influenza. Pathogens 2023; 12:pathogens12040571. [PMID: 37111457 PMCID: PMC10142714 DOI: 10.3390/pathogens12040571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
SARS-CoV-2 and influenza are primary causes of viral community-acquired pneumonia (CAP). Both pathogens have exhibited high transmissibility and are recognized causes of pandemics. Controversy still exists regarding the clinical outcomes between patients hospitalized with CAP due to these viruses. This secondary analysis identified patients with either influenza or SARS-CoV-2 infections from three cohorts of patients hospitalized for CAP. Clinical outcomes between patients with CAP due to influenza or due to SARS-CoV-2 were evaluated. Primary outcomes included length of stay and in-hospital mortality. To account for population differences between cohorts, each case of influenza CAP was matched to two controls with SARS-CoV-2 CAP. Matching criteria included sex, age, and nursing home residency. Stratified cox-proportional hazards regression or conditional logistic regression were used where appropriate. A total of 259 patients with influenza CAP were matched to two controls with SARS-CoV-2 CAP, totaling to 518 controls. Patients with SARS-CoV-2 CAP were 2.23 times more likely to remain hospitalized at any point in time (95% confidence interval: 1.77-2.80), and had 3.84 times higher odds of dying in-hospital (95% confidence interval: 1.91-7.76) when compared to patients with influenza CAP. After matching and adjusting for confounding variables, patients admitted with SARS-CoV-2 CAP had consistently worse outcomes in comparison to their influenza CAP counterparts. This information can help clinicians decide on the level of care needed for patients with confirmed infections due to these pathogens. Additionally, estimates of disease burden can inform individuals at-risk for poor clinical outcomes, and further highlight the importance of effective preventative strategies.
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Affiliation(s)
- Jeffrey Spindel
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY 40536, USA
| | - Stephen Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Thomas Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY 40202, USA
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY 40202, USA
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Chandler TR, Sheikh D, Cavallazzi R, Furmanek S. Response. Chest 2023; 163:e196. [PMID: 37031996 PMCID: PMC10080200 DOI: 10.1016/j.chest.2022.12.026] [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: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 04/11/2023] Open
Affiliation(s)
- Thomas R Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
| | - Daniya Sheikh
- Division of Infectious Diseases, University of Louisville, Louisville, KY.
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY
| | - Stephen Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
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Cavallazzi R, Bradley J, Chandler T, Furmanek S, Ramirez JA. Severity of Illness Scores and Biomarkers for Prognosis of Patients with Coronavirus Disease 2019. Semin Respir Crit Care Med 2023; 44:75-90. [PMID: 36646087 DOI: 10.1055/s-0042-1759567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The spectrum of disease severity and the insidiousness of clinical presentation make it difficult to recognize patients with coronavirus disease 2019 (COVID-19) at higher risk of worse outcomes or death when they are seen in the early phases of the disease. There are now well-established risk factors for worse outcomes in patients with COVID-19. These should be factored in when assessing the prognosis of these patients. However, a more precise prognostic assessment in an individual patient may warrant the use of predictive tools. In this manuscript, we conduct a literature review on the severity of illness scores and biomarkers for the prognosis of patients with COVID-19. Several COVID-19-specific scores have been developed since the onset of the pandemic. Some of them are promising and can be integrated into the assessment of these patients. We also found that the well-known pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) are good predictors of mortality in hospitalized patients with COVID-19. While neither the PSI nor the CURB-65 should be used for the triage of outpatient versus inpatient treatment, they can be integrated by a clinician into the assessment of disease severity and can be used in epidemiological studies to determine the severity of illness in patient populations. Biomarkers also provide valuable prognostic information and, importantly, may depict the main physiological derangements in severe disease. We, however, do not advocate the isolated use of severity of illness scores or biomarkers for decision-making in an individual patient. Instead, we suggest the use of these tools on a case-by-case basis with the goal of enhancing clinician judgment.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Norton Healthcare, Louisville, Kentucky
| | - James Bradley
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Norton Healthcare, Louisville, Kentucky
| | - Thomas Chandler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
| | - Stephen Furmanek
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
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12
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Restrepo MI, Marin-Corral J, Rodriguez JJ, Restrepo V, Cavallazzi R. Cardiovascular Complications in Coronavirus Disease 2019-Pathogenesis and Management. Semin Respir Crit Care Med 2023; 44:21-34. [PMID: 36646083 DOI: 10.1055/s-0042-1760096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused a devastating impact on morbidity and mortality around the world. Severe acute respiratory syndrome-coronavirus-2 has a characteristic tropism for the cardiovascular system by entering the host cells and binding to angiotensin-converting enzyme 2 receptors, which are expressed in different cells, particularly endothelial cells. This endothelial injury is linked by a direct intracellular viral invasion leading to inflammation, microthrombosis, and angiogenesis. COVID-19 has been associated with acute myocarditis, cardiac arrhythmias, new onset or worsening heart failure, ischemic heart disease, stroke, and thromboembolic disease. This review summarizes key relevant literature regarding the epidemiology, diagnosis, treatment, and preventive measures related to cardiovascular complications in the setting of COVID-19.
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Affiliation(s)
- Marcos I Restrepo
- Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas.,Section of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Judith Marin-Corral
- Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas.,Critical Care Department, Hospital del Mar-IMIM; Critical Illness Research Group (GREPAC), Barcelona, Spain.,Department of Critical Care, Critical Illness Research Group (GREPAC), Barcelona, Spain
| | - Juan J Rodriguez
- Department of Medicine, Universidad Autónoma de Bucaramanga, Colombia
| | - Valeria Restrepo
- Department of Biology, University of Texas San Antonio - UTSA, San Antonio, Texas
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, Kentucky
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Cavallazzi R, Ramirez JA. How and when to manage respiratory infections out of hospital. Eur Respir Rev 2022; 31:31/166/220092. [PMID: 36261157 DOI: 10.1183/16000617.0092-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/19/2022] [Indexed: 12/13/2022] Open
Abstract
Lower respiratory infections include acute bronchitis, influenza, community-acquired pneumonia, acute exacerbation of COPD and acute exacerbation of bronchiectasis. They are a major cause of death worldwide and often affect the most vulnerable: children, elderly and the impoverished. In this paper, we review the clinical presentation, diagnosis, severity assessment and treatment of adult outpatients with lower respiratory infections. The paper is divided into sections on specific lower respiratory infections, but we also dedicate a section to COVID-19 given the importance of the ongoing pandemic. Lower respiratory infections are heterogeneous entities, carry different risks for adverse events, and require different management strategies. For instance, while patients with acute bronchitis are rarely admitted to hospital and generally do not require antimicrobials, approximately 40% of patients seen for community-acquired pneumonia require admission. Clinicians caring for patients with lower respiratory infections face several challenges, including an increasing population of patients with immunosuppression, potential need for diagnostic tests that may not be readily available, antibiotic resistance and social aspects that place these patients at higher risk. Management principles for patients with lower respiratory infections include knowledge of local surveillance data, strategic use of diagnostic tests according to surveillance data, and judicious use of antimicrobials.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY, USA
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
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Ramirez JA, Chandler TR, Furmanek S, Carrico R, Wilde AM, Sheikh D, Ambadapoodi RS, Salunkhe V, Tahboub MT, Arnold FW, Bordon J, Cavallazzi R. 2110. Immunocompromised Adults Hospitalized with Community-Acquired Pneumonia in the United States: Incidence and Clinical Outcomes. Open Forum Infect Dis 2022. [PMCID: PMC9752967 DOI: 10.1093/ofid/ofac492.1731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is an important complication in immunocompromised adults (ICAs). In hospitalized patients, the burden of CAP in ICAs is not well defined. The primary objective of this study was to define incidence, epidemiology, and outcomes of ICAs hospitalized with CAP in the city of Louisville. The secondary objective of this study was to estimate the burden of CAP in ICAs in the US. Methods This was a prospective population-based cohort study of consecutive hospitalized adult Louisville residents with CAP at all adult hospitals in Louisville from 1 June 2014 to 31 May 2016. An ICA was defined as a patient with any of the following medical conditions or treatments: (1) primary immunodeficiency disease; (2) advanced-stage cancer (stage III or IV cancer or hematologic cancer); (3) advanced HIV infection (CD4 T-lymphocyte count < 200 cells/mL or < 14%); (4) solid organ transplantation; (5) hematopoietic stem cell transplantation; (6) receiving cancer chemotherapy; (7) receiving biological immune modulators; (8) receiving corticosteroid therapy with a dose ≥ 20 mg prednisone or equivalent daily for at least 14 days prior to hospitalization; or (9) receiving disease-modifying antirheumatic drugs (DMARDs). The annual population-based CAP incidence among ICAs was calculated. Mortality was evaluated during hospitalization and at 30 days, 6 months, and 1 year after hospitalization. Results A total of 7449 unique patients were included, with 854 (11%) ICAs identified. Figure 1 depicts the immunocompromising conditions. Per 100,000 adults in Louisville, each year 75 ICAs are hospitalized with CAP (95% CI: 68-78), corresponding to an estimated 190,106 ICAs hospitalized with CAP in the US. Mortality during hospitalization was 8% in ICAs vs 6% in non-ICAs; at 30 days 23% in ICAs vs 11% in non-ICAs, at 6 months 42% in ICAs vs 20% in non-ICAs, and at 1 year 52% in ICAs vs 27% in non-ICAs.
Frequency of Immunocompromising Conditions and Treatments Immunocompromising conditions and treatments among 7449 patients hospitalized for community-acquired pneumonia sorted by frequency. Abbreviations: DMARDs: Disease-modifying antirheumatic drugs; HIV: Human immunodeficiency virus. Conclusion This study indicates that nearly one out of nine hospitalized CAP patients are immunocompromised, and 190,000 ICAs may be hospitalized due to CAP each year in the US. We found a twofold increase in mortality at every time point after discharge for ICAs compared to non-ICAs hospitalized due to CAP. Further strategies to prevent CAP and improve outcomes in ICAs hospitalized with CAP are necessary. Disclosures Forest W. Arnold, DO, MSc, Gilead Sciences, Inc.: Grant/Research Support.
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Affiliation(s)
| | | | | | | | | | - Daniya Sheikh
- University of Louisville School of Medicine, Louisville, Kentucky
| | | | | | | | - Forest W Arnold
- University of Louisville School of Medicine, Louisville, Kentucky
| | - Jose Bordon
- George Washington University, Washington, District of Columbia
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15
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Sheikh D, Tripathi N, Chandler TR, Furmanek S, Bordon J, Ramirez JA, Cavallazzi R. Clinical outcomes in patients with COPD hospitalized with SARS-CoV-2 versus non- SARS-CoV-2 community-acquired pneumonia. Respir Med 2021; 191:106714. [PMID: 34915396 PMCID: PMC8654722 DOI: 10.1016/j.rmed.2021.106714] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 12/13/2022]
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) have poor outcomes in the setting of community-acquired pneumonia (CAP) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The primary objective is to compare outcomes of SARS-CoV-2 CAP and non-SARS-CoV-2 CAP in patients with COPD. The secondary objective is to compare outcomes of SARS-CoV-2 CAP with and without COPD. Methods In this analysis of two observational studies, three cohorts were analyzed: (1) patients with COPD and SARS-CoV-2 CAP; (2) patients with COPD and non-SARS-CoV-2 CAP; and (3) patients with SARS-CoV-2 CAP without COPD. Outcomes included length of stay, ICU admission, cardiac events, and in-hospital mortality. Results Ninety-six patients with COPD and SARS-CoV-2 CAP were compared to 1129 patients with COPD and non-SARS-CoV-2 CAP. 536 patients without COPD and SARS-CoV-2 CAP were analyzed for the secondary objective. Patients with COPD and SARS-CoV-2 CAP had longer hospital stay (15 vs 5 days, p < 0.001), 4.98 higher odds of cardiac events (95% CI: 3.74–6.69), and 7.31 higher odds of death (95% CI: 5.36–10.12) in comparison to patients with COPD and non-SARS-CoV-2 CAP. In patients with SARS-CoV-2 CAP, presence of COPD was associated with 1.74 (95% CI: 1.39–2.19) higher odds of ICU admission and 1.47 (95% CI: 1.05–2.05) higher odds of death. Conclusion In patients with COPD and CAP, presence of SARS-CoV-2 as an etiologic agent is associated with more cardiovascular events, longer hospital stay, and seven-fold increase in mortality. In patients with SARS-CoV-2 CAP, presence of COPD is associated with 1.5-fold increase in mortality.
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Affiliation(s)
- Daniya Sheikh
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA.
| | - Nishita Tripathi
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Thomas R Chandler
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Stephen Furmanek
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Jose Bordon
- Washington Health Institute, George Washington University, Washington, DC, USA
| | - Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine and Sleep Disorders, University of Louisville, Louisville, KY, USA
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16
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Bradley J, Sbaih N, Chandler TR, Furmanek S, Ramirez JA, Cavallazzi R. Pneumonia Severity Index and CURB-65 Are Good Predictors of Mortality in Hospitalized Patients with SARS-CoV-2 Community-Acquired Pneumonia. Chest 2021; 161:927-936. [PMID: 34740594 PMCID: PMC8562015 DOI: 10.1016/j.chest.2021.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 05/11/2021] [Revised: 09/23/2021] [Accepted: 10/24/2021] [Indexed: 11/26/2022] Open
Abstract
Background The Confusion, Urea > 7 mM, Respiratory Rate ≥ 30 breaths/min, BP < 90 mm Hg (Systolic) or < 60 mm Hg (Diastolic), Age ≥ 65 Years (CURB-65) score and the Pneumonia Severity Index (PSI) are well-established clinical prediction rules for predicting mortality in patients hospitalized with community-acquired pneumonia (CAP). SARS-CoV-2 has emerged as a new etiologic agent for CAP, but the role of CURB-65 score and PSI have not been established. Research Question How effective are CURB-65 score and PSI at predicting in-hospital mortality resulting from SARS-CoV-2 CAP compared with non-SARS-CoV-2 CAP? Can these clinical prediction rules be optimized to predict mortality in SARS-CoV-2 CAP by addition of procalcitonin and D-dimer? Study Design and Methods Secondary analysis of two prospective cohorts of patients with SARS-CoV-2 CAP or non-SARS-CoV-2 CAP from eight adult hospitals in Louisville, Kentucky. Results The in-hospital mortality rate was 19% for patients with SARS-CoV-2 CAP and 6.5% for patients with non-SARS-CoV-2 CAP. For the PSI score, receiver operating characteristic (ROC) curve analysis resulted in an area under the ROC curve (AUC) of 0.82 (95% CI, 0.78-0.86) and 0.79 (95% CI, 0.77-0.80) for patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP, respectively. For the CURB-65 score, ROC analysis resulted in an AUC of 0.79 (95% CI, 0.75-0.84) and 0.75 (95% CI, 0.73-0.77) for patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP, respectively. In SARS-CoV-2 CAP, the addition of D-dimer (optimal cutoff, 1,813 μg/mL) and procalcitonin (optimal cutoff, 0.19 ng/mL) to PSI and CURB-65 score provided negligible improvement in prognostic performance. Interpretation PSI and CURB-65 score can predict in-hospital mortality for patients with SARS-CoV-2 CAP and non-SARS-CoV-2 CAP comparatively. In patients with SARS-CoV-2 CAP, the inclusion of either D-dimer or procalcitonin to PSI or CURB-65 score did not improve the prognostic performance of either score. In patients with CAP, regardless of cause, PSI and CURB-65 score remain adequate for predicting mortality in clinical practice.
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Affiliation(s)
- James Bradley
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders
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17
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Sbaih N, Hawthorne K, Lutes J, Cavallazzi R. Nutrition Therapy in Non-intubated Patients with Acute Respiratory Failure. Curr Nutr Rep 2021; 10:307-316. [PMID: 34463939 PMCID: PMC8407133 DOI: 10.1007/s13668-021-00367-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/16/2022]
Abstract
Purpose of Review A challenging aspect of the care for patients with acute respiratory failure is their nutrition management. This manuscript consists of a literature review on nutrition therapy in non-intubated patients with acute respiratory failure receiving high-flow nasal cannula oxygenation or non-invasive positive pressure ventilation. Recent Findings Studies show that non-intubated patients with acute respiratory failure either on non-invasive ventilation or high-flow nasal cannula are largely underfed in the initial phase of their hospitalization. Although data is limited, the available evidence suggests the feasibility of initiating oral diet in the majority of these patients in the early phase. Summary Initial evaluation includes mental status evaluation, the Yale swallowing screening protocol, and an assessment of severity of illness. The goal should be to initiate oral diet within 24 h. If patient cannot initiate oral diet, the reason for not initiating oral diet should dictate the next step. For instance, if the reason is failure of the swallow screening, further evaluation with fiberoptic endoscopy is warranted. The inability to provide oral diet for a patient in respiratory distress may a harbinger of failure of non-invasive oxygen therapy and should prompt consideration for endotracheal intubation. We suggest placement of a small-bore feeding tube for enteral nutrition if patient is unable receive oral diet after 48 h. Conclusions The nutrition management of these patients is better provided by a multidisciplinary team in a protocolized manner.
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Affiliation(s)
- Nadine Sbaih
- Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Kelly Hawthorne
- Nutrition Services, University of Louisville Hospital, Louisville, KY, USA
| | - Jennifer Lutes
- Speech-Language Pathology, University of Louisville Hospital, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- Speech-Language Pathology, University of Louisville Hospital, Louisville, KY, USA. .,Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY, USA.
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18
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Morrissey SM, Geller AE, Hu X, Tieri D, Ding C, Klaes CK, Cooke EA, Woeste MR, Martin ZC, Chen O, Bush SE, Zhang HG, Cavallazzi R, Clifford SP, Chen J, Ghare S, Barve SS, Cai L, Kong M, Rouchka EC, McLeish KR, Uriarte SM, Watson CT, Huang J, Yan J. A specific low-density neutrophil population correlates with hypercoagulation and disease severity in hospitalized COVID-19 patients. JCI Insight 2021; 6:148435. [PMID: 33986193 PMCID: PMC8262329 DOI: 10.1172/jci.insight.148435] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [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: 02/04/2021] [Accepted: 03/31/2021] [Indexed: 01/08/2023] Open
Abstract
SARS coronavirus 2 (SARS-CoV-2) is a novel viral pathogen that causes a clinical disease called coronavirus disease 2019 (COVID-19). Although most COVID-19 cases are asymptomatic or involve mild upper respiratory tract symptoms, a significant number of patients develop severe or critical disease. Patients with severe COVID-19 commonly present with viral pneumonia that may progress to life-threatening acute respiratory distress syndrome (ARDS). Patients with COVID-19 are also predisposed to venous and arterial thromboses that are associated with a poorer prognosis. The present study identified the emergence of a low-density inflammatory neutrophil (LDN) population expressing intermediate levels of CD16 (CD16Int) in patients with COVID-19. These cells demonstrated proinflammatory gene signatures, activated platelets, spontaneously formed neutrophil extracellular traps, and enhanced phagocytic capacity and cytokine production. Strikingly, CD16Int neutrophils were also the major immune cells within the bronchoalveolar lavage fluid, exhibiting increased CXCR3 but loss of CD44 and CD38 expression. The percentage of circulating CD16Int LDNs was associated with D-dimer, ferritin, and systemic IL-6 and TNF-α levels and changed over time with altered disease status. Our data suggest that the CD16Int LDN subset contributes to COVID-19-associated coagulopathy, systemic inflammation, and ARDS. The frequency of that LDN subset in the circulation could serve as an adjunct clinical marker to monitor disease status and progression.
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Affiliation(s)
- Samantha M Morrissey
- Department of Microbiology and Immunology.,Division of Immunotherapy, the Hiram C. Polk, Jr., MD, Department of Surgery, Immuno-Oncology Program, James Graham Brown Cancer Center
| | - Anne E Geller
- Department of Microbiology and Immunology.,Division of Immunotherapy, the Hiram C. Polk, Jr., MD, Department of Surgery, Immuno-Oncology Program, James Graham Brown Cancer Center
| | - Xiaoling Hu
- Division of Immunotherapy, the Hiram C. Polk, Jr., MD, Department of Surgery, Immuno-Oncology Program, James Graham Brown Cancer Center
| | - David Tieri
- Department of Biochemistry and Molecular Genetics
| | - Chuanlin Ding
- Division of Immunotherapy, the Hiram C. Polk, Jr., MD, Department of Surgery, Immuno-Oncology Program, James Graham Brown Cancer Center
| | | | | | - Matthew R Woeste
- Department of Microbiology and Immunology.,Division of Immunotherapy, the Hiram C. Polk, Jr., MD, Department of Surgery, Immuno-Oncology Program, James Graham Brown Cancer Center
| | | | - Oscar Chen
- Department of Anesthesiology and Perioperative Medicine
| | - Sarah E Bush
- Department of Anesthesiology and Perioperative Medicine
| | | | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care and Sleep Disorders, Department of Medicine
| | | | - James Chen
- Department of Anesthesiology and Perioperative Medicine
| | - Smita Ghare
- University of Louisville Hepatobiology and Toxicology Center, Departments of Medicine and Pharmacology & Toxicology
| | - Shirish S Barve
- University of Louisville Hepatobiology and Toxicology Center, Departments of Medicine and Pharmacology & Toxicology
| | - Lu Cai
- Pediatric Research Institute, Department of Pediatrics
| | | | | | - Kenneth R McLeish
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Silvia M Uriarte
- Department of Oral Immunology and Infectious Diseases, School of Dentistry
| | | | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine
| | - Jun Yan
- Department of Microbiology and Immunology.,Division of Immunotherapy, the Hiram C. Polk, Jr., MD, Department of Surgery, Immuno-Oncology Program, James Graham Brown Cancer Center
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19
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Kim RY, Glick C, Furmanek S, Ramirez JA, Cavallazzi R. Association between body mass index and mortality in hospitalised patients with community-acquired pneumonia. ERJ Open Res 2021; 7:00736-2020. [PMID: 33778059 PMCID: PMC7983275 DOI: 10.1183/23120541.00736-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/12/2020] [Indexed: 11/05/2022] Open
Abstract
The obesity paradox postulates that increased body mass index (BMI) is protective in certain patient populations. We aimed to investigate the association of BMI and different weight classes with outcomes in hospitalised patients with community-acquired pneumonia (CAP). This cohort study is a secondary data analysis of the University of Louisville Pneumonia Study database, a prospective study of hospitalised adult patients with CAP from June, 2014, to May, 2016, in Louisville, KY, USA. BMI as a predictor was assessed both as a continuous and categorical variable. Patients were categorised as weight classes based on World Health Organization definitions: BMI of <18.5 kg·m-2 (underweight), BMI of 18.5 to <25 kg·m-2 (normal weight), BMI of 25.0 to <30 kg·m-2 (overweight), BMI of 30 to <35 kg·m-2 (obesity class I), BMI of 35 to <40 kg·m-2 (obesity class II), and BMI of ≥40 kg·m-2 (obesity class III). Study outcomes, including time to clinical stability, length of stay, clinical failure and mortality, were assessed in hospital, at 30 days, at 6 months and at 1 year. Clinical failure was defined as the need for noninvasive ventilation, invasive ventilation or vasopressors within 1 week of admission. Patient characteristics and crude outcomes were stratified by BMI categories, and generalised additive binomial regression models were performed to analyse the impact of BMI as a continuous variable on study outcomes adjusting for possible confounding variables. 7449 patients were included in the study. Median time to clinical stability was 2 days for every BMI group. There was no association between BMI as a continuous predictor and length of stay <5 days (chi-squared=1.83, estimated degrees of freedom (EDF)=2.74, p=0.608). Clinical failure was highest in the class III obesity group, and higher BMI as a continuous predictor was associated with higher odds of clinical failure. BMI as a continuous predictor was significantly associated with 30-day (chi-squared=39.97, EDF=3.07, p<0.001), 6-month (chi-squared=89.42, EDF=3.44, p<0.001) and 1-year (chi-squared=83.97, EDF=2.89, p<0.001) mortalities. BMI ≤24.14 kg·m-2 was a risk factor whereas BMI ≥26.97 kg·m-2 was protective for mortality at 1-year. The incremental benefit of increasing BMI plateaued at 35 kg·m-2. We found a protective benefit of obesity on mortality in CAP patients. However, we uniquely demonstrate that the association between BMI and mortality is not linear, and no incremental benefit of increasing BMI levels is observed in those with obesity classes II and III.
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Affiliation(s)
- Richard Y Kim
- University of Louisville School of Medicine, Dept of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, Louisville, KY, USA
| | - Connor Glick
- University of Louisville School of Medicine, Dept of Medicine, Division of Infectious Diseases, Louisville, KY, USA
| | - Stephen Furmanek
- University of Louisville School of Medicine, Dept of Medicine, Division of Infectious Diseases, Louisville, KY, USA
| | - Julio A Ramirez
- University of Louisville School of Medicine, Dept of Medicine, Division of Infectious Diseases, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- University of Louisville School of Medicine, Dept of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, Louisville, KY, USA
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20
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Zeb H, Cavallazzi R. A 52-Year-Old Man With Sudden Dyspnea, Chest Pain, and Seizure. Chest 2021; 159:e173-e179. [PMID: 33678288 DOI: 10.1016/j.chest.2020.03.088] [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: 09/18/2019] [Revised: 01/01/2020] [Accepted: 03/04/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Hassan Zeb
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville, KY.
| | - Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville, KY
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21
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Spindel J, Parikh I, Terry M, Cavallazzi R. Leucocytoclastic vasculitis due to acute bacterial endocarditis resolves with antibiotics. BMJ Case Rep 2021; 14:14/1/e239961. [PMID: 33495169 PMCID: PMC7839888 DOI: 10.1136/bcr-2020-239961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Infective endocarditis is associated with a variety of clinical signs, but its association with multisystem vasculitis is rarely reported. A high index of suspicion is necessary to differentiate a primary autoimmune vasculitis from an infectious cause as the wrong treatment can lead to significant morbidity and mortality. We present a 71-year-old female patient with negative blood cultures, on antibiotics for recent bacteraemia, who presented with cutaneous and renal leucocytoclastic vasculitis. Workup revealed a vegetation adjacent to her right atrial pacemaker lead consistent with infective endocarditis and her vasculitis completely resolved with appropriate antibiotics.
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Affiliation(s)
- Jeffrey Spindel
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Ishan Parikh
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Merryl Terry
- Pathology, University of Louisville, Louisville, Kentucky, USA
| | - Rodrigo Cavallazzi
- Department of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky, USA
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22
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Suliman S, Price J, Cahill M, Young T, Furmanek S, Galvis J, Shoff H, Parra F, Stevenson G, Cavallazzi R. Bedside Evaluation for Early Sepsis Intervention: Addition of a Sepsis Response Team Leads to Improvement in Sepsis Bundle Compliance. Crit Care Explor 2021. [DOI: 10.1097/cce.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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23
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Abstract
Obesity has been shown to have a paradoxical benefit in a number of conditions, but the long-term effects in obesity after chronic obstructive pulmonary disease (COPD) exacerbation is still unclear. In this study, the effects of obesity on short- and long-term outcomes after a COPD exacerbation were evaluated. This was a secondary analysis of the Rapid Empiric Treatment with Oseltamivir Study (RETOS): a prospective, randomized, unblinded clinical trial. Patients were included in the study if they were hospitalized for acute exacerbation of COPD. Obesity was noted as patients with BMI >30. Clinical outcomes of time to clinical stability, length of stay, and mortality were compared. A total of 301 patients were included in the study, 122 (41%) patients were obese. There was no significant difference in the length of stay and time to clinical stability between patients with and without obesity. Mortality for patients with and without obesity was 3% and 3% at 30 days, 7% and 18% at six months, and 8% and 28% at one year, respectively. After adjusting with multivariable regression analysis, patients with obesity had a significant reduction in odds of dying at one year (adjusted odds ratio (aOR): 0.18; 95% CI: 0.06-0.58; p = .004) and at six months (aOR: 0.28; 95% CI: 0.09-0.89; p = .031). Our study showed that obesity was associated with reduced mortality at one year and six months after a COPD exacerbation. Although patients with obesity had higher rates of comorbidities, they had reduced mortality at one year after multivariable regression analysis.
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Affiliation(s)
- David A DeLapp
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Connor Glick
- Department of Medicine, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA
| | - Stephen Furmanek
- Department of Medicine, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA
| | - Julio A Ramirez
- Department of Medicine, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, KY, USA
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24
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Ramirez JA, Musher DM, Evans SE, Dela Cruz C, Crothers KA, Hage CA, Aliberti S, Anzueto A, Arancibia F, Arnold F, Azoulay E, Blasi F, Bordon J, Burdette S, Cao B, Cavallazzi R, Chalmers J, Charles P, Chastre J, Claessens YE, Dean N, Duval X, Fartoukh M, Feldman C, File T, Froes F, Furmanek S, Gnoni M, Lopardo G, Luna C, Maruyama T, Menendez R, Metersky M, Mildvan D, Mortensen E, Niederman MS, Pletz M, Rello J, Restrepo MI, Shindo Y, Torres A, Waterer G, Webb B, Welte T, Witzenrath M, Wunderink R. Treatment of Community-Acquired Pneumonia in Immunocompromised Adults: A Consensus Statement Regarding Initial Strategies. Chest 2020; 158:1896-1911. [PMID: 32561442 PMCID: PMC7297164 DOI: 10.1016/j.chest.2020.05.598] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/03/2020] [Accepted: 05/09/2020] [Indexed: 12/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) guidelines have improved the treatment and outcomes of patients with CAP, primarily by standardization of initial empirical therapy. But current society-published guidelines exclude immunocompromised patients. Research Question There is no consensus regarding the initial treatment of immunocompromised patients with suspected CAP. Study Design and Methods This consensus document was created by a multidisciplinary panel of 45 physicians with experience in the treatment of CAP in immunocompromised patients. The Delphi survey methodology was used to reach consensus. Results The panel focused on 21 questions addressing initial management strategies. The panel achieved consensus in defining the population, site of care, likely pathogens, microbiologic workup, general principles of empirical therapy, and empirical therapy for specific pathogens. Interpretation This document offers general suggestions for the initial treatment of the immunocompromised patient who arrives at the hospital with pneumonia.
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Affiliation(s)
- Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY.
| | - Daniel M Musher
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX
| | - Scott E Evans
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles Dela Cruz
- Pulmonary, Critical Care and Sleep Medicine, Yale University, New Haven, CT
| | - Kristina A Crothers
- Veterans Puget Sound Health Care System, University of Washington, Seattle WA
| | - Chadi A Hage
- Thoracic Transplant Program, Indiana University, Indianapolis, IN
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Antonio Anzueto
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX
| | - Francisco Arancibia
- Pneumology Service, Instituto Nacional del Tórax and Clínica Santa María, Santiago de Chile, Chile
| | - Forest Arnold
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Elie Azoulay
- Medical ICU, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Jose Bordon
- Section of Infectious Diseases, Providence Health Center, Washington, DC
| | - Steven Burdette
- Wright State University Boonshoft School of Medicine, Dayton, OH
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville, KY
| | - James Chalmers
- Scottish Centre for Respiratory Research, School of Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Patrick Charles
- Department of Infectious Diseases, Austin Health and Department of Medicine, University of Melbourne, Australia
| | - Jean Chastre
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, APHP, Paris, France
| | | | - Nathan Dean
- Intermountain Medical Center and the University of Utah, Salt Lake City, UT
| | - Xavier Duval
- UMR 1137, IAME, INSERM, and CIC 1425, Hôpital Bichat-Claude Bernard, APHP, Paris, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Hôpital Tenon, APHP, and APHP, Sorbonne Université, Faculté de Médecine Sorbonne Université, Paris, France
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas File
- Infectious Disease Section, Northeast Ohio Medical University and Infectious Disease Division, Summa Health, Akron, OH
| | - Filipe Froes
- ICU, Chest Department, Hospital Pulido Valente-Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Stephen Furmanek
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Martin Gnoni
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Gustavo Lopardo
- Fundación del Centro de Estudios Infectológicos, Buenos Aires, Argentina
| | - Carlos Luna
- Pulmonary Diseases Division, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Takaya Maruyama
- Department of Respiratory Medicine, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Rosario Menendez
- Pneumology Department, La Fe University and Polytechnic Hospital, La Fe Health Research Institute, Valencia, Spain
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine and Center for Bronchiectasis Care, University of Connecticut Health, Farmington, CT
| | - Donna Mildvan
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric Mortensen
- Department of Medicine, University of Connecticut Health Center, Farmington, CT
| | - Michael S Niederman
- Pulmonary and Critical Care, New York Presbyterian/Weill Cornell Medical Center and Weill Cornell Medical College, New York, NY
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Jordi Rello
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, and Infections Area, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona. Barcelona, CIBERES, Spain
| | - Grant Waterer
- School of Medicine, University of Western Australia, Perth, Australia
| | - Brandon Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT and Division of Infectious Diseases and Geographic Medicine, Stanford Medicine, Palo Alto, CA
| | - Tobias Welte
- German Center for Lung Research, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Clinic of Pneumology, Hannover Medical School, Hannover, Germany
| | - Martin Witzenrath
- Division of Pulmonary Inflammation and Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Richard Wunderink
- Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
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Zeb H, Jalil BA, Cavallazzi R. A 77-Year-Old Man With Acute Blood Loss and No Apparent Hemorrhage. Chest 2020; 156:e73-e76. [PMID: 31511164 DOI: 10.1016/j.chest.2019.04.137] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/15/2019] [Accepted: 04/01/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hassan Zeb
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, Department of Medicine, University of Louisville, Louisville, KY.
| | - Bilal A Jalil
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, Department of Medicine, University of Louisville, Louisville, KY
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, Department of Medicine, University of Louisville, Louisville, KY
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Cavallazzi R, Furmanek S, Arnold FW, Beavin LA, Wunderink RG, Niederman MS, Ramirez JA. The Burden of Community-Acquired Pneumonia Requiring Admission to ICU in the United States. Chest 2020; 158:1008-1016. [PMID: 32298730 DOI: 10.1016/j.chest.2020.03.051] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 01/31/2020] [Accepted: 03/14/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND A paucity of studies have assessed the epidemiology of community-acquired pneumonia (CAP) that require ICU admission. We conducted a study on this group of patients with the primary objective of defining the incidence, epidemiology, and mortality rate of CAP in the ICUs in Louisville, Kentucky. The secondary objective was to estimate the number of patients who were hospitalized and the number of deaths that were associated with CAP in ICU in the United States. RESEARCH QUESTIONS What is epidemiology of CAP in the ICU in Louisville, Kentucky, and the projected incidence in the United States? STUDY DESIGN AND METHODS This was a secondary analysis of a prospective population-based cohort study. The setting was all nine adult hospitals in Louisville, Kentucky. The annual incidence of CAP in the ICU per 100,000 adults was calculated for the whole adult population of Louisville. The number of patients who were hospitalized because of CAP in ICU in the United States was estimated by multiplying the Louisville incidence rate of CAP in ICU by the 2014 US adult population. RESULTS From a total of 7,449 unique patients who were hospitalized with CAP, 1,707 patients (23%) were admitted to the ICU. The incidence of CAP in the ICU was 145 cases per 100,000 population of adults. Cases of CAP in the ICU were clustered in patients from areas of the city with high poverty. The mortality rate of patients with CAP in ICU was 27% at 30 days and 47% at one year. In the United States, the estimated number of patients who were hospitalized with CAP requiring the ICU was 356,326 per year, and the estimated number of deaths at 30 days and one year were 96,206 and 167,474, respectively. INTERPRETATION Almost one in five patients who are hospitalized with CAP requires intensive care. Poverty is associated with CAP in the ICU. Nearly one-half of patients with CAP in the ICU will die within one year. Because of its significant burden, CAP in the ICU should be a high priority in research agenda and health policy.
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Affiliation(s)
- Rodrigo Cavallazzi
- Divisions of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY.
| | - Stephen Furmanek
- Divisions of Infectious Diseases, University of Louisville, Louisville, KY
| | - Forest W Arnold
- Divisions of Infectious Diseases, University of Louisville, Louisville, KY
| | - Leslie A Beavin
- Divisions of Infectious Diseases, University of Louisville, Louisville, KY
| | - Richard G Wunderink
- Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Julio A Ramirez
- Divisions of Infectious Diseases, University of Louisville, Louisville, KY
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Cavallazzi R. SARS-CoV-2 and Bacterial Co-infection. JRI 2020. [DOI: 10.18297/jri/vol4/iss1/16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Peyrani P, Arnold FW, Bordon J, Furmanek S, Luna CM, Cavallazzi R, Ramirez J. Incidence and Mortality of Adults Hospitalized With Community-Acquired Pneumonia According to Clinical Course. Chest 2019; 157:34-41. [PMID: 31610158 DOI: 10.1016/j.chest.2019.09.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/28/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND After hospitalization for community-acquired pneumonia (CAP), patients' clinical course may progress to clinical improvement, clinical failure, or nonresolving pneumonia. The epidemiology and outcomes of patients with CAP according to clinical course has not been well studied. The objective of this study was to characterize the incidence and outcomes for each clinical course of hospitalized patients with CAP. METHODS This was a secondary data analysis of the University of Louisville Pneumonia Study. Clinical course was classified as improvement, failure, and nonresolving. Objective criteria were used to define improvement and failure during the first week of hospitalization. If neither group of criteria were met, the course was classified as nonresolving. Incidence for each clinical course was calculated. Mortality was evaluated at different time points through the first year. P < .05 was considered statistically significant. RESULTS A total of 7,449 patients were hospitalized with CAP during the study period. Improvement was documented in 5,732 patients (77%), failure was documented in 1,458 patients (20%), and nonresolving CAP was documented in 259 patients (3%). Mortality at 30 days was 6% for those who improved, 34% for those who failed, and 34% for those with nonresolving pneumonia. Mortality at 1 year was 23%, 52%, and 51%, respectively. CONCLUSIONS This study shows that > 75% of hospitalized patients with CAP will reach clinical improvement. One of two patients with clinical failure or nonresolving CAP may die 1 year after hospitalization. Understanding the pathogenesis of long-term mortality is critical to developing interventions.
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Affiliation(s)
- Paula Peyrani
- Vaccines Clinical Research and Development, Pfizer Inc, Collegeville, PA.
| | - Forest W Arnold
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY
| | - Jose Bordon
- Section of Infectious Diseases, Providence Hospital, Washington, DC
| | - Stephen Furmanek
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY
| | - Carlos M Luna
- Department of Medicine, Pulmonary Diseases Division, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY
| | - Julio Ramirez
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY
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Gearhart AM, Furmanek S, English C, Ramirez J, Cavallazzi R. Predicting the need for ICU admission in community-acquired pneumonia. Respir Med 2019; 155:61-65. [PMID: 31302580 DOI: 10.1016/j.rmed.2019.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 07/02/2019] [Accepted: 07/05/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multiple criteria have been proposed to define community-acquired pneumonia (CAP) severity and predict ICU admission. Validity studies have found differing results. We tested four models to assess severe CAP built upon the criteria included in the 2007 IDSA/ATS guidelines, hypothesizing that a model providing different weights for each individual criterion may be of better predictability. METHODS Retrospective analysis of a prospective cohort study of adult hospitalizations for CAP at nine hospitals in Louisville, KY from June 2014 to May 2016. Four models were tested. Model 1: original 2007 IDSA/ATS criteria. Model 2: modified IDSA/ATS criteria by removing multilobar infiltrates and changing BUN threshold to ≥30 mg/dL; adding lactate level >2 mmol/L and requirement of non-invasive mechanical ventilation (NIMV). CAP was severe with 1 major criterion or 3 minor criteria. Model 3: same criteria as model 2, CAP was severe with 1 major criterion or 4 minor criteria. Model 4: multiple regression analysis including the modified criteria as described in models 2 and 3 with a score assigned to each variable according to the magnitude of association between variable and need for ICU. RESULTS 8284 CAP hospitalizations were included. 1458 (18%) required ICU. Model 4 showed highest prediction of need for ICU with an area under the curve of 0.91, highest accuracy, specificity, positive predictive value, and agreement among models. CONCLUSION Assigning differential weights to clinical predictive variables generated a score with accuracy that outperformed the original 2007 IDSA/ATS criteria for severe CAP and ICU admission.
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Affiliation(s)
| | | | - Connor English
- Division of Infectious Diseases, University of Louisville, USA
| | - Julio Ramirez
- Division of Infectious Diseases, University of Louisville, USA
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, USA
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Bordon J, Slomka M, Gupta R, Furmanek S, Cavallazzi R, Sethi S, Niederman M, Ramirez JA. Hospitalization due to community-acquired pneumonia in patients with chronic obstructive pulmonary disease: incidence, epidemiology and outcomes. Clin Microbiol Infect 2019; 26:220-226. [PMID: 31254714 DOI: 10.1016/j.cmi.2019.06.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/08/2019] [Accepted: 06/17/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Community-acquired pneumonia (CAP) is an important complication in patients with chronic obstructive pulmonary disease (COPD). This study aimed to define incidence, and outcomes of COPD patients hospitalized with pneumonia in the city of Louisville, and to estimate the burden of disease in the US population. METHODS This was a secondary analysis of a prospective population-based cohort study of residents in Louisville, Kentucky, 40 years old and older, from 1 June 2014 to 31 May 2016. All adults hospitalized with CAP were enrolled. The annual incidence of pneumonia in COPD patients in Louisville was calculated and the total number of adults with COPD hospitalized in the United States was estimated. Clinical outcomes included time to clinical stability (TCS), length of hospital stay (LOS) and mortality. RESULTS From a Louisville population of 18 246 patients with COPD, 3419 pneumonia hospitalizations were documented during the 2-year study. The annual incidence was 9369 patients with pneumonia per 100 000 COPD population, corresponding to an estimated 506 953 adults with COPD hospitalized due to pneumonia in the United States. The incidence of CAP in patients without COPD was 509 (95% CI 485-533) per 100 000. COPD patients had a median (interquartile range) TCS and LOS of 2 (1-4) and 5 (3-9) days respectively. The mortality of COPD patients during hospitalization, at 30 days, 6 months and 1 year was 193 of 3419 (5.6%), 400 of 3374 (11.9%), 816 of 3363 (24.3%) and 1104 of 3349 (33.0%), respectively. CONCLUSIONS There was an annual incidence of 9369 cases of hospitalized CAP per 100 000 COPD patients in the city of Louisville. This was an approximately 18-fold greater incidence of CAP in COPD patients than in those without COPD.
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Affiliation(s)
- J Bordon
- Providence Health Center, Section of Infectious Diseases, Washington, DC, USA.
| | - M Slomka
- University of Maryland Medical Center, Division of Infectious Diseases, Baltimore, MD, USA
| | - R Gupta
- Cleveland Clinic, Department of Medicine, Division of Hematology and Oncology, Cleveland, OH, USA
| | - S Furmanek
- University of Louisville, Department of Medicine, Division of Infectious Diseases, Louisville, KY, USA
| | - R Cavallazzi
- University of Louisville, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders, Louisville, KY, USA
| | - S Sethi
- University at Buffalo, Jacobs School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Buffalo, NY, USA
| | - M Niederman
- Weill Cornell Medical College, Pulmonary and Critical Care Medicine, New York, NY, USA
| | - J A Ramirez
- University of Louisville, Department of Medicine, Division of Infectious Diseases, Louisville, KY, USA
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Affiliation(s)
- John D Price
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, Louisville, Kentucky
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, Louisville, Kentucky.
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Varajic B, Cavallazzi R, Mann J, Furmanek S, Guardiola J, Saad M. High versus low mean arterial pressures in hepatorenal syndrome: A randomized controlled pilot trial. J Crit Care 2019; 52:186-192. [PMID: 31096099 DOI: 10.1016/j.jcrc.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022]
Abstract
There is controversy regarding the mean arterial pressure (MAP) goals that should be targeted in the treatment of hepatorenal syndrome (HRS.) We conducted a study to assess different MAP targets in HRS in the intensive care unit (ICU). MATERIALS AND METHODS This is a prospective randomized controlled pilot trial. ICU patients had target mean arterial pressure (MAP) ≥ 85 mmHg (control arm) or 65-70 mmHg (study arm). Urine output and serum creatinine were trended and recorded. RESULTS A total of 18 patients were enrolled. The day four urine output in the high and low MAP group was 1194 (SD = 1249) mL/24 h and 920 (SD = 812) mL/24 h, respectively. The difference in day four - day one urine output was -689 (SD = 1684) mL/24 h and 272 (SD = 582) mL/24 h for the high and low MAP groups. The difference in serum creatinine at day four - day one was -0.54 (SD = 0.63) mg/dL and - 0.77 (SD = 1.14) mg/dL in the high and low MAP groups, respectively. CONCLUSION In this study, we failed to prove non-inferiority between a low and high target MAP in patients with HRS. TRIAL REGISTRATION This trial was registered with and approved by the University of Louisville Internal Review Board and hospital research review committees (IRB # 14.1190). The trial was registered with ClinicalTrials.gov (ID # NCT02789150). The IRB committee roster 7/21/2014-2/26/2015 is registered with IORG (IORG # IORG0000147; OMB # 0990-0279) and is available at http://louisville.edu/research/humansubjects/about-the-irb/rosters/RosterEffective20140721thru20150226.pdf.
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Affiliation(s)
- Benadin Varajic
- Department of Internal Medicine, University of Louisville, USA.
| | - Rodrigo Cavallazzi
- Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, USA
| | - Jason Mann
- Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, USA
| | | | - Juan Guardiola
- Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, USA
| | - Mohamed Saad
- Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, USA
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El-Kersh K, Cavallazzi R, McClave SA, Saad M. Reply. J Crit Care 2019; 45:251-252. [PMID: 29754943 DOI: 10.1016/j.jcrc.2018.02.007] [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: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Karim El-Kersh
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville School of Medicine, Department of Internal Medicine, University of Louisville, KY, United States.
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville School of Medicine, Department of Internal Medicine, University of Louisville, KY, United States
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Department of Internal Medicine, University of Louisville, KY, United States
| | - Mohamed Saad
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville School of Medicine, Department of Internal Medicine, University of Louisville, KY, United States
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Borkhetaria N, Howsare M, Cavallazzi R. A 30-Year-Old Woman With Tricuspid Valvectomy Presents With Shock. Chest 2019; 155:e5-e7. [PMID: 30616744 DOI: 10.1016/j.chest.2018.08.1090] [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: 02/01/2018] [Revised: 06/25/2018] [Accepted: 08/07/2018] [Indexed: 11/26/2022] Open
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Kim R, Chandler T, Furmanek S, Wiemken T, Cavallazzi R. Severity of disease and mortality for hospitalized patients with community-acquired viral pneumonia compared to patients with community-acquired bacterial pneumonia. JRI 2019. [DOI: 10.18297/jri/vol3/iss1/3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Influenza and other respiratory viruses are commonly identified in patients with community-acquired pneumonia, hospital-acquired pneumonia, and in immunocompromised patients with pneumonia. Clinically, it is difficult to differentiate viral from bacterial pneumonia. Similarly, the radiological findings of viral infection are nonspecific. The advent of polymerase chain reaction testing has enormously facilitated the identification of respiratory viruses, which has important implications for infection control measures and treatment. Currently, treatment options for patients with viral infection are limited, but there is ongoing research on the development and clinical testing of new treatment regimens and strategies.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders, University of Louisville, 550 South Jackson Street, ACB, A3R27, Louisville, KY 40202, USA.
| | - Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Med Center One, 501 E. Broadway Suite 100, Louisville, KY 40202, USA
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Abstract
We conducted a retrospective chart review to examine the efficacy of adenotonsillectomy for the treatment of severe obstructive sleep apnea (OSA) in children. Our study population was made up of 85 patients-58 boys and 27 girls, aged 1 to 17 years (mean: 6.9 ± 4.4)-with severe OSA who had undergone adenotonsillectomy and pre- and postoperative attended polysomnography (PSG) over a 4-year period. Severe OSA was defined as an apnea-hypopnea index (AHI) of >10 events per hour of sleep. Patients who had an underlying genetic or craniofacial anomaly were excluded. In addition to demographic and PSG data, we compiled information on selected characteristics of patients according to postoperative residual AHIs of ≤5 and >5. Finally, information on body mass index z score was available on 72 patients; the mean score was 1.55 ± 1.51, with 36 patients (50.0%) fulfilling the criteria for obesity. In the group as a whole, we found that adenotonsillectomy resulted in a significant reduction in AHI from 35.4 to 7.1 (p < 0.001). We also found an improvement in mean oxygen saturation nadir from 75.2 to 85.5 (p < 0.001). Postoperatively, only 8 patients (9.4%) achieved an AHI of ≤1; AHIs were >1 to ≤5 in 39 patients (45.9%), >5 to ≤10 in 24 patients (28.2%), and >10 in 14 patients (16.5%). A significantly higher proportion of boys had a residual AHI of >5 after surgery compared with those whose postoperative AHI was ≤5 (78.9 vs. 59.6%; p = 0.04). We conclude that adenotonsillectomy leads to a significant improvement in sleep-disordered breathing in children with severe OSA, but residual disease is common so close postoperative follow-up is essential.
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Affiliation(s)
- Karim El-Kersh
- Division of Pulmonary, Critical Care and Sleep Disorders Medicine, Department of Medicine, University of Louisville School of Medicine, Ambulatory Care Bldg., 550 S. Jackson St., Louisville, KY 40202, USA.
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Burkes RM, Mkorombindo T, Chaddha U, Bhatt A, El-Kersh K, Cavallazzi R, Kubiak N. Impact of Quality Improvement on Care of Chronic Obstructive Pulmonary Disease Patients in an Internal Medicine Resident Clinic. Healthcare (Basel) 2018; 6:E88. [PMID: 30044381 PMCID: PMC6165540 DOI: 10.3390/healthcare6030088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/14/2018] [Accepted: 07/23/2018] [Indexed: 12/04/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Guideline-discordant care of COPD is not uncommon. Further, there is a push to incorporate quality improvement (QI) training into internal medicine (IM) residency curricula. This study compared quality of care of COPD patients in an IM residents' clinic and a pulmonary fellows' clinic and, subsequently, the results of a quality improvement program in the residents' clinic. Pre-intervention rates of quality measure adherence were compared between the IM teaching clinic (n = 451) and pulmonary fellows' clinic (n = 177). Patient encounters in the residents' teaching clinic after quality improvement intervention (n = 119) were reviewed and compared with pre-intervention data. Prior to intervention, fellows were significantly more likely to offer smoking cessation counseling (p = 0.024) and document spirometry showing airway obstruction (p < 0.001). Smoking cessation counseling, pneumococcal vaccination, and diagnosis of COPD by spirometry were targets for QI. A single-cycle, resident-led QI project was initiated. After, residents numerically improved in the utilization of spirometry (66.5% vs. 74.8%) and smoking cessation counseling (81.8% vs. 86.6%), and significantly improved rates of pneumococcal vaccination (p = 0.024). One cycle of resident-led QI significantly improved the rates of pneumococcal vaccination, with numerical improvement in other areas of COPD care.
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Affiliation(s)
- Robert M Burkes
- Department of Internal Medicine, University of Louisville, 550 S. Jackson Street, ACB 3rd Floor, Louisville, KY 40202, USA.
| | - Takudzwa Mkorombindo
- Department of Internal Medicine, University of Louisville, 550 S. Jackson Street, ACB 3rd Floor, Louisville, KY 40202, USA.
| | - Udit Chaddha
- Department of Internal Medicine, University of Louisville, 550 S. Jackson Street, ACB 3rd Floor, Louisville, KY 40202, USA.
| | - Alok Bhatt
- Department of Internal Medicine, University of Louisville, 550 S. Jackson Street, ACB 3rd Floor, Louisville, KY 40202, USA.
| | - Karim El-Kersh
- Division of Pulmonary, Critical Care, and Sleep Medicine Disorders, Department of Internal Medicine, University of Louisville, 550 S. Jackson Street, Pulmonary, Critical Care and Sleep Disorders Medicine Offices, ACB 3rd Floor, Louisville, KY 40202, USA.
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Medicine Disorders, Department of Internal Medicine, University of Louisville, 550 S. Jackson Street, Pulmonary, Critical Care and Sleep Disorders Medicine Offices, ACB 3rd Floor, Louisville, KY 40202, USA.
| | - Nancy Kubiak
- Department of General Internal Medicine, University of Louisville, Palliative Care, and Medical Education, 550 S. Jackson Street, General Internal Medicine and Palliative Care Offices, ACB 3rd Floor, Louisville, KY 40202, USA.
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Jalil B, Thompson P, Cavallazzi R, Marik P, Mann J, El-Kersh K, Guardiola J, Saad M. Comparing Changes in Carotid Flow Time and Stroke Volume Induced by Passive Leg Raising. Am J Med Sci 2018; 355:168-173. [DOI: 10.1016/j.amjms.2017.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/13/2017] [Accepted: 09/18/2017] [Indexed: 01/25/2023]
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Chen D, Cavallazzi R. Use of Ultrasound for Diagnosis of Pneumonia in Adults, a Review. JRI 2018. [DOI: 10.18297/jri/vol2/iss2/2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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El-Kersh K, Cavallazzi R, Fernandez A, Moeller K, Senthilvel E. Sleep Disordered Breathing and Magnetic Resonance Imaging Findings in Children With Chiari Malformation Type I. Pediatr Neurol 2017; 76:95-96. [PMID: 28943363 DOI: 10.1016/j.pediatrneurol.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 08/06/2017] [Accepted: 08/07/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Karim El-Kersh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky.
| | - Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky
| | - Alicia Fernandez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky
| | - Karen Moeller
- Department of Radiology, Kosair Children's Hospital, Louisville, Kentucky
| | - Egambaram Senthilvel
- Department of Pediatrics, Division of Sleep Medicine, University of Louisville, Louisville, Kentucky
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Cavallazzi R, Ramirez JA. Using Steroids in Patients with Community-Acquired Pneumonia at the University of Louisville Hospital: Who, What, and When. JRI 2017. [DOI: 10.18297/jri/vol1/iss4/1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Morello Gearhart A, Cavallazzi R, Peyrani P, Wiemken TL, Furmanek SP, Reyes-Vega A, Gauhar U, Rivas-Perez H, Roman J, Ramirez JA, Fernandez-Botran R. Lung Cytokines and Systemic Inflammation in Patients with COPD. JRI 2017. [DOI: 10.18297/jri/vol1/iss4/4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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El-Kersh K, Jalil B, McClave SA, Cavallazzi R, Guardiola J, Guilkey K, Persaud AK, Furmanek SP, Guinn BE, Wiemken TL, Alhariri BC, Kellie SP, Saad M. Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study. J Crit Care 2017; 43:108-113. [PMID: 28865339 DOI: 10.1016/j.jcrc.2017.08.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/07/2017] [Accepted: 08/22/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress-related gastrointestinal (GI) bleeding in mechanically ventilated patients. MATERIALS AND METHODS Prospective, double blind, randomized, placebo-controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress-ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups. RESULTS 124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24-hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p=0.99). CONCLUSION We found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid-suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation.
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Affiliation(s)
- Karim El-Kersh
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States.
| | - Bilal Jalil
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Stephen A McClave
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, KY, United States
| | - Rodrigo Cavallazzi
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Juan Guardiola
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Karen Guilkey
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Annuradha K Persaud
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Stephen P Furmanek
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Brian E Guinn
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Timothy L Wiemken
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Infectious Disease, University of Louisville, KY, United States
| | - Bashar Chihada Alhariri
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Scott P Kellie
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
| | - Mohamed Saad
- University of Louisville School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Louisville, KY, United States
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Ramirez JA, Wiemken TL, Peyrani P, Arnold FW, Kelley R, Mattingly WA, Nakamatsu R, Pena S, Guinn BE, Furmanek SP, Persaud AK, Raghuram A, Fernandez F, Beavin L, Bosson R, Fernandez-Botran R, Cavallazzi R, Bordon J, Valdivieso C, Schulte J, Carrico RM. Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality. Clin Infect Dis 2017; 65:1806-1812. [DOI: 10.1093/cid/cix647] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/25/2017] [Indexed: 12/26/2022] Open
Affiliation(s)
| | | | - Paula Peyrani
- Department of Medicine, Division of Infectious Diseases
| | | | - Robert Kelley
- Department of Medicine, Division of Infectious Diseases
| | | | | | - Senen Pena
- Department of Medicine, Division of Infectious Diseases
| | - Brian E Guinn
- Department of Medicine, Division of Infectious Diseases
| | | | | | | | | | - Leslie Beavin
- Department of Medicine, Division of Infectious Diseases
| | - Rahel Bosson
- Department of Medicine, Division of Infectious Diseases
| | | | - Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Kentucky
| | - Jose Bordon
- Infectious Diseases, Providence Hospital, Washington, District of Columbia
| | | | - Joann Schulte
- Louisville Metro Department of Public Health and Wellness, Kentucky
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Nikhanj N, Raschke R, Groves R, Cavallazzi R, Ramos K. Telemedicine using stationary hard-wire audiovisual equipment or robotic systems in critical care: a brief review. Southwest J Pulm Crit Care 2017. [DOI: 10.13175/swjpcc087-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Peyrani P, Wiemken TL, Metersky ML, Arnold FW, Mattingly WA, Feldman C, Cavallazzi R, Fernandez-Botran R, Bordon J, Ramirez JA. The order of administration of macrolides and beta-lactams may impact the outcomes of hospitalized patients with community-acquired pneumonia: results from the community-acquired pneumonia organization. Infect Dis (Lond) 2017; 50:13-20. [PMID: 28699429 DOI: 10.1080/23744235.2017.1350881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The beneficial effect of macrolides for the treatment of community-acquired pneumonia (CAP) in combination with beta-lactams may be due to their anti-inflammatory activity. In patients with pneumococcal meningitis, the use of steroids improves outcomes only if they are administered before beta-lactams. The objective of this study was to compare outcomes in hospitalized patients with CAP when macrolides were administered before, simultaneously with, or after beta-lactams. METHODS Secondary data analysis of the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study database. Study groups were defined based on the sequence of administration of macrolides and beta-lactams. The study outcomes were time to clinical stability (TCS), length of stay (LOS) and in-hospital mortality. Accelerated failure time models were used to evaluate the adjusted impact of sequential antibiotic administration and time-to-event outcomes, while a logistic regression model was used to evaluate their adjusted impact on mortality. RESULTS A total of 99 patients were included in the macrolide before group and 305 in the macrolide after group. Administration of a macrolide before a beta-lactam compared to after a beta-lactam reduced TCS (3 vs. 4 days, p = .011), LOS (6 vs. 7 days, p = .002) and mortality (3 vs. 7.2%, p = .228). CONCLUSIONS The administration of macrolides before beta-lactams was associated with a statistically significant decrease in TCS and LOS and a non-statistically significant decrease in mortality. The beneficial effect of macrolides in hospitalized patient with CAP may occur only if administered before beta-lactams.
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Affiliation(s)
- Paula Peyrani
- a Division of Infectious Diseases , University of Louisville , Louisville , KY , USA
| | - Timothy L Wiemken
- a Division of Infectious Diseases , University of Louisville , Louisville , KY , USA.,b Department of Epidemiology and Population Health , School of Public Health and Information Sciences, University of Louisville , Louisville , KY , USA
| | - Mark L Metersky
- c Division of Pulmonary and Critical Care Medicine , University of Connecticut School of Medicine , Farmington , CT , USA
| | - Forest W Arnold
- a Division of Infectious Diseases , University of Louisville , Louisville , KY , USA
| | - William A Mattingly
- a Division of Infectious Diseases , University of Louisville , Louisville , KY , USA
| | - Charles Feldman
- d Division of Pulmonology, Faculty of Health Sciences , University of the Witwatersrand Medical School , Johannesburg , South Africa
| | - Rodrigo Cavallazzi
- e Division of Pulmonary and Critical Care Medicine , University of Louisville , Louisville , KY , USA
| | - Rafael Fernandez-Botran
- f Department of Pathology and Laboratory Medicine , University of Louisville , Louisville , KY , USA
| | - Jose Bordon
- g Section of Infectious Diseases , Providence Hospital , Washington, D.C , USA
| | - Julio A Ramirez
- a Division of Infectious Diseases , University of Louisville , Louisville , KY , USA
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Burk M, El-Kersh K, Saad M, Wiemken T, Ramirez J, Cavallazzi R. Viral infection in community-acquired pneumonia: a systematic review and meta-analysis. Eur Respir Rev 2017; 25:178-88. [PMID: 27246595 DOI: 10.1183/16000617.0076-2015] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/17/2015] [Indexed: 01/17/2023] Open
Abstract
The advent of PCR has improved the identification of viruses in patients with community-acquired pneumonia (CAP). Several studies have used PCR to establish the importance of viruses in the aetiology of CAP.We performed a systematic review and meta-analysis of the studies that reported the proportion of viral infection detected via PCR in patients with CAP. We excluded studies with paediatric populations. The primary outcome was the proportion of patients with viral infection. The secondary outcome was short-term mortality.Our review included 31 studies. Most obtained PCR via nasopharyngeal or oropharyngeal swab. The pooled proportion of patients with viral infection was 24.5% (95% CI 21.5-27.5%). In studies that obtained lower respiratory samples in >50% of patients, the proportion was 44.2% (95% CI 35.1-53.3%). The odds of death were higher in patients with dual bacterial and viral infection (OR 2.1, 95% CI 1.32-3.31).Viral infection is present in a high proportion of patients with CAP. The true proportion of viral infection is probably underestimated because of negative test results from nasopharyngeal or oropharyngeal swab PCR. There is increased mortality in patients with dual bacterial and viral infection.
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Affiliation(s)
- Michael Burk
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville, Louisville, KY, USA
| | - Karim El-Kersh
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville, Louisville, KY, USA
| | - Mohamed Saad
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville, Louisville, KY, USA
| | - Timothy Wiemken
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Julio Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville, Louisville, KY, USA
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Wiemken TL, Kelley RR, Fernandez-Botran R, Mattingly WA, Arnold FW, Furmanek SP, Restrepo MI, Chalmers JD, Peyrani P, Cavallazzi R, Bordon J, Aliberti S, Ramirez JA. Using cluster analysis of cytokines to identify patterns of inflammation in hospitalized patients with community-acquired pneumonia: a pilot study. Univ Louisville J Respir Infect 2017; 1:3-11. [PMID: 28393141 DOI: 10.18297/jri/vol1/iss1/1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Patients with severe community-acquired pneumonia (CAP) are believed to have an exaggerated inflammatory response to bacterial infection. Therapies aiming to modulate the inflammatory response have been largely unsuccessful, perhaps reflecting that CAP is a heterogeneous disorder that cannot be modulated by a single anti-inflammatory approach. We hypothesize that the host inflammatory response to pneumonia may be characterized by distinct cytokine patterns, which can be harnessed for personalized therapies. METHODS Here, we use hierarchical cluster analysis of cytokines to examine if patterns of inflammatory response in 13 hospitalized patients with CAP can be defined. This was a secondary data analysis of the Community-Acquired Pneumonia Inflammatory Study Group (CAPISG) database. The following cytokines were measured in plasma and sputum on the day of admission: interleukin (IL)-1β, IL-1 receptor antagonist (IL-1ra), IL-6, CXCL8 (IL-8), IL-10, IL-12p40, IL-17, interferon (IFN)γ, tumor necrosis factor (TNF)α, and CXCL10 (IP-10). Hierarchical agglomerative clustering algorithms were used to evaluate clusters of patients within plasma and sputum cytokine determinations. RESULTS A total of thirteen patients were included in this pilot study. Cluster analysis identified distinct inflammatory response patterns of cytokines in the plasma, sputum, and the ratio of plasma to sputum. CONCLUSIONS Inflammatory response patterns in plasma and sputum can be identified in hospitalized patients with CAP. Characterization of the local and systemic inflammatory response may help to better discriminate patients for enrollment into clinical trials of immunomodulatory therapies.
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Affiliation(s)
- Timothy L Wiemken
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
| | - Robert R Kelley
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
| | - Rafael Fernandez-Botran
- University of Louisville Department of Pathology and Laboratory Medicine, Louisville, Kentucky, USA
| | - William A Mattingly
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
| | - Forest W Arnold
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
| | - Stephen P Furmanek
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
| | - Marcos I Restrepo
- Department of Pulmonary Diseases, South Texas Veterans Health Care System and University of Texas at San Antonio, San Antonio, Texas, USA
| | - James D Chalmers
- Department of Respiratory Medicine, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Paula Peyrani
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
| | - Rodrigo Cavallazzi
- University of Louisville Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, Louisville, Kentucky USA
| | - Jose Bordon
- Providence Hospital Section of Infectious Diseases, Washington DC, USA
| | - Stefano Aliberti
- Department of Health Sciences, University of Milano - Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Julio A Ramirez
- University of Louisville Division of Infectious Diseases, Louisville, Kentucky, USA
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Cavallazzi R, Maurici R, Ramirez JA. Tuberculosis is always a possibility (even in the intensive care unit). Rev Bras Ter Intensiva 2017; 28:97-9. [PMID: 27410402 PMCID: PMC4943044 DOI: 10.5935/0103-507x.20160021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 02/23/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Louisville, Louisville, KY, USA
| | - Rosemeri Maurici
- Programa de Pós-graduação em Ciências Médicas, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
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