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1. Implementation of a Virtual Interprofessional ICU Learning Collaborative: Successes, Challenges, and Initial Reactions From the Structured Team-Based Optimal Patient-Centered Care for Virus COVID-19 Collaborators

Author

Simon Zec, MD, Nika Zorko Garbajs, MD, Yue Dong, MD, Ognjen Gajic, MD, Christina Kordik, MA, Lori Harmon, RRT, MBA, CPHQ, Marija Bogojevic, MD, Romil Singh, MD, Yuqiang Sun, MD, Vikas Bansal, MD, Linh Vu, MD, Kelly Cawcutt, MD, John M. Litell, DO, Sarah Redmond, PhD, Eleanor Fitzpatrick, RN, Kirstin J. Kooda, PharmD, Michelle Biehl, MD, Neha S. Dangayach, MD, Viren Kaul, MD, June M. Chae, MD, Aaron Leppin, MD, Mathew Siuba, MD, Rahul Kashyap, MBBS, Allan J. Walkey, MD, Alexander S. Niven, MD, on behalf of the Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 (STOP-VIRUS) Collaborative, Anthony Martinez, MD, Dean Meadows, MD, Helen Stinnett, BA, RRT, Michael Allison, MD, Olubukola Adeyemi, PharmD, Terry Herbert, BSN, RN, Gerald L. Weinhouse, MD, Namrata Patil, MD, MPH, Gaspar Hacobian, PharmD, BCPS, Kamen Rangelov, MD, Jillian Parker, RRT, Michael P. Smith, PharmD, BCCCP, Rachel Smith, RN, MSN, MBA, CCRN, Eliza Deery, MD, Andrea Harper, MS, Emily Davis, RN, CCRN, Grace M. Arteaga, MD, FAAP, FCCM, Jennifer L. Fleegel, RN, CCRN, Julie M. Duncan, RN, Kevin K. Graner, RPh, Tammy J. Schultz, RRT, LRT, Abhishek Giri, MBBS, Ashley Gill, RRT, Catherine L. Mielke, MS, APRN, CNS, Devang Sanghavi, MD, MHA, Jonathan K. Clark, RRT, Julie Shimp, RN, Lisa Marshall, MSN, RN, Michael Spiros, MSN, RN, Nirmaljot Kaur, MD, Sean P. Kiley, MD, Siva Naga Yarrarapu, MBBS, Teresa Keister, RN, Gage Stroope, LRT, CRT, Jackie Stark, PharmD, BCPS, Jessica Poehler, RN, Juan Pablo, Domecq Garces, MD, Nitesh Kumar Jain, MD, MBBS, Syed Anjum Khan, MD, Thoyaja Koritala, MD, Abigail La Nou, MD, FACEP, Christina Hall, MS, RN, Cindy Christensen, MSN, RN, FNP-BC, Kirsten Holbrook, RRT, Sara Toufar, PharmD, RPh, Sarah Normand, PharmD, RPh, Amy Spitzner, RN, CCRN, Carissa Quinn, APRN, CNS, DNP, Christina Xia, PharmD, BCCCP, Holly D. Behrns, LRT, RRT, Erin Barreto, PharmD, RPh, Jennifer Elmer, APRN, CNS, DNP, Sarah Chalmers, MD, PCCM, Macy Cooper, RN, Aaron Harthan, PharmD, BCPPS, Edmundo A. Martinez, MD, Jennifer A. Bandy, RN, BSN, John Sanford, RRT-ACCS, RRT-NPS, Jackie A. Guiliani, BSRT, RRT-NPS, Megan Kupferschmid, MSN, RN, P-CCRN, Anand Pariyadath, MD, Brandy Vitielliss, BSN, RN, Daniel Temas, MD, Smith F. Heavner, MS, RN, PCCN, Amanda Frary, MSN, RN, Murtaza Akhter, MD, Rania Rahman, MD, Mary Mulrow, RN, MN, CCRP, Tracy Cooper, RN, John M. Litell, DO, FACEP, June Mee Chae, MD, Kelly Cawcutt, MD, MS, FACP, FIDSA, Kirstin J. Kooda, PharmD, RPh, Neha S. Dangayach, MD, MSCR, Matthew Siuba, DO, Aaron B. Holley, MD, Alexander A. Kon, MD, MS, Amita Avadhani, PhD, DNP, CNE, DCC, ACNP-BC, NP-C, CCRN, FAANP, FCCM, Amy L. Dzierba, PharmD, FCCP, BCCCP, FCCM, Andre C. Kalil, MD, MPH, FACP, Ashley D. DePriest, MS, RDN, CNSC, Bradley Peters, PharmD, RPh, BCSP, BCCCP, Brenda T. Pun, DNP, RN, FCCM, Courtney E. Bennett, DO, Eric Kriner, BS, RRT, Erin S. DeMartino, MD, Erin Strong, BSN, RN, CCRN, Giora Netzer, MD, Greg S. Martin, MD, MSc, FCCM, Jerry J. Zimmerman, MD, PhD, FCCM, Julia Taylor, MD, MA, HEC-C, Karen A. Korzick, MD, MA, FCCP, FACP, FCCM, Katherine Fischkoff, MD, MPA, FACS, Lewis J. Kaplan, MD, FACS, FCCM, Marlies Ostermann, MD, PhD, Mary Susan Gaeta, MD, FACP, Mary Faith Marshall, HEC-C, PhD, Nahreen Ahmed, MD, MPH, Paul Alan Nyquist, MD, MPH, Pooja A. Nawathe, MD, FAAP, CHSE-A, CHSOS, FCCM, Preeti R. John, MD, MPH, FACS, CPE, HEC-C, and Uzma Syed, DO, FIDSA

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

IMPORTANCE:. Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes. OBJECTIVES:. The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices. DESIGN, SETTING, AND PARTICIPANTS:. This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning. MAIN OUTCOMES AND MEASURES:. Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams. RESULTS:. Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes. CONCLUSIONS AND RELEVANCE:. Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care.

Published
2023
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2. Neurologic Manifestations of Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Hospitalized Patients During the First Year of the COVID-19 Pandemic

Author

Anna M. Cervantes-Arslanian, MD, Chakradhar Venkata, MD, Pria Anand, MD, Joseph D. Burns, MD, Charlene J. Ong, MD, Allison M. LeMahieu, MS, Phillip J. Schulte, PhD, Tarun D. Singh, MD, Alejandro A. Rabinstein, MD, Neha Deo, BS, Vikas Bansal, MBBS, MPH, Karen Boman, BS, Juan Pablo Domecq Garces, MD, Donna Lee Armaignac, PhD, APRN, Amy B. Christie, MD, Roman R. Melamed, MD, Yasir Tarabichi, MD, MSCR, Sreekanth R. Cheruku, MD, MPH, Ashish K. Khanna, MD, FCCP, FCCM, FASA, Joshua L. Denson, MD, MS, Valerie M. Banner-Goodspeed, MPH, Harry L. Anderson, III, MD, FACS, FICS, FCCM, FCCP, FAIM, Ognjen Gajic, MD, MS, Vishakha K. Kumar, MD, MBA, Allan Walkey, MD, Rahul Kashyap, MD, MBA, on behalf of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry Investigator Group, Jean-Baptiste Mesland, Pierre Henin, Hélène Petre, Isabelle Buelens, Anne-Catherine Gerard, Philippe Clevenbergh, Rolando Claure-Del Granado, Jose A. Mercado, Esdenka Vega-Terrazas, Maria F. Iturricha-Caceres, Ruben Garza, Eric Chu, Victoria Chan, Oscar Y Gavidia, Felipe Pachon, Yeimy A Sanchez, Danijel knežević, Mohamed El Kassas, Mohamed Badr, Ahmed Tawheed, Hend Yahia, Dimitrios Kantas, Vasileios Koulouras, Estela Pineda, Gabina María Reyes Guillen, Helin Archaga Soto, Ana Karen Vallecillo Lizardo, Csaba Kopitkó, Ágnes Bencze, István Méhész, Zsófia Gerendai,, Girish Vadgaonkar, Rekha Ediga, Shilpa Basety, Shwetha Dammareddy, Phani Sreeharsha Kasumalla, Smitha S. Segu, Tuhin Chakraborty, Epcebha Joyce, Sridhar Papani, Mahesh Kamuram, Mradul Kumar Daga, Munisha Agarwal, Ishan Rohtagi, Anusha Cherian, Sreejith Parameswaran, Magesh Parthiban, Phaneendra Doddaga, Neethi Chandra, Puneet Rijhwani, Ashish Jain, Aviral Gupta, Ram Mohan Jaiswal, Ambika Tyagi, Nimish Mathur, Madhav Prabhu, Vishal Jakati, Mukur Petrolwala, Bharat Ladva, Surapaneni Krishna Mohan, Ekambaram Jyothisree, Umamaheswara Raju, Janaki Manduva, Naresh Kolakani, Shreeja Sripathi, Sheetal Chaitanya, Kamlesh Kumar Agrawal, Vijendra Baghel, Kirti Kumar Patel, Nooshin Dalili, Mohsen Nafa, Wataru Matsuda, Reina Suzuki, Michihito Kyo, Shu Tahara, Mineji Hayakawa, Kunihiko Maekawa, Masamitsu Sanui, Sho Horikita, Yuki Itagaki, Akira Kodate, Yuki Takahashi, Koyo Moriki, Takuya Shiga, Yudai Iwasaki, Hidenobu Shigemitsu, Yuka Mishima, Nobuyuki Nosaka, Michio Nagashima, Abdulrahman Al-Fares, Rene Rodriguez-Gutierrez, Jose Gerardo Gonzalez-Gonzalez, Alejandro Salcido-Montenegro, Adrian Camacho-Ortiz, Mariana Janeth Hermosillo Ulloa, Fatimah Hassan-Hanga, Hadiza Galadanci, Abubakar Shehu Gezawa, Halima M. S. Kabara, Taiwo Gboluwaga Amole, Halima Kabir, Dalha Gwarzo Haliru, Abdullahi S Ibrahim, Muhammad Sohaib Asghar, Mashaal Syed, Syed Anosh Ali Naqvi, Igor Borisovich Zabolotskikh,, Konstantin Dmitrievich Zybin, Sergey Vasilevich Sinkov, Tatiana Sergeevna Musaeva, Razan K Alamoudi, Hassan M. AlSharif, Sarah A. Almazwaghi, Mohammed S Elsakran, Mohamed A Aid, Mouaz A Darwich, Omnia M Hagag, Salah A Ali, Alona rocacorba, Kathrine Supeña, Efren Ray Juane, Jenalyn Medina, Jowany Baduria, Marwa Ridha Amer, Mohammed Abdullah, Bawazeer, Talal I. Dahhan, Eiad Kseibi, Abid Shahzad Butt, Syed Moazzum Khurshid, Muath Rabee, Mohammed Abujazar, Razan Alghunaim, Maal Abualkhair, Abeer Turki AlFirm, Yaseen M Arabi, Sheryl Ann Abdukahil, Mohammed A Almazyad, Mohammed I Alarifi, Jara M Macarambon, Ahmad Abdullah Bukhari, Hussain A. Albahrani, Kazi N Asfina, Kaltham M Aldossary, Marija Zdravkovic, Zoran Todorovic, Viseslav Popadic, Slobodan Klasnja, Ana Andrijevic, Srdjan Gavrilovic, Vladimir Carapic, Bojan Kovacevic, Jovana Bojicic, Stevanovic Predrag, Dejan S Stojakov, Duska K Ignjatovic, Suzana C Bojic, Marina M Bobos, Irina B Nenadic, Milica S Zaric, Marko D Djuric, Vladimir R Djukic, Santiago Y. Teruel, Belen C. Martin, Uluhan Sili, Huseyin Bilgin, Pinar Ay, Varsha P Gharpure, Usman Raheemi, Kenneth W. Dodd, Nicholas Goodmanson, Kathleen Hesse, Paige Bird, Chauncey Weinert, Nathan Schoenrade, Abdulrahman Altaher, Esmael Mayar, Matthew Aronson, Tyler Cooper, Monica Logan, Brianna Miner, Gisele Papo, Eric M. Siegal, Phyllis Runningen, Suzanne Barry, Christopher Woll, Gregory Wu, Erin Carrole, Kathryn Burke, Mustafa Mohammed, Roman R. Melamed, David M. Tierney, Love A. Patel, Vino S. Raj, Barite U. Dawud, Narayana Mazumder, Abbey Sidebottom, Alena M. Guenther, Benjamin D. Krehbiel, Nova J. Schmitz, Stacy L. Jepsen, Lynn Sipsey, Anna Schulte, Whitney Wunderlich, Cecely Hoyt, Abhijit A Raval, Andrea Franks, Katherine Irby, Ronald C. Sanders, Jr., Glenda Hefley, Jennifer M. Jarvis, Anmol Kharbanda, Sunil Jhajhria, Zachary Fyffe, Stephen Capizzi, Bethany Alicie, Martha Green, Lori Crockarell, Amelia Drennan, Kathleen Dubuque, Tonya Fambrough, Nikole Gasaway, Briana Krantz, Peiman Nebi, Jan Orga, Margaret Serfass, Alina Simion, Kimberly Warren, Cassie Wheeler, CJ Woolman, Amy B. Christie, Dennis W. Ashley, Rajani Adiga, Andrew S. Moyer, George M. Verghese, Andrea Sikora Newsome, Christy C. Forehand, Rebecca Bruning, Timothy W. Jones, Moldovan Sabov, Fatema Zaidi, Fiona Tissavirasingham, Dhatri Malipeddi, Jarrod M Mosier, Karen Lutrick, Beth Salvagio Campbell, Cathleen Wilson, Patrick Rivers, Jonathan Brinks, Mokenge Ndiva Mongoh, Boris Gilson, Donna Lee Armaignac, Don Parris, Maria Pilar Zuniga, Ilea Vargas, Viviana Boronat, Anneka Hutton, Navneet Kaur, Prashank Neupane, Nohemi Sadule-Rios, Lourdes M. Rojas, Aashish Neupane, Priscilla Rivera, Carlos Valle Carlos, Gregory Vincent, Mahesh Amin, Mary E Schelle, Amanda Steadham, Christopher M Howard, Cameron McBride, Jocelyn Abraham, Orlando Garner, Katherine Richards, Keegan Collins, Preethi Antony, Sindhu Mathew, Valerie C. Danesh, Gueorgui Dubrocq, Amber L. Davis, Marissa J Hammers, ill M. McGahey, Amanda C. Farris, Elisa Priest, Robyn Korsmo, Lorie Fares, Kathy Skiles, Susan M. Shor, Kenya Burns, Corrie A Dowell, Gabriela “Hope” Gonzales, Melody Flores, Lindsay Newman, Debora A Wilk, Jason Ettlinger, Jaccallene Bomar, Himani Darji, Alejandro Arroliga, Alejandro C Arroliga, Corrie A. Dowell, Gabriela Hope Conzales, Debora A. Wilk, Paras B. Khandhar, Elizabeth Kring, Valerie M. Banner-Goodspeed, Somnath Bose, Lauren E. Kelly, Melisa Joseph, Marie McGourty, Krystal Capers, Benjamin Hoenig, Maria C. Karamourtopoulos, Anica C. Law, Elias N. Baedorf Kassis, Allan J. Walkey, Sushrut S. Waikar, Michael A. Garcia, Mia Colona, Zoe Kibbelaar, Michael Leong, Daniel Wallman, Kanupriya Soni, Jennifer Maccarone, Joshua Gilman, Ycar Devis, Joseph Chung, Munizay Paracha, David N. Lumelsky, Madeline DiLorenzo, Najla Abdurrahman, Shelsey Johnson, Maj Andrew M. Hersh, CPT Stephanie L Wachs, Brittany S. Swigger, Stephanie L Wachs, Capt Lauren A. Sattler, Capt Michael N. Moulton, Kimberly Zammit, Patrick, J McGrath, William Loeffler, Maya, R. Chilbert, Aaron S. Miller, Edwin L. Anderson, Rosemary Nagy, Ravali R. Inja, Pooja A. Nawathe, Isabel Pedraza, Jennifer Tsing, Karen Carr, Anila Chaudhary, Kathleen Guglielmino, Raghavendra Tirupathi, Alymer Tang, Arshad Safi, Cindy Green, Jackie Newell, Rayan E. Ihle, Shelda A. Martin, Elaine A. Davis, Katja M. Gist, Imran A Sayed, John Brinton, Larisa Strom, Kathleen Chiotos, Allison M. Blatz, Giyoung Lee, Ryan H. Burnett, Guy I. Sydney, Danielle M. Traynor, Karissa Nauert, Annika Gonzalez, Mariel Bagley, Anita Santpurkar, Salim Surani, Joshua White, Aftab Khan, Rahul Dhahwal, Sreekanth Cheruku, Farzin Ahmed, Christopher Deonarine, Ashley Jones, Mohammad-Ali Shaikh, David Preston, Jeanette Chin, Vidula Vachharajani, Abhijit Duggal, Prabalini Rajendram, Omar Mehkri, Siddharth Dugar, Michelle Biehl, Gretchen Sacha, Stuart Houltham, Alexander King, Kiran Ashok, Bryan Poynter, Mary Beukemann, Richard Rice, Susan Gole, Valerie Shaner, Adarsh Conjeevaram, Michelle Ferrari, Narendrakumar Alappan, Steven Minear, Jaime Hernandez-Montfort, Syed Sohaib Nasim, Ravi Sunderkrishnan, Debasis Sahoo, Patrick S. Milligan, Sandeep K. Gupta, Joy M. Koglin, Regina Gibson, Lana Johnson, Felicia Preston, Crimson Scott, Bethany Nungester, Dana D Byrne, Christa A Schorr, Katie Grant, Katherine L Doktor, Maura C Porto, Olga Kaplan, James E. Siegler, III, Brian Schonewald, Ashley Woodford, Alan Tsai, Savina Reid, Kuntal Bhowmick, Saba Daneshpooy, Cyrus Mowdawalla, Trishna Akshay Dave, Wilhemina Kennedy, Connor Crudeli, Christopher Ferry, Long Nguyen, Sneha Modi, Niharika Padala, Pavan Jitendra Patel, Belle Lin, Lena Chatterjee, Jamie Qiuyun, Fan Mandi Liu, Rasagna Kota, Annesha Banerjee, Steven K. Daugherty, Sam Atkinson, Kelly Shrimpton, Sidney Ontai, Brian Contreras, Uzoma Obinwanko, Nneka Amamasi, Amir Sharafi, Sarah Lee, Zahia Esber, Chetna Jinjvadia, Raquel R Bartz, Vijay Krishnamoorthy, Bryan Kraft, Aaron Pulsipher, Eugene Friedman, Sachin Mehta, Margit Kaufman, Gregg Lobel, Nisha Gandhi, Amr Abdelaty, Elizabeth Shaji, Kiana Lim, Juan Marte, Dani Ashley Sosa, David P. Yamane, Ivy Benjenk, Nivedita Prasanna, Nicholas Perkins, Prera J. Roth, Banu Sivaraj, Haley Fulton, Madison G Herin, Marissa Crum, Morgan E. Fretwell, Emily-Rose Zhou, Christine Waller, Kara Kallies, Jonean Thorsen, Alec Fitzsimmons, Haley Olsen, Heda R. Dapul, Sourabh Verma, Alan Salas, Ariel Daube, Michelle Korn, Michelle Ramirez, Logi Rajagopalan, Laura Santos, Héctor Collazo Santiago, Ricardo Alan Hernandez, Norma Smalls, Asher G Bercow, Mark Shlomovich, Christine Crandall, Sasko Stojanovski, Kristin Johnson, Kelly Michienzi, Steven Q. Davis, Valentina Jovic, Max Masuda, Amanda Hayes, Katharine Nault, Michael Smith, William Snow, Riley Liptak, Hannah Durant, Valerie Pendleton, Alay Nanavati, Risa Mrozowsk, Namrata Nag, Jeff Brauer, Ashwin Dharmadhikari, Sahib Singh, Franco Laghi, Ghania Naeem, Andrew Wang, Kevin Bliden, Amit Rout, Jaime Barnes, Martin Gesheff, Asha Thomas, Melbin Thomas, Alicia R. Liendo, Jovan Milosavljevic, Kenan Abbasi, Nicholas B. Burley, Nicole Rapista, Samuel Amankwah, Sanjay K Poude, Saroj Timilsina, Sauradeep Sarkar, Oluwasayo Akinyosoye, Shashi K. Yalamanchili, Sheena Moorthy, Sonia Sugumar, Jonathan Ford, Martin C. Taylor, Charlotte Dunderdale, Alyssa Henshaw, Mary K. Brunk, Jessica Hagy, Shehryar Masood, Sushrutha Sridhar, Yuk Ming Liu, Sarah Zavala, Esther Shim, Ronald A. Reilkoff, Julia A. Heneghan, Sarah Eichen, Lexie Goertzen, Scott Rajala, Ghislaine Feussom, Ben Tang, Christine C. Junia, Robert Lichtenberg, Hasrat Sidhu, Diana Espinoza, Shelden Rodrigues, Maria Jose Zabala, Daniela Goyes, Ammu Susheela, Buddhi Hatharaliyadda, Naveen Rameshkumar, Amulya Kasireddy, Genessis Maldonado, Lisseth Beltran, Akshata Chaugule, Hassan Khan, Namrata Patil, Ruhi Patil, Rodrigo Cartin-Ceba, Ayan Sen, Fahimeh Talaei, Rahul Kashyap, Juan Pablo Domecq, Ognjen Gajic, Vikas Bansal, Aysun Tekin, Amos Lal, John C. O’Horo, Neha N. Deo, Mayank Sharma, Shahraz Qamar, Romil Singh, Diana J. Valencia Morales, Abigail T. La Nou, Marija Bogojevic, Simon Zec, Devang Sanghavi, Pramod Guru, Pablo Moreno Franco, Karthik Gnanapandithan, Hollie Saunders, Zachary Fleissner, Juan Garcia, Alejandra Yu Lee Mateus, Siva Naga Yarrarapu, Nirmaljot Kaur, Abhisekh Giri, Mohammed Mustafa Hasan, Ashrita Donepudi, Syed Anjum Khan, Nitesh Kumar Jain, Thoyaja Koritala, Alexander Bastidas, Gabriela Orellana, Adriana Briceno Bierwirth, Eliana Milazzo, Juan Guillermo Sierra, Thao Dang, Rahul S Nanchal, Paul A Bergl, Jennifer L Peterson, Jessica Timmer, Kimberly Welker, Travis Yamanaka, Nicholas A. Barreras, Michael Markos, Anita Fareeduddin, Rohan Mehta, Chakradhar Venkata, Miriam Engemann, Annamarie Mantese, Yasir Tarabichi, Adam Perzynski, Christine Wang, Dhatri Kotekal, Adriana C Briceno Bierwirth, Gabriela M Orellana, Gerardo Catalasan, Shohana Ahmed, Carlos F Matute, Ahmad Hamdan, Ivania Salinas, Genesis Del Nogal, Angel Tejada, Anna Eschler, Mary Hejna, Emily Lewandowski, Kristen Kusmierski, Clare Martin, Jen-Ting Chen, Aluko Hope, Zoe Tsagaris, Elise Ruen, Aram Hambardzumyan, Nasar A Siddiqi, Lesly Jurado, Lindsey Tincher, Carolyn Brown, Prithvi Sendi, Meghana Nadiger, Balagangadhar Totapally, Bhagat S. Aulakh, Sandeep Tripathi, Jennifer A. Bandy, Lisa M. Kreps, Dawn R. Bollinger, Neha Gupta, Brent R Brown, Tracy L Jones, Kassidy Malone, Lauren A Sinko, Amy B Harrell, Shonda C Ayers, Lisa M Settle, Taylor J Sears, Roger Scott Stienecker, Andre G. Melendez, Tressa A. Brunner, Sue M Budzon, Jessica L. Heffernan, Janelle M. Souder, Tracy L. Miller, Andrea G. Maisonneuve, Roberta E. Redfern, Jessica Shoemaker, Jennifer Micham, Lynn Kenney, Gabriel Naimy, Victoria Schauf, Sara Utley, Holly Balcer, Kerry P. J. Pulver, Jennifer Yehle, Alicia Weeks, Terra Inman, Majdi Hamarshi, Jeannette Ploetz, Nick Bennett, Kyle Klindworth, Moustafa Younis, Adham Mohamed, Brian L. Delmonaco, Anthony Franklin, Mitchell Heath, Diane Barkas, Antonia L. Vilella, Sara B. Kutner, Kacie Clark, Danielle Moore, Shina Menon, John K McGuire, Deana Rich, Harry L. Anderson, III, Dixy Rajkumar, Ali Abunayla, Jerrilyn Heiter, Howard A. Zaren, Stephanie J. Smith, Grant C. Lewis, Lauren Seames, Cheryl Farlow, Judy Miller, Gloria Broadstreet, John Lin, Cindy Terrill, Brock Montgomery, Sydney Reyes, Summer Reyes, Alex Plattner, Anthony Martinez, Micheal Allison, Aniket Mittal, Rafael Ruiz, Aleta Skaanland, Robert Ross, Umang Patel, Jordesha Hodge, Krunal Kumar Patel, Shivani Dalal, Himanshu Kavani, Sam Joseph, Michael A. Bernstein, Ian K. Goff, Matthew Naftilan, Amal Mathew, Deborah Williams, Sue Murdock, Maryanne Ducey, Kerianne Nelson, Jason Block, James Mitchel, Connor G O’Brien, Sylvan Cox, William Marx, Ioana Amzuta, Asad J. Choudhry, Mohammad T. Azam, Kristina L Carter, Michael A Olmos, Brittany M Parker, Julio Quintanilla, Tara A Craig, Brendon J Clough, Jeffrey T Jameson, Utpal S. Bhalala, Joshua Kuehne, Melinda Garcia, Morgan Beebe, Heather Herrera, Chris Fiack, Stephanie Guo, May Vawer, Beth Blackburn, Caleb Darby, Kristy Page, Amanda Brown, Jessie McAbee, Katherine A. Belden, Michael Baram, Devin M. Weber, Rosalie DePaola, Yuwei Xia, Hudson Carter, Aaron Tolley, Mary Barletta, Mark Steele, Laurie Kemble, Joshua L. Denson, A. Scott Gillet, Margo Brown, Rachael Stevens, Andrew Wetherbie, Kevin Tea, Mathew Moore, Abdurrahman Husain, Atul Malhotra, Qais Zawaydeh, Benjamin J Sines, Thomas J Bice, Emily A. Vail, Susannah Nicholson, Rachelle B. Jonas, AnnaRose E. Dement, William Tang, Mark DeRosa, Robert E. Villarreal, Rajany V. Dy, Alfredo Iardino, Jill Sharma, Richard Czieki, Julia Christopher, Ryan Lacey, Marwan Mashina, Kushal Patel, Erica C. Bjornstad, Nancy M. Tofil, Scott House, Isabella Aldana, Nikhil K. Meena, Jose D. Caceres, Nikhil K Meena, Sarenthia M. Epps, Harmeen Goraya, Kelsey R. Besett, Ryan James, Lana Y. Abusalem, Akash K. Patel, Lana S Hasan, Dina Gomaa, Michael Goodman, Devin Wakefield, Anthony Spuzzillo, John O. Shinn II, Robert MacLaren, Azra Bihorac, Tezcan Ozrazgat Baslanti, George Omalay, Haleh Hashemighouchani, Julie S. Cupka, Matthew M Ruppert, Patrick W. McGonagill, Colette Galet, Janice Hubbard, David Wang, Lauren Allan, Aditya Badheka, Madhuradhar Chegondi, Usman Nazir, Garrett Rampon, Jake Riggle, Nathan Dismang, Vicki Montgomery, Janice Sullivan, Sarah Morris, Jennifer Nason, Ozan Akca, Rainer Lenhardt, Rodrigo S. Cavallazzi, Ann Jerde, Alexa Black, Allison Polidori, Haily Griffey, Justin Winkler, Thomas Brenzel, Roger A. Alvarez, Amarilys Alarcon-Calderon, Marie Anne Sosa, Sunita K. Mahabir, Mausam J. Patel, Pauline Park, Andrew Admon, Sinan Hanna, Rishi Chanderraj, Maria Pliakas, Ann Wolski, Jennifer Cirino, Dima Dandachi, Hariharan Regunath, Maraya N. Camazine, Grant. E. Geiger, Abdoulie O. Njai, Baraa M. Saad, Faraaz Ali Shah, Byron Chuan, Sagar L. Rawal, Manal Piracha, Joseph E. Tonna, Nicholas M. Levin, Kayte Suslavich, Rachel Tsolinas, Zachary T. Fica, Chloe R. Skidmore, Renee D. Stapleton, Anne E. Dixon, Olivia Johnson, Sara S. Ardren, Stephanie Burns, Anna Raymond, Erika Gonyaw, Kevin Hodgdon, Chloe Housenger, Benjamin Lin, Karen McQuesten, Heidi Pecott-Grimm, Julie Sweet, Sebastian Ventrone, Nita Khandelwal, T. Eoin West, Ellen S. Caldwell, Lara Lovelace-Macon, Navya Garimella, Denisse B. Dow, Sreekanth R. Cheruku, Catherine Chen, Murtaza Akhter, Rania Abdul Rahman, Mary Mulrow, Erin M. Wilfong, Kelsi Vela, Ashish K. Khanna, Lynne Harris, Bruce Cusson, Jacob Fowler, David Vaneenenaam, Glen McKinney, Imoh Udoh, Kathleen Johnson, Patrick G. Lyons, Andrew P Michelson, Sara S. Haluf, Lauren M. Lynch, Nguyet M. Nguyen, Aaron Steinberg, Nicholas Braus, Vishwanath Pattan, Jessica Papke, Ismail Jimada, Nida Mhid, Samuel Chakola, Kevin Sheth, Abdalla Ammar, Mahmoud Ammar, Victor Torres Lopez, Charles Dela Cruz,, Akhil Khosla, and Samir Gautam

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

OBJECTIVES:. To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningitis/encephalitis) among patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN:. Prospective observational study. SETTING:. One hundred seventy-nine hospitals in 24 countries within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 Registry. PATIENTS:. Hospitalized adults with laboratory-confirmed SARS-CoV-2 infection. INTERVENTIONS:. None. RESULTS:. Of 16,225 patients enrolled in the registry with hospital discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations of COVID-19 were older with median (interquartile range) age 72 years (61.0–81.0 yr) versus 61 years (48.0–72.0 yr) and had higher prevalence of chronic medical conditions, including vascular risk factors. Adjusting for age, sex, and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (odds ratio [OR], 1.49; p < 0.001) as defined by the World Health Organization ordinal disease severity scale for COVID-19 infection. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR, 1.45; p < 0.001) and require critical care interventions (extracorporeal membrane oxygenation: OR, 1.78; p = 0.009 and renal replacement therapy: OR, 1.99; p < 0.001). Hospital, ICU, and 28-day mortality for patients with neurologic manifestations was higher (OR, 1.51, 1.37, and 1.58; p < 0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (estimated difference in days, –0.84, –1.34, and –0.84; p < 0.001). CONCLUSIONS:. Encephalopathy at admission is common in hospitalized patients with SARS-CoV-2 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.

Published
2022
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3. Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome Due to COVID-19

Author

Shelsey W. Johnson, MD, Michael A. Garcia, MD, Emily K. Q. Sisson, MA, Christopher R. Sheldrick, PhD, Vishakha K. Kumar, MD, MBA, Karen Boman, BA, Scott Bolesta, PharmD, Vikas Bansal, MBBS, MPH, Amos Lal, MBBS, J. P. Domecq, MD, MS, Roman R. Melamed, MD, Amy B. Christie, MD, Abdurrahman Husain, MD, Santiago Yus, MBBS, Ognjen Gajic, MD, MSc, Rahul Kashyap, MBBS, MBA, Allan J. Walkey, MD, MSc, from the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry Investigator Group, Oscar Y. Gavidia, Felipe Pachon, Yeimy A. Sanchez, Mohamed El Kassas, Mohamed Badr, Ahmed Tawheed, Hend Yahia, Wataru Matsuda, Reina Suzuki, Masamitsu Sanui, Sho Horikita, Yuki Itagaki, Akira Kodate, Yuki Takahashi, Koyo Moriki, Muhammad Sohaib, Asghar, Mashaal Syed, Syed Anosh, Ali Naqvi, Borisovich Zabolotskikh, Konstantin Dmitrievich Zybin, Sergey Vasilevich Sinkov, Tatiana Sergeevna Musaeva, Mohammed A. Almazyad, Mohammed I. Alarifi, Jara M. Macarambon, Ahmad Abdullah Bukhari, Hussain A. Albahrani, Kazi N. Asfina, Kaltham M. Aldossary, Marija Zdravkovic, Zoran Todorovic, Viseslav Popadic, Slobodan Klasnja, Predrag D. Stevanovic, Dejan S. Stojakov, Duska K. Ignjatovic, Suzana C. Bojic, Marina M. Bobos, Irina B. Nenadic, Milica S. Zaric, Marko D. Djuric, Vladimir R. Djukic, Santiago Yus, Belen C. Martin, Uluhan Sili, Huseyin Bilgin, Pinar Ay, Roman R. Melamed, David M. Tierney, Love A. Patel, Vino S. Raj, Barite U. Dawud, Narayana Mazumder, Abbey Sidebottom, Alena M. Guenther, Benjamin D. Krehbiel, Nova J. Schmitz, Stacy L. Jepsen, Lynn Sipsey, Anna Schulte, Whitney Wunderlich, Cecely Hoyt, Kenneth W. Dodd, Nicholas Goodmanson, Kathleen Hesse, Paige Bird, Chauncey Weinert, Nathan Schoenrade, Abdulrahman Altaher, Esmael Mayar, Matthew Aronson, Tyler Cooper, Monica Logan, Brianna Miner, Gisele Papo, Abdulrahman Al-Fares, Anmol Kharbanda, Sunil Jhajhria, Zachary Fyffe, Amy B. Christie, Dennis W. Ashley, Rajani Adiga, Andrea Sikora Newsome, Christy C. Forehand, Rebecca Bruning, Timothy W. Jones, Moldovan Sabov, Fatema Zaidi, Fiona Tissavirasingham, Dhatri Malipeddi, Valerie M. Banner-Goodspeed, Somnath Bose, Lauren E. Kelly, Melisa Joseph, Marie McGourty, Krystal Capers, Benjamin Hoenig, Maria C. Karamourtopoulos, Anica C. Law, Elias N. Baedorf Kassis, Allan J. Walkey, Sushrut S. Waikar, Michael A. Garcia, Mia Colona, Zoe Kibbelaar, Michael Leong, Daniel Wallman, Kanupriya Soni, Jennifer Maccarone, Joshua Gilman, Ycar Devis, Joseph Chung, Munizay Paracha, David N. Lumelsky, Madeline DiLorenzo, Najla Abdurrahman, Shelsey Johnson, Kimberly Zammit, Patrick J. McGrath, William Loeffler, Maya R. Chilbert, Jean-Baptiste Mesland, Pierre Henin, Hélène Petre, Isabelle Buelens, Anne-Catherine Gerard, Rayan E. Ihle, Shelda A. Martin, Elaine A. Davis, Salim Surani, Joshua White, Aftab Khan, Rahul Dhahwal, Sreekanth Cheruku, Farzin Ahmed, Christopher Deonarine, Ashley Jones, Mohammad-Ali Shaikh, David Preston, Jeanette Chin, Steven K. Daugherty, Sam Atkinson, Kelly Shrimpton, Raquel R. Bartz, Vijay Krishnamoorthy, Bryan Kraft, Aaron Pulsipher, Eugene Friedman, Sachin Mehta, David P. Yamane, Ivy Benjenk, Nivedita Prasanna, Katharine Nault, Ronald A. Reilkoff, Julia A. Heneghan, Sarah Eichen, Lexie Goertzen, Scott Rajala, Ghislaine Feussom, Ben Tang, Mayo Clinic Arizona, Rodrigo Cartin-Ceba, Ayan Sen, Amanda Palacios, Giyth M. Mahdi, Rahul Kashyap, Ognjen Gajic, Vikas Bansal, Aysun Tekin, Amos Lal, John C. O’Horo, Neha N. Deo, Mayank Sharma, Shahraz Qamar, Juan Pablo Domecq, Romil Singh, Alex Niven, Mayo Clinic, Eau Claire, Abigail T. La Nou, Marija Bogojevic, Barbara Mullen, Devang Sanghavi, Pramod Guru, Pablo Moreno Franco, Karthik Gnanapandithan, Hollie Saunders, Zachary Fleissner, Juan Garcia, Alejandra Yu Lee Mateus, Siva Naga Yarrarapu, Nirmaljot Kaur, Abhisekh Giri, Syed Anjum Khan, Nitesh Kumar Jain, Thoyaja Koritala, Chakradhar Venkata, Miriam Engemann, Annamarie Mantese, Yasir Tarabichi, Adam Perzynski, Christine Wang, Dhatri Kotekal, Bhagat S. Aulakh, Sandeep Tripathi, Jennifer A. Bandy, Lisa M. Kreps, Dawn R. Bollinger, Roger Scott Stienecker, Andre G. Melendez, Tressa A. Brunner, Sue M. Budzon, Jessica L. Heffernan, Janelle M. Souder, Tracy L. Miller, Andrea G. Maisonneuve, Antonia L. Vilella, Sara B. Kutner, Kacie Clark, Danielle Moore, Harry L. Anderson, III, Dixy Rajkumar, Ali Abunayla, Jerrilyn Heiter, Howard A. Zaren, Stephanie J. Smith, Grant C. Lewis, Lauren Seames, Cheryl Farlow, Judy Miller, Gloria Broadstreet, Anthony Martinez, Micheal Allison, Aniket Mittal, Rafael Ruiz, Aleta Skaanland, Robert Ross, Neha Gupta, Tracy L. Jones, Shonda C. Ayers, Amy B. Harrell, Dr. Brent R. Brown, Abdurrahman Husain, Atul Malhotra, Qais Zawaydeh, Dragana Markotić, Ivana Bošnjak, Emily A. Vail, Susannah Nicholson, Rachelle B. Jonas, AnnaRose E. Dement, William Tang, Mark DeRosa, Robert E. Villarreal, Patrick W. McGonagill, Colette Galet, Janice Hubbard, David Wang, Lauren Allan, Aditya Badheka, Madhuradhar Chegondi, Roger A. Alvarez, Amarilys Alarcon-Calderon, Marie Anne Sosa, Sunita K. Mahabir, Mausam J. Patel, Faraaz Ali Shah, Byron Chuan, Sagar L. Rawal, Manal Piracha, Joseph E. Tonna, Nicholas M. Levin, Kayte Suslavich, Rachel Tsolinas, Zachary T. Fica, Chloe R. Skidmore, Renee D. Stapleton, Anne E. Dixon, Olivia Johnson, Sara S. Ardren, Stephanie Burns, Anna Raymond, Erika Gonyaw, Kevin Hodgdon, Chloe Housenger, Benjamin Lin, Karen McQuesten, Heidi Pecott-Grimm, Julie Sweet, Sebastian Ventrone, Murtaza Akhter, Rania Abdul Rahman, Mary Mulrow, Ashish K. Khanna, Lynne Harris, Bruce Cusson, Jacob Fowler, David Vaneenenaam, Glen McKinney, Imoh Udoh, Kathleen Johnson, Vishwanath Pattan, Jessica Papke, Ismail Jimada, Nida Mhid, and Samuel Chakola

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

OBJECTIVES:. To describe hospital variation in use of “guideline-based care” for acute respiratory distress syndrome (ARDS) due to COVID-19. DESIGN:. Retrospective, observational study. SETTING:. The Society of Critical Care Medicine’s Discovery Viral Infection and RESPIRATORY ILLNESS UNIVERSAL STUDY COVID-19 REGISTRY. PATIENTS:. Adult patients with ARDS due to COVID-19 between February 15, 2020, and April 12, 2021. INTERVENTIONS:. Hospital-level use of “guideline-based care” for ARDS including low-tidal-volume ventilation, plateau pressure less than 30 cm H2O, and prone ventilation for a Pao2/Fio2 ratio less than 100. MEASUREMENTS AND MAIN RESULTS:. Among 1,495 adults with COVID-19 ARDS receiving care across 42 hospitals, 50.4% ever received care consistent with ARDS clinical practice guidelines. After adjusting for patient demographics and severity of illness, hospital characteristics, and pandemic timing, hospital of admission contributed to 14% of the risk-adjusted variation in “guideline-based care.” A patient treated at a randomly selected hospital with higher use of guideline-based care had a median odds ratio of 2.0 (95% CI, 1.1–3.4) for receipt of “guideline-based care” compared with a patient receiving treatment at a randomly selected hospital with low use of recommended therapies. Median-adjusted inhospital mortality was 53% (interquartile range, 47–62%), with a nonsignificantly decreased risk of mortality for patients admitted to hospitals in the highest use “guideline-based care” quartile (49%) compared with the lowest use quartile (60%) (odds ratio, 0.7; 95% CI, 0.3–1.9; p = 0.49). CONCLUSIONS:. During the first year of the COVID-19 pandemic, only half of patients received “guideline-based care” for ARDS management, with wide practice variation across hospitals. Strategies that improve adherence to recommended ARDS management strategies are needed.

Published
2022
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4. Risk Factors for Critical Coronavirus Disease 2019 and Mortality in Hospitalized Young Adults: An Analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) Coronavirus Disease 2019 Registry

Author

Sandeep Tripathi, MD, MS, Imran A. Sayed, MD, Heda Dapul, MD, Jeremy S. McGarvey, MS, Jennifer A. Bandy, RN, Karen Boman, BS, Vishakha K. Kumar, MD, MBA, Vikas Bansal, MBBS, MPH, Lynn Retford, CAE, Sreekanth Cheruku, MD, MPH, Margit Kaufman, MD, FASA, Smith F. Heavner, MS, RN, Valerie C. Danesh, PhD, RN, Catherine A. St. Hill, DVM, PhD, Ashish K. Khanna, MD, Utpal Bhalala, MD, Rahul Kashyap, MBBS, MBA, Ognjen Gajic, MD, MS, Allan J. Walkey, MD, MS, Katja M. Gist, DO, MSc, for The Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry Investigator Group, Jean-Baptiste Mesland, Pierre Henin, Hélène Petre, Isabelle Buelens, Anne-Catherine Gerard, Philippe Clevenbergh, Rolando Claure-Del Granado, Jose A. Mercado, Esdenka Vega-Terrazas, Maria F. Iturricha-Caceres, Ruben Garza, Eric Chu, Victoria Chan, Oscar Y Gavidia, Felipe Pachon, Yeimy A Sanchez, Mohamed El Kassas, Mohamed Badr, Ahmed Tawheed, Hend Yahia, Sierra-Hoffman, Fernando Valerio, Oscar Diaz, Jose Luis Ramos Coello, Guillermo Perez, Ana Karen Vallecillo Lizardo, Gabina María Reyes Guillen, Helin Archaga Soto, Mradul Kumar Daga, Munisha Agarwal, Ishan Rohtagi, Anusha Cherian, Sreejith Parameswaran, Magesh Parthiban, Menu Priya A., Girish Vadgaonkar, Rekha Ediga, Shilpa Basety, Shwetha Dammareddy, Phani Sreeharsha Kasumalla, Sridhar Papani, Mahesh Kamuram, Smitha S. Segu, Tuhin Chakraborty, Epcebha Joyce, Umamaheswara Raju, Janaki Manduva, Naresh Kolakani, Shreeja Sripathi, Sheetal Chaitanya, Surapaneni Krishna Mohan, Ekambaram Jyothisree, Kamlesh Kumar Agrawal, Vijendra Baghel, Kirti Kumar Patel, Nooshin Dalili, Mohsen Nafa, Sandeep Tripathi, Yuki Itagaki, Akira Kodate, Reina Suzuki, Yuki Takahashi, Koyo Moriki, Michihito Kyo, Masamitsu Sanui, Sho Horikita, Wataru Matsuda, Shu Tahara, Mineji Hayakawa, Kunihiko Maekawa, Takuya Shiga, Yudai Iwasaki, Abdulrahman AlFares, Rene Rodriguez-Gutierrez, Jose Gerardo Gonzalez-Gonzalez, Alejandro Salcido-Montenegro, Adrian Camacho-Ortiz, Fatimah Hassan-Hanga, Hadiza Galadanci, Abubakar Shehu Gezawa, Halima M. S. Kabara, Taiwo Gboluwaga Amole, Halima Kabir, Dalha Gwarzo, Haliru, Abdullahi S Ibrahim, Muhammad Sohaib Asghar, Mashaal Syed, Syed Anosh Ali Naqvi, Igor Borisovich Zabolotskikh, Konstantin Dmitrievich Zybin, Sergey Vasilevich Sinkov, Tatiana Sergeevna Musaeva, Marwa Ridha Amer, Mohammed Abdullah Bawazeer, Talal I. Dahhan, Eiad Kseibi, Abid Shahzad Butt, Syed Moazzum Khurshid, Muath Rabee, Mohammed Abujazar, Razan Alghunaim, Maal Abualkhair, Abeer Turki AlFirm, Razan K Alamoudi, Hassan M. AlSharif, Sarah A. Almazwaghi, Mohammed S Elsakran, Mohamed A Aid, Mouaz A Darwich, Omnia M Hagag, Salah A Ali, Alona rocacorba, Kathrine Supeña, Efren Ray Juane, Jenalyn Medina, Jowany Baduria, Mohammed A Almazyad, Mohammed I Alarifi, Jara M Macarambon, Ahmad Abdullah Bukhari, Hussain A. Albahrani, Kazi N Asfina, Kaltham M Aldossary, Predrag D Stevanovic, Dejan S Stojakov, Duska K Ignjatovic, Suzana C Bojic, Marina M Bobos, Irina B Nenadic, Milica S Zaric, Marko D Djuric, Vladimir R Djukic, Bojan Kovacevic, Jovana Bojicic, Marija Zdravkovic, Zoran Todorovic, Viseslav Popadic, Slobodan Klasnja, Santiago Y. Teruel, Belen C. Martin, Himat Sulaimonov, Firuza Khudonazarova, Nabi Bakhtibekov, Nekruz Jamshedov, Uluhan Sili, Huseyin Bilgin, Pinar Ay, Varsha P Gharpure, Usman Raheemi, Kenneth W. Dodd, Nicholas Goodmanson, Kathleen Hesse, Paige Bird, Chauncey Weinert, Nathan Schoenrade, Abdulrahman Altaher, Esmael Mayar, Matthew Aronson, Tyler Cooper, Monica Logan, Brianna Miner, Gisele Papo, Eric M. Siegal, Phyllis Runningen, Catherine A. St. Hill, Roman R. Melamed, David M. Tierney, Love A. Patel, Vino S. Raj, Barite U. Dawud, Narayana Mazumder, Abbey Sidebottom, Alena M. Guenther, Benjamin D. Krehbiel, Nova J. Schmitz, Stacy L. Jepsen, Abhijit A Raval, Andrea Franks, Katherine Irby, Ronald C. Sanders, Jr., Glenda Hefley, Anmol Kharbanda, Sunil Jhajhria, Zachary Fyffe, Stephen Capizzi, Bethany Alicie, Martha Green, Lori Crockarell, Amelia Drennan, Kathleen Dubuque, Tonya Fambrough, Nikole Gasaway, Briana Krantz, Peiman Nebi, Jan Orga, Margaret Serfass, Alina Simion, Kimberly Warren, Cassie Wheeler, CJ Woolman, Andrew S. Moyer, George M. Verghese, Andrea Sikora Newsome, Christy C. Forehand, Rebecca Bruning, Timothy W. Jones, Moldovan Sabov, Fatema Zaidi, Fiona Tissavirasingham, Dhatri Malipeddi, Jarrod M Mosier, Karen Lutrick, Beth Salvagio Campbell, Cathleen Wilson, Patrick Rivers, Jonathan Brinks, Mokenge Ndiva Mongoh, Boris Gilson, Donna Lee Armaignac, Don Parris, Maria Pilar Zuniga, Ilea Vargas, Viviana Boronat, Anneka Hutton, Navneet Kaur, Prashank Neupane, Nohemi Sadule-Rios, Lourdes M. Rojas, Aashish Neupane, Priscilla Rivera, Carlos Valle Carlos, Gregory Vincent, Mahesh Amin, Mary E Schelle, Amanda Steadham, Christopher M Howard, Cameron McBride, Jocelyn Abraham, Orlando Garner, Katherine Richards, Keegan Collins, Preethi Antony, Sindhu Mathew, Valerie C. Danesh, Gueorgui Dubrocq, Amber L. Davis, Marissa J Hammers, ill M. McGahey, Amanda C. Farris, Elisa Priest, Robyn Korsmo, Lorie Fares, Kathy Skiles, Susan M. Shor, Kenya Burns, Corrie A Dowell, Melody Flores, Lindsay Newman, Debora A Wilk, Jason Ettlinger, Jaccallene Bomar, Himani Darji, Alejandro Arroliga, Alejandro C Arroliga, Corrie A. Dowell, Gabriela Hope Conzales, Debora A. Wilk, Paras B. Khandhar, Elizabeth Kring, Valerie M. Banner-Goodspeed, Somnath Bose, Lauren E. Kelly, Melisa Joseph, Marie McGourty, Krystal Capers, Benjamin Hoenig, Maria C. Karamourtopoulos, Anica C. Law, Elias N. Baedorf Kassis, Allan J. Walkey, Sushrut S. Waikar, Michael A. Garcia, Mia Colona, Zoe Kibbelaar, Michael Leong, Daniel Wallman, Kanupriya Soni, Jennifer Maccarone, Joshua Gilman, Ycar Devis, Joseph Chung, Munizay Paracha, David N. Lumelsky, Madeline DiLorenzo, Najla Abdurrahman, Shelsey Johnson, Andrew M. Hersh, Stephanie L Wachs, Brittany S. Swigger, Lauren A. Sattler, Michael N. Moulton, Kimberly Zammit, J Patrick, William McGrath, Maya Loeffler, R Chilbert, Aaron S. Miller, Edwin L. Anderson, Rosemary Nagy, Ravali R. Inja, Raghavendra Tirupathi, Alymer Tang, Arshad Safi, Cindy Green, Jackie Newell, Rayan E. Ihle, Shelda A. Martin, Elaine A. Davis, Katja M. Gist, Imran A Sayed, John Brinton, Larisa Strom, Kathleen Chiotos, Allison M. Blatz, Giyoung Lee, Ryan H. Burnett, Guy I. Sydney, Danielle M. Traynor, Karissa Nauert, Annika Gonzalez, Mariel Bagley, Anita Santpurkar, Salim Surani, Joshua White, Aftab Khan, Rahul Dhahwal, Sreekanth Cheruku, Farzin Ahmed, Christopher Deonarine, Ashley Jones, Mohammad-Ali Shaikh, David Preston, Jeanette Chin, Vidula Vachharajani, Abhijit Duggal, Prabalini Rajendram, Omar Mehkri, Siddharth Dugar, Michelle Biehl, Gretchen Sacha, Stuart Houltham, Alexander King, Kiran Ashok, Bryan Poynter, Mary Beukemann, Richard Rice, Susan Gole, Valerie Shaner, Adarsh Conjeevaram, Michelle Ferrari, Narendrakumar Alappan, Steven Minear, Jaime Hernandez-Montfort, Syed Sohaib Nasim, Ravi Sunderkrishnan, Debasis Sahoo, Patrick S. Milligan, Sandeep K. Gupta, Joy M. Koglin, Regina Gibson, Lana Johnson, Felicia Preston, Crimson Scott, Bethany Nungester, Steven K. Daugherty, Sam Atkinson, Kelly Shrimpton, Sidney Ontai, Brian Contreras, Uzoma Obinwanko, Nneka Amamasi, Amir Sharafi, Sarah Lee, Zahia Esber, Chetna Jinjvadia, Kimberly Welker, Francis M. Maguire, Jessica Timmer, Raquel R Bartz, Vijay Krishnamoorthy, Bryan Kraft, Aaron Pulsipher, Eugene Friedman, Sachin Mehta, Margit Kaufman, Gregg Lobel, Nisha Gandhi, Amr Abdelaty, Elizabeth Shaji, Kiana Lim, Juan Marte, Dani Ashley Sosa, David P. Yamane, Ivy Benjenk, Nivedita Prasanna, Smith F. Heavner-Sullivan, Prera J. Roth, Banu Sivaraj, Haley Fulton, Madison G Herin, Marissa Crum, Morgan E. Fretwell, Emily-Rose Zhou, Christine Waller, Kara Kallies, Jonean Thorsen, Alec Fitzsimmons, Haley Olsen, Heda R. Dapul, Sourabh Verma, Alan Salas, Ariel Daube, Michelle Korn, Michelle Ramirez, Logi Rajagopalan, Laura Santos, Orma Smalls, Atul Malhotra, Abdurrahman Husain, Qais Zawaydeh, J.H. Steuernagle, Steven Q. Davis, Valentina Jovic, Max Masuda, Amanda Hayes, Katharine Nault, Michael Smith, William Snow, Riley Liptak, Hannah Durant, Valerie Pendleton, Alay Nanavati, Risa Mrozowsk, LiManoj K Gupta, Franscene E. Oulds, Akshay Nandavar, Yuk Ming Liu, Sarah Zavala, Esther Shim, Ronald A. Reilkoff, Julia A. Heneghan, Sarah Eichen, Lexie Goertzen, Scott Rajala, Ghislaine Feussom, Ben Tang, Christine C. Junia, Robert Lichtenberg, Hasrat Sidhu, Diana Espinoza, Shelden Rodrigues, Maria Jose Zabala, Daniela Goyes, Ammu Susheela, Buddhi Hatharaliyadda, Naveen Rameshkumar, Amulya Kasireddy, Genessis Maldonado, Lisseth Beltran, Akshata Chaugule, Hassan Khan, Namrata Patil, Ruhi Patil, Rodrigo Cartin-Ceba, Ayan Sen, Amanda Palacios, Giyth M. Mahdi, Rahul Kashyap, Ognjen Gajic, Vikas Bansal, Aysun Tekin, Amos Lal, John C. O’Horo, Neha N. Deo, Mayank Sharma, Shahraz Qamar, Cory J. Kudrna, Juan Pablo Domecq Garces, Abigail T. La Nou, Marija Bogojevic, Devang Sanghavi, Pramod Guru, Karthik Gnanapandithan, Hollie Saunders, Zachary Fleissner, Juan Garcia, Alejandra Yu Lee Mateus, Siva Naga Yarrarapu, Syed Anjum Khan, Juan Pablo Domecq, Nitesh Kumar Jain, Thoyaja Koritala, Alexander Bastidas, Gabriela Orellana, Adriana Briceno Bierwirth, Eliana Milazzo, Juan Guillermo Sierra, Thao Dang, Amy B. Christie, Dennis W. Ashley, Rajani Adiga, Rahul S Nanchal, Paul A Bergl, Jennifer L Peterson, Travis Yamanaka, Nicholas A. Barreras, Michael Markos, Anita Fareeduddin, Rohan Mehta, Chakradhar Venkata, Miriam Engemann, Annamarie Mantese, Yasir Tarabichi, Adam Perzynski, Christine Wang, Dhatri Kotekal, Adriana C Briceno Bierwirth, Gabriela M Orellana, Gerardo Catalasan, Shohana Ahmed, Carlos F Matute, Ahmad Hamdan, Ivania Salinas, Genesis Del Nogal, Angel Tejada, Anna Eschler, Mary Hejna, Emily Lewandowski, Kristen Kusmierski, Clare Martin, Jen-Ting Chen, Aluko Hope, Zoe Tsagaris, Elise Ruen, Aram Hambardzumyan, Prithvi Sendi, Meghana Nadiger, Balagangadhar Totapally, Bhagat S. Aulakh, Jennifer A. Bandy, Lisa M. Kreps, Dawn R. Bollinger, Roger Scott Stienecker, Andre G. Melendez, Tressa A. Brunner, Sue M Budzon, Jessica L. Heffernan, Janelle M. Souder, Tracy L. Miller, Andrea G. Maisonneuve, Roberta E. Redfern, Jessica Shoemaker, Jennifer Micham, Lynn Kenney, Gabriel Naimy, Sara Utley, Holly Balcer, Kerry P. J. Pulver, Jennifer Yehle, Alicia Weeks, Terra Inman, Brian L. Delmonaco, Anthony Franklin, Mitchell Heath, Antonia L. Vilella, Sara B. Kutner, Kacie Clark, Danielle Moore, Shina Menon, John K McGuire, Deana Rich, Harry L. Anderson, III, Dixy Rajkumar, Ali Abunayla, Jerrilyn Heiter, Howard A. Zaren, Stephanie J. Smith, Grant C. Lewis, Lauren Seames, Cheryl Farlow, Judy Miller, Gloria Broadstreet, John Lin, Cindy Terrill, Brock Montgomery, Sydney Reyes, Summer Reyes, Alex Plattner, Anthony Martinez, Micheal Allison, Aniket Mittal, Rafael Ruiz, Aleta Skaanland, Robert Ross, Umang Patel, Jordesha Hodge, KrunalKumar Patel, Shivani Dalal, Himanshu Kavani, Sam Joseph, Michael A. Bernstein, Ian K. Goff, Matthew Naftilan, Amal Mathew, Deborah Williams, Sue Murdock, Maryanne Ducey, Kerianne Nelson, Paul K Mohabir, Connor G O’Brien, Komal Dasani, William Marx, Ioana Amzuta, Asad J. Choudhry, Mohammad T. Azam, Kristina L Carter, Michael A Olmos, Brittany M Parker, Julio Quintanilla, Tara A Craig, Brendon J Clough, Jeffrey T Jameson, Neha Gupta, Tracy L Jones, Shonda C Ayers, Amy B Harrell, Dr.Brent R Brown, Utpal S. Bhalala, Joshua Kuehne, Melinda Garcia, Morgan Beebe, Heather Herrera, Chris Fiack, Stephanie Guo, May Vawer, Beth Blackburn, Megan Edwards, Caleb Darby, Kristy Page, Amanda Brown, Jessie McAbee, Katherine A. Belden, Michael Baram, Devin M. Weber, Rosalie DePaola, Yuwei Xia, Hudson Carter, Aaron Tolley, Mark Steele, Laurie Kemble, Joshua L. Denson, A. Scott Gillet, Margo Brown, Rachael Stevens, Andrew Wetherbie, Kevin Tea, Mathew Moore, Benjamin J Sines, Thomas J Bice, Emily A. Vail, Susannah Nicholson, Rachelle B. Jonas, AnnaRose E. Dement, William Tang, Mark DeRosa, Robert E. Villarreal, Rajany V. Dy, Alfredo Iardino, Jill Sharma, Richard Czieki, Julia Christopher, Ryan Lacey, Marwan Mashina, Kushal Patel, Erica C. Bjornstad, Nancy M. Tofil, Scott House, Isabella Aldana, Nikhil K. Meena, Jose D. Caceres, Nikhil K Meena, Sarenthia M. Epps, Harmeen Goraya, Kelsey R. Besett, Ryan James, Lana Y. Abusalem, Akash K. Patel, Lana S Hasan, Dina Gomaa, Michael Goodman, Devin Wakefield, Anthony Spuzzillo, John O. Shinn, II, Azra Bihorac, Tezcan Ozrazgat Baslanti, George Omalay, Haleh Hashemighouchani, Julie S. Cupka, Matthew M Ruppert, Patrick W. McGonagill, Colette Galet, Janice Hubbard, David Wang, Lauren Allan, Aditya Badheka, Madhuradhar Chegondi, Usman Nazir, Garrett Rampon, Jake Riggle, Nathan Dismang, Vicki Montgomery, Janice Sullivan, Sarah Morris, Jennifer Nason, Roger A. Alvarez, Amarilys Alarcon-Calderon, Marie Anne Sosa, Sunita K. Mahabir, Mausam J. Patel, Pauline Park, Andrew Admon, Sinan Hanna, Rishi Chanderraj, Maria Pliakas, Ann Wolski, Jennifer Cirino, Dima Dandachi, Hariharan Regunath, Maraya N. Camazine, Grant. E. Geiger, Abdoulie O. Njai, Baraa M. Saad, Faraaz Ali Shah, Byron Chuan, Sagar L. Rawal, Manal Piracha, Joseph E. Tonna, Nicholas M. Levin, Kayte Suslavich, Rachel Tsolinas, Zachary T. Fica, Chloe R. Skidmore, Renee D. Stapleton, Anne E. Dixon, Olivia Johnson, Sara S. Ardren, Stephanie Burns, Anna Raymond, Erika Gonyaw, Kevin Hodgdon, Chloe Housenger, Benjamin Lin, Karen McQuesten, Heidi Pecott-Grimm, Julie Sweet, Sebastian Ventrone, Nita Khandelwal, T. Eoin West, Ellen S. Caldwell, Lara Lovelace-Macon, Navya Garimella, Denisse B. Dow, Murtaza Akhter, Rania Abdul Rahman, Mary Mulrow, Erin M. Wilfong, Kelsi Vela, Ashish K. Khanna, Lynne Harris, Bruce Cusson, Jacob Fowler, David Vaneenenaam, Glen McKinney, Imoh Udoh, Kathleen Johnson, Patrick G. Lyons, Andrew P Michelson, Sara S. Haluf, Lauren M. Lynch, Nguyet M. Nguyen, Aaron Steinberg, Nicholas Braus, Vishwanath Pattan, Jessica Papke, Ismail Jimada, Nida Mhid, and Samuel Chakola

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

IMPORTANCE:. Even with its proclivity for older age, coronavirus disease 2019 has been shown to affect all age groups. However, there remains a lack of research focused primarily on the young adult population. OBJECTIVES:. To describe the epidemiology and outcomes of coronavirus disease 2019 and identify the risk factors associated with critical illness and mortality in hospitalized young adults. DESIGN, SETTINGS, AND PARTICIPANTS:. A retrospective cohort study of the Society of Critical Care Medicine’s Viral Infection and Respiratory Illness Universal Study registry. Patients 18–40 years old, hospitalized from coronavirus disease 2019 from March 2020 to April 2021, were included in the analysis. MAIN OUTCOMES AND MEASURES:. Critical illness was defined as a composite of mortality and 21 predefined interventions and complications. Multivariable logistic regression was used to assess associations with critical illness and mortality. RESULTS:. Data from 4,005 patients (152 centers, 19 countries, 18.6% non-U.S. patients) were analyzed. The median age was 32 years (interquartile range, 27–37 yr); 51% were female, 29.4% Hispanic, and 42.9% had obesity. Most patients (63.2%) had comorbidities, the most common being hypertension (14.5%) and diabetes (13.7%). Hospital and ICU mortality were 3.2% (129/4,005) and 8.3% (109/1,313), respectively. Critical illness occurred in 25% (n = 996), and 34.3% (n = 1,376) were admitted to the ICU. Older age (p = 0.03), male sex (adjusted odds ratio, 1.83 [95% CI, 1.2–2.6]), and obesity (adjusted odds ratio, 1.6 [95% CI, 1.1–2.4]) were associated with hospital mortality. In addition to the above factors, the presence of any comorbidity was associated with critical illness from coronavirus disease 2019. Multiple sensitivity analyses, including analysis with U.S. patients only and patients admitted to high-volume sites, showed similar risk factors. CONCLUSIONS:. Among hospitalized young adults, obese males with comorbidities are at higher risk of developing critical illness or dying from coronavirus disease 2019.

Published
2021
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5. Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates

Author

Jeffrey R. Stowell, Paul Pugsley, Heather Jordan, and Murtaza Akhter

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates. Methods: This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015–March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not. Results: Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%–5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%–3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%–5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%–63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%–0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters. Conclusion: ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

Published
2019
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6. Ruling out Pulmonary Embolism in Patients with High Pretest Probability

Author

Murtaza Akhter, Jeffrey Kline, Bikash Bhattarai, Mark Courtney, and Christopher Kabrhel

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients. Methods: We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE or deep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%. Results: A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells >6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval {2.2%–40.0%}]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up. Conclusion: Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients.

Published
2018
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7. Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice

Author

Jeremy J. Hess, Joshua Wallenstein, Jeremy D. Ackerman, Murtaza Akhter, Douglas Ander, Matthew T. Keadey, and James P. Capes

Subjects
Emergency medicine, scribes, academic medical center, clinical productivity, medical education, Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: Physicians dedicate substantial time to documentation. Scribes are sometimes used to improve efficiency by performing documentation tasks, although their impacts have not been prospectively evaluated. Our objective was to assess a scribe program’s impact on emergency department (ED) throughput, physician time utilization, and job satisfaction in a large academic emergency medicine practice. Methods: We evaluated the intervention using pre- and post-intervention surveys and administrative data. All site physicians were included. Pre- and post-intervention data were collected in fourmonth periods one year apart. Primary outcomes included changes in monthly average ED length of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate tests for paired pre-post differences in continuous, categorical, and ranked variables. Results: Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded positively to the intervention, although 9.5% reported negative impressions. There was a 36% reduction (25%-50%; p

Published
2015
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9. Guidelines for reasonable and appropriate care in the emergency department 3 ( <scp>GRACE</scp> ‐3): Acute dizziness and vertigo in the emergency department

Author

Jonathan A. Edlow, Christopher Carpenter, Murtaza Akhter, Danya Khoujah, Evie Marcolini, William J. Meurer, David Morrill, James G. Naples, Robert Ohle, Rodney Omron, Sameer Sharif, Matt Siket, Suneel Upadhye, Lucas Oliveira J. e Silva, Etta Sundberg, Karen Tartt, Simone Vanni, David E. Newman‐Toker, and Fernanda Bellolio

Subjects
Emergency Medicine, General Medicine
Published
2023

14. Impact of COVID-19 Pandemic on Emergency Department Visits: A Regional Case Study of Informatics Challenges and Opportunities

Author

Hamid, Ghaderi, Jeffrey R, Stowell, Murtaza, Akhter, Craig, Norquist, Paul, Pugsley, and Vignesh, Subbian

Subjects
Adult, Informatics, COVID-19, Humans, Public Health, Articles, Emergency Service, Hospital, Pandemics, humanities
Abstract

In this paper, we examined informatics challenges and opportunities related to emergency department visit data during public health emergencies. We investigated the impact of COVID-19 pandemic on the volume and acuity of adult patients visiting the emergency department (ED) of a medical center in Arizona during the pandemic compared to the pre-pandemic period. We performed a negative binomial regression analysis to understand how different public health-related mandates and statewide business opening/closing orders in Arizona affected the daily emergency department visits. The results of this study show that the average daily ED visits decreased by 20% during the COVID-19 pandemic in comparison with the same period in 2019. In addition, the business closure order had the most impact on emergency department visits in comparison to other public health mandates.

Published
2022

15. Risk of contrast extravasation with vascular access in computed tomography

Author

Carl E. Mitchell, Daniel Orosco, Jeffrey R. Stowell, Mary Connell, Levi Filler, Roy Colglazier, Murtaza Akhter, and Daniel Rigdon

Subjects
Male, medicine.medical_specialty, business.industry, Ultrasound, Absolute risk reduction, Contrast Media, Soft tissue, Retrospective cohort study, Middle Aged, Phlebotomy, Extravasation, Peripheral, Risk Factors, Relative risk, Injections, Intravenous, Emergency Medicine, medicine, Humans, Female, Radiology, Nuclear Medicine and imaging, Radiology, Tomography, X-Ray Computed, business, Extravasation of Diagnostic and Therapeutic Materials, Retrospective Studies
Abstract

Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging. The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR). Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21–0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3–5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69–21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61–4.47%) when compared to upper arm catheters. IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach.

Published
2020

19. Characterization and Outcomes of Hospitalized Children With Coronavirus Disease 2019: A Report From a Multicenter, Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) Registry

Author

Utpal S, Bhalala, Katja M, Gist, Sandeep, Tripathi, Karen, Boman, Vishakha K, Kumar, Lynn, Retford, Kathleen, Chiotos, Allison M, Blatz, Heda, Dapul, Sourabh, Verma, Imran A, Sayed, Varsha P, Gharpure, Erica, Bjornstad, Nancy, Tofil, Katherine, Irby, Ronald C, Sanders, Julia A, Heneghan, Melissa, Thomas, Manoj K, Gupta, Franscene E, Oulds, Grace M, Arteaga, Emily R, Levy, Neha, Gupta, Margit, Kaufman, Amr, Abdelaty, Mark, Shlomovich, Shivanand S, Medar, A M, Iqbal O'Meara, Joshua, Kuehne, Shina, Menon, Paras B, Khandhar, Aaron S, Miller, Suzanne M, Barry, Valerie C, Danesh, Ashish K, Khanna, Kimberly, Zammit, Casey, Stulce, Patrick W, McGonagill, Asher, Bercow, Ioana G, Amzuta, Sandeep, Gupta, Mohammed A, Almazyad, Louisdon, Pierre, Prithvi, Sendi, Sidra, Ishaque, Harry L, Anderson, Pooja, Nawathe, Murtaza, Akhter, Patrick G, Lyons, Catherine, Chen, Allan J, Walkey, Azra, Bihorac, Imam, Wada Bello, Judith, Ben Ari, Tanja, Kovacevic, Vikas, Bansal, John T, Brinton, Jerry J, Zimmerman, Rahul, Kashyap, and Kathleen, Johnson

Subjects
Male, medicine.medical_specialty, Adolescent, Comorbidity, Overweight, Critical Care and Intensive Care Medicine, Logistic regression, outcomes, intensive care unit, children, coronavirus disease 2019, multisystem inflammatory syndrome in children, severe acute respiratory syndrome coronavirus 2, Body Mass Index, Interquartile range, Internal medicine, medicine, Humans, Mass index, Hospital Mortality, Child, Retrospective Studies, Study Registry, business.industry, SARS-CoV-2, Age Factors, Online Clinical Investigations, COVID-19, Infant, Retrospective cohort study, Systemic Inflammatory Response Syndrome, Intensive Care Units, Logistic Models, Child, Preschool, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Observational study, Median body, Female, medicine.symptom, business, Child, Hospitalized
Abstract

Supplemental Digital Content is available in the text., Objectives: Multicenter data on the characteristics and outcomes of children hospitalized with coronavirus disease 2019 are limited. Our objective was to describe the characteristics, ICU admissions, and outcomes among children hospitalized with coronavirus disease 2019 using Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 registry. Design: Retrospective study. Setting: Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) registry. Patients: Children (< 18 yr) hospitalized with coronavirus disease 2019 at participating hospitals from February 2020 to January 2021. Interventions: None. Measurements and Main Results: The primary outcome was ICU admission. Secondary outcomes included hospital and ICU duration of stay and ICU, hospital, and 28-day mortality. A total of 874 children with coronavirus disease 2019 were reported to Viral Infection and Respiratory Illness Universal Study registry from 51 participating centers, majority in the United States. Median age was 8 years (interquartile range, 1.25–14 yr) with a male:female ratio of 1:2. A majority were non-Hispanic (492/874; 62.9%). Median body mass index (n = 817) was 19.4 kg/m2 (16–25.8 kg/m2), with 110 (13.4%) overweight and 300 (36.6%) obese. A majority (67%) presented with fever, and 43.2% had comorbidities. A total of 238 of 838 (28.2%) met the Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children, and 404 of 874 (46.2%) were admitted to the ICU. In multivariate logistic regression, age, fever, multisystem inflammatory syndrome in children, and pre-existing seizure disorder were independently associated with a greater odds of ICU admission. Hospital mortality was 16 of 874 (1.8%). Median (interquartile range) duration of ICU (n = 379) and hospital (n = 857) stay were 3.9 days (2–7.7 d) and 4 days (1.9–7.5 d), respectively. For patients with 28-day data, survival was 679 of 787, 86.3% with 13.4% lost to follow-up, and 0.3% deceased. Conclusions: In this observational, multicenter registry of children with coronavirus disease 2019, ICU admission was common. Older age, fever, multisystem inflammatory syndrome in children, and seizure disorder were independently associated with ICU admission, and mortality was lower among children than mortality reported in adults.

Published
2021

20. Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates

Author

Murtaza Akhter, Jeffrey R. Stowell, Heather Jordan, and Paul Pugsley

Subjects
Adult, Male, medicine.medical_specialty, Treatment completion, Patient Dropouts, Health Personnel, lcsh:Medicine, medicine, Humans, Phlebotomy, Emergency Services, Organizational Efficiency, Delivery of Health Care, Health Care Quality, Original Research, Retrospective Studies, Phlebotomist, Blood Specimen Collection, business.industry, lcsh:R, Arizona, lcsh:Medical emergencies. Critical care. Intensive care. First aid, Retrospective cohort study, lcsh:RC86-88.9, General Medicine, Emergency department, Phlebotomy, Triage, Confidence interval, Emergency medicine, Emergency Medicine, Female, Emergency Department Operations, Emergency Service, Hospital, Blood specimen, business
Abstract

Author(s): Stowell, Jeffrey R.; Pugsley, Paul; Jordan, Heather; Akhter, Murtaza | Abstract: Introduction: The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates.Methods: This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015-March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of g 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not.Results: Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%-5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%-3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%-5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%-63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%-0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters.Conclusion: ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

Published
2019

21. Evaluation and Management of the Emergency Department Headache

Author

Murtaza Akhter, Perrin Nimlos, and Levi Filler

Subjects
medicine.medical_specialty, Subarachnoid hemorrhage, Physical examination, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Outcome Assessment, Health Care, Health care, medicine, Humans, Disease management (health), Intensive care medicine, medicine.diagnostic_test, business.industry, Headache, Disease Management, Emergency department, medicine.disease, Review article, Neurology, Neurology (clinical), Headaches, medicine.symptom, Emergency Service, Hospital, business, Meningitis, 030217 neurology & neurosurgery
Abstract

The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache—which may be broadly categorized into structural, infectious, and vascular causes—is the primary focus of evaluation in the ED. Secondary headaches are associated with a high morbidity and mortality, and require strict scrutiny of the history and physical examination to adequately risk-stratify patients. Innovative and emerging technologies may further assist providers in the diagnosis of headache, and challenge previous gold-standard diagnostic evaluations. Herein, we present a general overview of the workup and management of headaches in the ED, with a special section for diagnostic considerations in evaluating for acute meningitis, subarachnoid hemorrhage, and acute angle-closure glaucoma.

Published
2019

22. An update on the rod microglia variant in experimental and clinical brain injury and disease

Author

Jonathan Lifshitz, Charlotte R. Denman, Katherine R. Giordano, Phoebe S Dubisch, and Murtaza Akhter

Subjects
0301 basic medicine, rod microglia, genetic structures, Traumatic brain injury, Hippocampus, microglia, Review Article, Hippocampal formation, 03 medical and health sciences, 0302 clinical medicine, Cortex (anatomy), medicine, Process (anatomy), Microglia, Chemistry, AcademicSubjects/SCI01870, traumatic brain injury, General Engineering, medicine.disease, 030104 developmental biology, medicine.anatomical_structure, nervous system, inflammation, Circumnutation, Soma, AcademicSubjects/MED00310, pathology, sense organs, Neuroscience, 030217 neurology & neurosurgery
Abstract

Contemporary microglia morphologies include ramified, activated and amoeboid, with the morphology of microglia considered highly coupled to the cellular function. Rod microglia are an additional activated microglia variant observed in the ageing, injured and diseased brain. Rod microglia were reported frequently in the early 1900s by neuropathologists in post-mortem cases of general paresis, Alzheimer’s disease and encephalitis, and then remained largely ignored for almost 100 years. Recent reports have renewed interest in rod microglia, most notably after experimental traumatic brain injury. Rod microglia are formed by the narrowing of the soma and retraction of planar processes, which results in the appearance of an elongated, rod-shaped cell. Rod microglia are most commonly observed in the cortex, aligned perpendicular to the dural surface and adjacent to neuronal processes; in the hippocampus, they are aligned perpendicular to hippocampal layers. Furthermore, rod microglia form trains with one another, apical end to basal end. By replicating the process of sketching microscopic observation, rod microglia are re-defined by circumnutation around the long axis. In this update, we summarize the rod microglia variant in clinical and experimental literature and advocate for investigation into mechanisms of rod microglia origin and function., Rod microglia are a variant of activated microglia reported in the brain after neurological injury and disease. Despite their discovery over 100 years ago, little is known about their formation, expression, or function. Advanced molecular tools are required to elucidate the role of rod microglia., Graphical Abstract Graphical Abstract

Published
2021

24. The safety of the sepsis fluid bolus for patients at increased risk of volume overload

Author

Jeffrey R. Stowell, Murtaza Akhter, and Terence Potter

Subjects
medicine.medical_specialty, business.industry, MEDLINE, Volume overload, General Medicine, medicine.disease, Risk Assessment, End stage renal disease, Sepsis, Cohort Studies, Increased risk, Pulmonology, Internal medicine, Emergency Medicine, Cardiology, Medicine, Fluid Therapy, Humans, business, Fluid bolus, Retrospective Studies
Published
2020

25. Real-world Time to Positivity of 2 Widely Used Commercial Blood Culture Systems in Patients With Severe Manifestations of Sepsis: An Analysis of the FABLED Study

Author

Murtaza Akhter, Robert Stenstrom, Cedric P. Yansouni, Adam C. Davidson, Matthew P. Cheng, Koray Demir, Todd C. Lee, Katryn Paquette, Chelsea Caya, Sassan Sangsari, Rehman Jinah, Amirali Mahpour, David Sweet, Sarah N Stabler, Zahid Saeed, Marko Gavric, Kelly Huang, Greg Clark, Chris Shamatutu, Titus Wong, Guillaume Butler-Laporte, Alexander Lawandi, and Jean Marc Troquet

Subjects
0301 basic medicine, medicine.medical_specialty, medicine.drug_class, 030106 microbiology, Antibiotics, Population, bloodstream infection, time to positivity, Major Articles, sepsis, Sepsis, 03 medical and health sciences, 0302 clinical medicine, Interquartile range, Internal medicine, Medicine, Blood culture, 030212 general & internal medicine, education, Prospective cohort study, education.field_of_study, medicine.diagnostic_test, business.industry, microbiology, medicine.disease, AcademicSubjects/MED00290, Infectious Diseases, Oncology, Cohort, business, Blood drawing
Abstract

Background Of all microbiological tests performed, blood cultures have the most impact on patient care. Timely results are essential, especially in the management of sepsis. While there are multiple available blood culture systems on the market, they have never been compared in a prospective study in a critically ill population. Methods We performed an analysis of the FABLED study cohort to compare culture results and time to positivity (TTP) of 2 widely used blood culture systems: BacT/Alert and BACTEC. In this multisite prospective study, patients with severe manifestations of sepsis had cultures drawn before antibiotics using systematic enrollment criteria and blood drawing methodology allowing for minimization of pre-analytical biases. Results We enrolled 315 patients; 144 had blood cultures (47 positive) with BacT/Alert and 171 with BACTEC (53 positive). Patients whose blood cultures were processed using the BacT/Alert system were younger (median, 64 vs 70 years; P = .003), had a higher proportion of HIV (9.03% vs 1.75%; P = .008) and a lower qSOFA (P = .003). There were no statistically significant differences in the most commonly identified bacterial species. TTP was shorter for BACTEC (median [interquartile range {IQR}], 12.5 [10–14] hours) compared with BacT/Alert (median [IQR], 17 [14–21] hours; P Conclusions In this large prospective multi-centre study comparing the two blood culture systems among patients with severe manifestations of sepsis, and using a rigorous pre-analytical methodology, the BACTEC system yielded positive culture results 4.5 hours earlier than BacT/Alert. These results apply to commonly isolated bacteria. However, our study design did not allow direct comparison of TTP for unusual pathogens nor of clinical sensitivity between systems. More research is needed to determine the clinical implications of this finding.

Published
2020

26. Intranasal treatment of cluster headache

Author

Murtaza Akhter and Mani Hashemi

Subjects
Neurology, Headache, Sphenopalatine Ganglion Block, Humans, Cluster Headache, Neurology (clinical), Administration, Intranasal
Published
2022

27. Ruling out Pulmonary Embolism in Patients with High Pretest Probability

Author

Jeffrey A. Kline, Christopher Kabrhel, Murtaza Akhter, Bikash Bhattarai, and D. Mark Courtney

Subjects
Male, medicine.medical_specialty, lcsh:Medicine, 030204 cardiovascular system & hematology, Fibrin Fibrinogen Degradation Products, 03 medical and health sciences, 0302 clinical medicine, Predictive Value of Tests, Internal medicine, Pulmonary angiography, Medicine, Humans, In patient, 030212 general & internal medicine, Prospective Studies, Prospective cohort study, Probability, Venous Thrombosis, business.industry, Treatment Protocol Assessment, lcsh:R, lcsh:Medical emergencies. Critical care. Intensive care. First aid, General Medicine, lcsh:RC86-88.9, Brief Research Report, Middle Aged, medicine.disease, Confidence interval, Pulmonary embolism, Vein thrombosis, Pre- and post-test probability, Predictive value of tests, Emergency Medicine, Female, business, Emergency Service, Hospital, Pulmonary Embolism
Abstract

Author(s): Akhter, Murtaza; Kline, Jeffrey; Bhattarai, Bikash; Courtney, Mark; Kabrhel, Christopher | Abstract: Introduction: The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients.Methods: We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE ordeep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%.Results: A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells g6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval 2.2%-40.0%]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up.Conclusion: Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients.

Published
2018

28. Optimizing cost as well as yield of blood cultures in sepsis

Author

Murtaza Akhter and Matthew P. Cheng

Subjects
Veterinary medicine, medicine.diagnostic_test, business.industry, Yield (finance), Bacteremia, General Medicine, medicine.disease, Sepsis, Blood Culture, Emergency Medicine, Humans, Medicine, Blood culture, business
Published
2021

29. Hepatic steatosis in Hispanics

Author

Murtaza Akhter and Albert T. Roh

Subjects
Text mining, business.industry, Emergency Medicine, medicine, General Medicine, Steatosis, medicine.disease, business, Bioinformatics
Published
2021

30. Timing of INR reversal using fresh-frozen plasma in warfarin-associated intracerebral hemorrhage

Author

Christopher D. Anderson, Anand Viswanathan, Mahmut Edip Gurol, Murtaza Akhter, Abigail S. Cohen, Andrea Morotti, Jonathan Rosand, Alison M. Ayres, Yuchiao Chang, Steven M. Greenberg, Joshua N. Goldstein, and Kristin Schwab

Subjects
Male, Vitamin K, Blood Component Transfusion, 030204 cardiovascular system & hematology, Statistics, Nonparametric, Cohort Studies, Plasma, 03 medical and health sciences, 0302 clinical medicine, Hematoma, Modified Rankin Scale, health services administration, Internal Medicine, medicine, Coagulopathy, Humans, International Normalized Ratio, cardiovascular diseases, Stroke, Aged, Cerebral Hemorrhage, Retrospective Studies, Aged, 80 and over, Intracerebral hemorrhage, Chi-Square Distribution, business.industry, Warfarin, Anticoagulants, Middle Aged, medicine.disease, Antifibrinolytic Agents, Treatment Outcome, Massachusetts, Anesthesia, Cohort, Emergency Medicine, Female, Fresh frozen plasma, Tomography, X-Ray Computed, business, 030217 neurology & neurosurgery, medicine.drug
Abstract

Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome. We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis. 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3–3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5–14) h vs. 10 (IQR 7–16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6–14) h vs. 12 (8–19) h, p = 0.064). We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.

Published
2017

31. Discrepancy Between Clinician Gestalt and Subjective Component of the Wells Score in the Evaluation of Pulmonary Embolism

Author

Christopher Kabrhel, Jeffrey A. Kline, D. Mark Courtney, Murtaza Akhter, and Vijay Kannan

Subjects
medicine.medical_specialty, business.industry, MEDLINE, 030208 emergency & critical care medicine, 030204 cardiovascular system & hematology, medicine.disease, Pulmonary embolism, 03 medical and health sciences, 0302 clinical medicine, Component (UML), Emergency Medicine, medicine, Physical therapy, Gestalt psychology, business, Wells score
Published
2018

32. Intracerebral hemorrhage in the mouse altered sleep-wake patterns and activated microglia

Author

Jonathan Lifshitz, Katherine R. Giordano, Fabian Fernandez, Hannah K. Dollish, Charlotte R. Denman, Rachel K. Rowe, and Murtaza Akhter

Subjects
0301 basic medicine, Male, medicine.medical_treatment, Inflammation, Striatum, Pharmacology, 03 medical and health sciences, Mice, 0302 clinical medicine, Developmental Neuroscience, medicine, Animals, cardiovascular diseases, Circadian rhythm, Cerebral Hemorrhage, Intracerebral hemorrhage, Microglia, business.industry, medicine.disease, Pathophysiology, Corpus Striatum, nervous system diseases, Circadian Rhythm, Disease Models, Animal, 030104 developmental biology, medicine.anatomical_structure, Cytokine, Neurology, Cytokines, medicine.symptom, business, Sleep, 030217 neurology & neurosurgery, Blood vessel
Abstract

Sleep-wake disturbances are both a risk factor and reported morbidity for intracerebral hemorrhage (ICH). ICH begins with a ruptured blood vessel and blood leakage into the parenchyma. In response to initial damage, pathophysiological processes ensue that both exacerbate and repair damage. Inflammation is a hallmark process of ICH, which includes microglia activation and increased cytokine signaling. Due to the dual role of cytokines as inflammatory signaling proteins and sleep regulatory substances (SRSs), we hypothesized that ICH would activate microglia, increase SRSs, and alter sleep-wake patterns following an experimental model of ICH in the mouse. Male mice were randomized to receive an injection of collagenase (ICH; n = 8) or saline (sham; n = 11) in the striatum of the right hemisphere. Sleep-wake activity was recorded for 6 full days after ICH via noninvasive sleep cages. Blood and tissue were collected at 7 days after ICH to quantify pro-inflammatory cytokines/SRSs (IL-1β, TNF-α, IL-6) and microglia deramification by skeleton analysis. There was an overall injury effect on sleep in mice subjected to ICH at the transition from dark (wake) to light (sleep) at 2, 3, 4, 5, and 6 days after ICH compared with shams. Further analysis confirmed that ICH mice had significantly earlier wake offsets at the dark/light transition and more robust circadian patterns of wake behavior than saline control mice. Spatiotemporal skeleton analysis indicated an increase in microglial cell number with a decrease in endpoints per cell (decreased ramification) for the ipsilateral ICH perihematomal region compared with saline control. There were no changes to plasma cytokine levels at 7 days after ICH when comparing each condition. This is the first known study to show changes in sleep-wake patterns after experimental ICH. Elucidation of mechanisms that link sleep, inflammation, and ICH offers new pharmacological opportunities and rehabilitative strategies to improve recovery in stroke patients.

Published
2019

33. Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study

Author

Matthew P, Cheng, Robert, Stenstrom, Katryn, Paquette, Sarah N, Stabler, Murtaza, Akhter, Adam C, Davidson, Marko, Gavric, Alexander, Lawandi, Rehman, Jinah, Zahid, Saeed, Koray, Demir, Kelly, Huang, Amirali, Mahpour, Chris, Shamatutu, Chelsea, Caya, Jean-Marc, Troquet, Greg, Clark, Cedric P, Yansouni, David, Sweet, and Farzaneh, Osati

Subjects
Male, medicine.medical_specialty, 01 natural sciences, Sensitivity and Specificity, Sepsis, 03 medical and health sciences, 0302 clinical medicine, Pharmacotherapy, Anti-Infective Agents, Interquartile range, Internal medicine, Internal Medicine, Medicine, Humans, Blood culture, 030212 general & internal medicine, 0101 mathematics, Aged, Antiinfective agent, medicine.diagnostic_test, business.industry, 010102 general mathematics, General Medicine, Emergency department, Antimicrobial, medicine.disease, Blood pressure, Blood Culture, Acute Disease, Female, business
Abstract

Background Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity. Objective To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis. Design Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905). Setting 7 emergency departments in North America. Participants Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more. Intervention Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment. Measurements Sensitivity of blood cultures obtained after initiation of antimicrobial therapy. Results Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients. Limitation Only a proportion of screened patients were recruited. Conclusion Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation. Primary Funding Source Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Sante-Quebec, and the Maricopa Medical Foundation.

Published
2019

34. Freestanding Emergency Department Entry and Market-level Spending on Emergency Care

Author

Murtaza Akhter, Yingying Xu, and Vivian Ho

Subjects
Male, Emergency Medical Services, Databases, Factual, media_common.quotation_subject, Microdata (statistics), Beneficiary, Ambulatory Care Facilities, American Community Survey, 03 medical and health sciences, 0302 clinical medicine, Public use, North Carolina, Medicine, Humans, Reimbursement, media_common, business.industry, Arizona, 030208 emergency & critical care medicine, General Medicine, Middle Aged, Quarter (United States coin), Payment, Texas, Freestanding Emergency Department, Emergency Medicine, Florida, Female, Health Expenditures, business, Demography
Abstract

BACKGROUND Freestanding emergency departments (FrEDs) could reduce wait times in overcrowded emergency departments (EDs), but they might also increase usage and overall spending for emergency care. We investigate the relationship between the number of FrEDs entering a local market and overall spending on emergency care. METHODS We accessed data from Arizona, Florida, North Carolina, and Texas in Blue Cross Blue Shield Axis; a limited data set of deidentified insurance data claims that we linked to Public Use Microdata Area (PUMA) data from the American Community Survey; and lists of licensed FrEDs from state agencies. Regression analysis was used to estimate the association between changes in the number of FrEDs in 495 PUMAs and total spending on emergency care, out-of-pocket spending, utilization, and price per visit from January 2013 to December 2017. Final estimates came from a PUMA-level fixed-effects model, with controls for state, quarter, and PUMA-level demographics. RESULTS Entry of an additional FrED in a PUMA was associated with a 3.6 percentage point (pp; CI = 2.4 to 4.9) increase in emergency provider reimbursement per insured beneficiary in Texas, Florida, and North Carolina. There was no change in spending (2.5 pp; CI = -8.2 to 3.1) associated with a FrED's entry in Arizona. Entry of an additional FrED was associated with a 0.18 (CI = 0.12 to 0.23) increase in the number of emergency care visits per 100 enrollees in Texas, Florida, and Arizona. In contrast, entry of another FrED was not associated with a change in utilization (-0.03; CI = -0.09 to 0.02) in North Carolina. Estimated out-of-pocket payments for emergency care increased 3.6 pp (CI = 2.5 to 4.8) with the entry of a FrED in Texas, Florida, and Arizona, but declined by 15.3 pp (CI = -26.8 to -3.7) in North Carolina. CONCLUSIONS Rather than functioning as substitutes for hospital-based EDs, FrEDs have increased local market spending on emergency care in three of four states' markets where they have entered. State policy makers and researchers should carefully track spending and utilization of emergency care as FrEDs disseminate to better understand their potential health benefits and cost implications for patients.

Published
2019

35. Concordance between blood and cerebrospinal fluid cultures in meningitis

Author

Murtaza Akhter, Kyle M. Watanabe, Ryan J. Phillips, and Jeffrey R. Stowell

Subjects
Fungal meningitis, Adult, Male, medicine.medical_specialty, Time Factors, Adolescent, medicine.drug_class, Concordance, Antibiotics, Polymerase Chain Reaction, Spinal Puncture, Meningitis, Bacterial, Young Adult, Cerebrospinal fluid, Predictive Value of Tests, Internal medicine, medicine, Humans, Blood culture, Child, Aged, Retrospective Studies, medicine.diagnostic_test, Lumbar puncture, business.industry, Infant, Retrospective cohort study, General Medicine, Middle Aged, medicine.disease, Child, Preschool, Emergency Medicine, Female, business, Meningitis
Abstract

Objective To examine the association between cerebrospinal fluid (CSF) cultures and blood cultures in patients with suspected bacterial or fungal meningitis. Methods A 5-year retrospective chart review, conducted from April 2012 to January 2017 of consecutive patient encounters with bacterial or fungal organism growth in CSF culture, when a blood culture was also obtained. Patients were excluded if they received antibiotics prior to either lumbar puncture (LP) or blood culture acquisition, or if CSF cultures were positive for common bacterial skin contaminants. Descriptive statistics were used to characterize the dataset. Results 21 patient encounters met study inclusion criteria. 13 (61.9%; 95% CI 40.2–80.5%) had blood culture growth of the same organism as the CSF culture. 1 patient had a different organism in the blood culture compared to the CSF culture. 6 patients (33.3%, 95% CI 14.8%–56.9%) with positive CSF cultures had negative blood cultures. Conclusions Our results suggest an insufficient degree of agreement between CSF and blood culture results. PCR may be a prudent approach in patients requiring immediate antibiotics and delayed LP.

Published
2019

36. 847. The Effect of Antimicrobial Administration on Blood Culture Positivity in Patients with Severe Manifestations of Sepsis

Author

David Sweet, Adam C. Davidson, Sarah N Stabler, Amirali Mahpour, Koray Demir, Katryn Paquette, Zahid Saheed, Chelsea Caya, Murtaza Akhter, Jean-Marc Troquet, Kelly Huang, Matthew P. Cheng, Marko Gavric, Cedric P. Yansouni, Robert Stenstrom, Rehman Jinah, Alexander Lawandi, Greg Clark, and Chris Shamatutu

Subjects
medicine.medical_specialty, Intention-to-treat analysis, medicine.diagnostic_test, business.industry, Time to treatment, medicine.disease, Antimicrobial, Pathogenic organism, Sepsis, Abstracts, Infectious Diseases, Blood pressure, Oral Abstracts, Oncology, Internal medicine, medicine, Blood culture, In patient, business
Abstract

Background Current guidelines recommend obtaining blood cultures prior to antimicrobial therapy in patients with sepsis. Administering antimicrobials immediately without waiting for blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear the degree to which this strategy impacts diagnostic yield. Methods We performed a patient-level, single-arm, diagnostic trial. Seven urban emergency departments affiliated with academic medical centers across Canada and the United States participated in the study. Adults ≥18 years of age presenting to the emergency department with evidence of severe manifestations of sepsis, including a systolic blood pressure Results Of the 3,164 participants screened, 325 were included in the study (mean age, 65.6 years; 63.0% men) and had repeat blood cultures drawn after the initiation of antimicrobial therapy (median time of 70 minutes, IQR 50 to 110 minutes). Pre-antimicrobial blood cultures were positive for one or more microbial pathogens in 102/325 (31.4%) patients. Fifty-four participants (52.9%) had matching blood culture results after initiation of antimicrobial treatment. The absolute difference in pathogen recovery rates was 14.5% ([95% CI 8.0 to 21.0%]; P < 0.0001) between pre- and post-antimicrobial blood cultures. Results were consistent in an analysis of the per-protocol population (absolute difference, 13.3% [95% CI 6.1 to 20.4%]; P < 0.0001). Including the results of other microbiological cultures done as part of routine care, microbial pathogens were recovered in 69 of 102 (67.7%) participants (absolute difference, 10.2% [95% CI 3.4 to 16.8%]; P < 0.0001). Conclusion Among patients with severe manifestations of sepsis, the administration of empiric antimicrobial therapy significantly reduces the yield of pathogen recovery when blood cultures are drawn shortly after treatment initiation. Disclosures All Authors: No reported Disclosures.

Published
2019

39. Rho-kinase inhibitors do not expand hematoma volume in acute experimental intracerebral hemorrhage

Author

Hyung-Hwan Kim, Joshua N. Goldstein, Murtaza Akhter, Cenk Ayata, Michael J. Whalen, Paul Fischer, Homa Sadeghian, and Tom Qin

Subjects
0301 basic medicine, Intracerebral hemorrhage, medicine.diagnostic_test, business.industry, General Neuroscience, Fasudil, medicine.disease, 03 medical and health sciences, 030104 developmental biology, 0302 clinical medicine, Hematoma, Bleeding time, Diabetes mellitus, Anesthesia, Antithrombotic, medicine, cardiovascular diseases, Neurology (clinical), business, Rho-associated protein kinase, Stroke, 030217 neurology & neurosurgery
Abstract

Rho-associated kinase (ROCK) is an emerging target in acute ischemic stroke. Early pre-hospital treatment with ROCK inhibitors may improve their efficacy, but their antithrombotic effects raise safety concerns in hemorrhagic stroke, precluding use prior to neuroimaging. Therefore, we tested whether ROCK inhibition affects the bleeding times, and worsens hematoma volume in a model of intracerebral hemorrhage (ICH) induced by intrastriatal collagenase injection in mice. Tail bleeding time was measured 1 h after treatment with isoform-nonselective inhibitor fasudil, or ROCK2-selective inhibitor KD025, or their vehicles. In the ICH model, treatments were administered 1 h after collagenase injection. Although KD025 but not fasudil prolonged the tail bleeding times, neither drug expanded the volume of ICH or worsened neurological deficits at 48 h compared with vehicle. Although more testing is needed in aged animals and comorbid models such as diabetes, these results suggest ROCK inhibitors may be safe for pre-hospital administration in acute stroke.

Published
2017

40. Implications of language barrier on the diagnostic yield of computed tomography in pulmonary embolism

Author

Albert T. Roh, Murtaza Akhter, Jeffrey R. Stowell, Levi Filler, and Marya S. Sabir

Subjects
medicine.medical_specialty, Pulmonary angiogram, Computed Tomography Angiography, Yield (finance), Language barrier, Computed tomography, Risk Assessment, 03 medical and health sciences, 0302 clinical medicine, medicine, Humans, 030212 general & internal medicine, Computed tomography angiography, Retrospective Studies, Physician-Patient Relations, medicine.diagnostic_test, business.industry, 030503 health policy & services, Communication Barriers, Retrospective cohort study, General Medicine, Hispanic or Latino, medicine.disease, Pulmonary embolism, Language group, Emergency Medicine, Radiology, 0305 other medical science, business, Pulmonary Embolism
Abstract

To determine if a physician-patient language barrier impacts the diagnostic accuracy of pulmonary embolism (PE) evaluation.A retrospective chart review, conducted between June 2015 and December 2016, of a consecutive sample of diagnostic computed tomography pulmonary angiogram (CTPA) studies performed on adult patients. Positive and negative CTPA scans were further categorized by patient language and the positive diagnostic yield was determined for each language group. A post collection sub-analysis was performed to determine the yield when interpreter services were identified as necessary.The yield for English speaking patients was 10.24% (92/898, 95% CI 8.39% to 12.36%), similar to the yield in Spanish speaking patients of 9.40% (25/266, 95% CI 6.31% to 13.37%, P=0.69). This contrasted with the yield in patients who identified as bilingual, which was significantly lower at 1.41% (1/71, 95% CI 0.07% to 6.75%) compared to both English-(P0.02) and Spanish-only speakers (P0.03). The yield for non-English speaking patients who requested an interpreter was 7.37% (14/190, 95% CI 4.26% to 11.77%) versus 3.23% (2/62, 95% CI 0.54% to 10.25%, P=0.25) in those who did not.The diagnostic yield in English- and Spanish-only speaking patients was similar, however, the yield in those that self-identified as bilingual was significantly lower. In patient groups in which a language barrier existed and an interpreter was not utilized, there was a trend toward a lower diagnostic yield. This suggests an increased propensity to order diagnostic imaging when potential communication barriers exist.

Published
2017

41. Headache: When to Image, When to Tap

Author

Levi Filler, Murtaza Akhter, and Perrin T. Considine

Subjects
Severe headache, medicine.medical_specialty, Evening, business.industry, General surgery, medicine, Emergency department, business, humanities
Abstract

A 47-year-old female presents to your emergency department at 6 pm on a Sunday evening complaining of severe headache. She stated she felt fine when she woke up (at 7 am), and the headache started at 9 am while she was getting ready for church. It was severe on onset and was minimally helped with acetaminophen and ibuprofen. She has vomited four times since, and light and loud sounds make it feel worse.

Published
2017

42. Alternative effects of transportation time on out-of-hospital cardiac arrests

Author

Stephen R. Pitts, Cristian Patterson, and Murtaza Akhter

Subjects
Out of hospital, business.industry, 030208 emergency & critical care medicine, Transportation, Emergency Nursing, medicine.disease, Cardiopulmonary Resuscitation, 03 medical and health sciences, 0302 clinical medicine, Text mining, Emergency Medicine, medicine, Humans, 030212 general & internal medicine, Medical emergency, Cardiology and Cardiovascular Medicine, business, Out-of-Hospital Cardiac Arrest
Published
2017

43. Neurology Concepts: Young Women and Ischemic Stroke-Evaluation and Management in the Emergency Department

Author

Joshua Z. Willey, Charles R. Wira, Lauren M. Nentwich, Bradley E. Barth, Murtaza Akhter, Tracy E. Madsen, Bernard P. Chang, and Joseph B Miller

Subjects
Adult, medicine.medical_specialty, Neurology, Adolescent, Population, Migraine with Aura, 030204 cardiovascular system & hematology, Tissue plasminogen activator, Article, Brain Ischemia, 03 medical and health sciences, Young Adult, 0302 clinical medicine, Sex Factors, Pregnancy, Risk Factors, medicine, Humans, Young adult, education, Stroke, Retrospective Studies, education.field_of_study, business.industry, Smoking, Retrospective cohort study, General Medicine, Emergency department, medicine.disease, Pregnancy Complications, Tissue Plasminogen Activator, Emergency medicine, Emergency Medicine, Female, business, Emergency Service, Hospital, 030217 neurology & neurosurgery, Postpartum period, medicine.drug, Contraceptives, Oral
Abstract

Objective Ischemic stroke is a leading cause of morbidity and mortality worldwide. While the incidence of ischemic stroke is highest in older populations, incidence of ischemic stroke in adults has been rising particularly rapidly among young (e.g., premenopausal) women. The evaluation and timely diagnosis of ischemic stroke in young women presents a challenging situation in the emergency department, due to a range of sex-specific risk factors and to broad differentials. The goals of this concepts paper are to summarize existing knowledge regarding the evaluation and management of young women with ischemic stroke in the acute setting. Methods A panel of six board-certified emergency physicians, one with fellowship training in stroke and one with training in sex- and sex-based medicine, along with one vascular neurologist were coauthors involved in the paper. Each author used various search strategies (e.g., PubMed, PsycINFO, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors. Results Estimates on the incidence of ischemic stroke in premenopausal women range from 3.65 to 8.9 per 100,000 in the United States. Several risk factors for ischemic stroke exist for young women including oral contraceptive (OCP) use and migraine with aura. Pregnancy and the postpartum period (up to 12 weeks) is also an important transient state during which risks for both ischemic stroke and cerebral hemorrhage are elevated, accounting for 18% of strokes in women under 35. Current evidence regarding the management of acute ischemic stroke in young women is also summarized including use of thrombolytic agents (e.g., tissue plasminogen activator) in both pregnant and nonpregnant individuals. Conclusion Unique challenges exist in the evaluation and diagnosis of ischemic stroke in young women. There are still many opportunities for future research aimed at improving detection and treatment of this population.

Published
2017

44. Soft tissue oxygen saturation prediction of admission from the ED

Author

Murtaza Akhter and Guy Raz

Subjects
medicine.medical_specialty, MEDLINE, chemistry.chemical_element, 030204 cardiovascular system & hematology, Oxygen, 03 medical and health sciences, 0302 clinical medicine, Humans, Medicine, Oximetry, Prospective Studies, Intensive care medicine, Oxygen saturation (medicine), medicine.diagnostic_test, business.industry, Soft tissue, 030208 emergency & critical care medicine, General Medicine, Triage, Hospitalization, Pulse oximetry, chemistry, Emergency medicine, Emergency Medicine, Emergency Service, Hospital, business
Published
2018

45. 3EMF Rod Microglia in Traumatic Brain Injury

Author

S. Ridgeway, Jonathan Lifshitz, Rachel K. Rowe, Murtaza Akhter, and Katherine R. Giordano

Subjects
medicine.anatomical_structure, Microglia, Traumatic brain injury, business.industry, Emergency Medicine, medicine, medicine.disease, business, Neuroscience
Published
2017

46. Oncogenic osteomalacia of the cervical spine: a rare case of curative resection and reconstruction

Author

Rick Bains, Yevgeniy A. Khavkin, Patrick A. Sugrue, and Murtaza Akhter

Subjects
medicine.medical_specialty, business.industry, Radiography, Connective tissue, General Medicine, medicine.disease, Cervical spine, Phosphaturic mesenchymal tumor, Surgery, Oncogenic osteomalacia, Lesion, medicine.anatomical_structure, medicine, medicine.symptom, business, Pathological, Hypophosphatemia
Abstract

Oncogenic osteomalacia (OO) is a rare paraneoplastic syndrome, with only 100 reported cases in the literature. The majority of OO-associated mesenchymal tumors are due to a lesion called phosphaturic mesenchymal tumor, mixed connective tissue (PMTMCT) variant. There have been only 6 reported cases of OO of the spine. With this paper the authors present a case of OO of the cervical spine in a patient who initially presented with multiple pathological fractures of unknown cause, and who eventually underwent staged C-5 spondylectomy followed by circumferential stabilization. Resection of the cervical lesion led to resolution of his hypophosphatemia and prevention of any further pathological fractures. The authors describe a rare cervical neoplasm, its treatment, and review the literature on this rare bony pathological entity.

Published
2011

47. Assessment of Linked Associations in Predictors of Life Expectancy Inequality

Author

Murtaza Akhter

Subjects
0301 basic medicine, Inequality, media_common.quotation_subject, MEDLINE, 030105 genetics & heredity, Racism, White People, 03 medical and health sciences, Life Expectancy, Time frame, Economic inequality, Research Letter, Ethnicity, Internal Medicine, Humans, Medicine, Minority Groups, media_common, Statistics::Applications, business.industry, Censuses, Health Status Disparities, Hispanic or Latino, United States, Black or African American, Income, Indians, North American, Life expectancy, Demographic economics, business
Abstract

This data analysis compares the rise of income inequality, as well as racial inequality, over a same time frame as the rise in life expectancy inequality.

Published
2018

48. No major role for theEMX2gene in schizencephaly

Author

William B. Dobyns, Patrizia De Marco, Valeria Capra, Eric Swanson, Pasquale Striano, Richard J. Leventer, Elisa Merello, Renzo Guerrini, Armando Cama, Murtaza Akhter, and Andrea Rossi

Subjects
Adult, Male, Pathology, medicine.medical_specialty, Adolescent, DNA Mutational Analysis, EMX2, Biology, medicine.disease_cause, Polymorphism, Single Nucleotide, Mice, polycyclic compounds, Genetics, medicine, Animals, Humans, heterocyclic compounds, Child, Pathological, Gene, Genetics (clinical), Homeodomain Proteins, Mice, Knockout, Mutation, fungi, Infant, Newborn, Brain, Infant, medicine.disease, Major gene, Phenotype, Malformations of Cortical Development, nervous system, Schizencephaly, Child, Preschool, Female, Transcription Factors
Abstract

Schizencephaly (SCH) is a rare disorder of cerebral cortical development, characterized by full thickness clefts spanning the wall of the cerebral hemispheres that are lined and surrounded by polymicrogyric cortex. Based on pathological analysis, SCH was originally considered to have multiple causes including infectious and vascular injuries, and toxic agents. However, a few reports of familial SCH have suggested a possible genetic etiology. Ten years ago two articles identified EMX2 as the first causative gene for human SCH in 13 of 18 patients, although for several putative mutations no pathogenic role was demonstrated. Here, we reinterpret the original articles as showing a significantly lower mutational rate (17%) than originally reported (72%), and provide results of EMX2 sequencing in 39 new SCH patients, detecting no pathogenic mutations. We conclude that the reported association between SCH and EMX2 mutations is not adequately supported by current data, and that diagnostic testing of EMX2 is not justified, as any results would be uninterpretable.

Published
2008

49. Vascular Emergencies and Shared Decision‐making in Patients With Thunderclap Headache

Author

Shih Pin Chen and Murtaza Akhter

Subjects
medicine.medical_specialty, Headache Disorders, Primary, business.industry, Decision Making, Headache, 030208 emergency & critical care medicine, General Medicine, medicine.disease, 03 medical and health sciences, 0302 clinical medicine, Emergency medicine, Emergency Medicine, medicine, Humans, In patient, Emergencies, business, 030217 neurology & neurosurgery, Thunderclap headaches
Published
2016

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