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1. Risk factors for Venous Thromboembolism and clinical outcomes in adults with sickle cell disease

Author

Brittany Scarpato, Rachel Strykowski, Romy Lawrence, Sarah L. Khan, Julia Newman, Matthew R. Spring, Vishal K. Gupta, Jay Patel, Robyn T. Cohen, J. Mark Sloan, S. Mehdi Nouraie, and Elizabeth S. Klings

Subjects
Sickle cell disease, Venous thromboembolism prophylaxis, Venous thromboembolism diagnosis, Venous thromboembolism treatment, Thrombosis, Anticoagulation, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Introduction: The natural history of venous thromboembolism (VTE) in sickle cell disease (SCD) is incompletely understood. We hypothesized that VTE recurrence is common in SCD and associated with increased disease severity. We sought to understand the short- and long-term clinical outcomes of VTE in SCD. Methods: We conducted a single-center retrospective chart review study of patients with SCD 18 years and older at our institution between 2003 and 2018. Demographics, hemoglobin (Hb) genotype, medical history, and laboratory values were collected. We recorded VTE occurrence and potential provoking factors, duration of anti-coagulation and subsequent recurrence of VTE. We compared rates of emergency department (ED) visits, and hospitalizations for five years post-VTE to rates of ED visits and hospitalizations among those without VTE. Results: Fifty-five (23.6%) of 233 individuals with SCD in our cohort (69% HbSS/HbS-β0) had a VTE. Increased BMI, prior splenectomy, and white blood cell count were significantly associated with increased risk of VTE while Hb genotype, and severity of anemia were not. Recurrent VTE occurred in 27/55 (49%); 13 VTE recurrences occurred during active treatment with anticoagulants. Patients with a VTE had significantly higher rates of ED visits and hospital admissions than those without a VTE. Conclusion: Nearly a quarter of our single institution cohort had a VTE with a high recurrence rate even in those receiving anti-coagulation therapy. SCD patients had a higher rate of healthcare utilization after a VTE suggesting a link to disease severity.

Published
2022
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2. Timing of Intubation in Coronavirus Disease 2019: A Study of Ventilator Mechanics, Imaging, Findings, and Outcomes

Author

Avni A. Bavishi, MD, MS, Ruben J. Mylvaganam, MD, Rishi Agarwal, MD, Ryan J. Avery, MD, Michael J. Cuttica, MD, For the NU COVID Investigators, A. Christine Argento, Ajay A. Wagh, Alexander V. Misharin, Alexandra C. McQuattie-Pimentel, Alexis Rose Wolfe, Alvaro Donayre, Ankit Bharat, Anna E. Pawlowski, Anne R. Levenson, Anthony M. Joudi, Benjamin D. Singer, Betty Tran, Catherine A. Gao, Chao Qi, Chiagozie O. Pickens, Chitaru Kurihara, Clara J. Schroedl, Daniel Meza, Daniel Schneider, David A. Kidd, David D. Odell, David W. Kamp, Elizabeth S. Malsin, Emily M. Leibenguth, Eric P. Cantey, Gabrielle Y. Liu, G. R. Scott Budinger, Helen K. Donnelly, Isaac A. Goldberg, Jacob I. Sznajder, Jacqueline M. Kruser, James M. Walter, Jane E. Dematte, Jason M. Arnold, John Coleman, Joseph I. Bailey, Joseph S. Deters, Justin A. Fiala, Katharine Secunda, Kaitlyn Vitale, Khalilah L. Gates, Kristy Todd, Lindsey D. Gradone, Lindsey N. Textor, Lisa F. Wolfe, Lorenzo L. Pesce, Luisa Morales-Nebreda, Madeline L. Rosenbaum, Manu Jain, Marc A. Sala, Mary Carns, Marysa V. Leya, Mengjia Kang, Michael J. Alexander, Michael J. Cuttica, Michelle Hinsch Prickett, Natalie Jensema, Nicole Borkowski, Nikolay S. Markov, Orlyn R. Rivas, Paul A. Reyfman, Peter H. S. Sporn, Prasanth Nannapaneni, Rachel B. Kadar, Rachel M. Kaplan, Rade Tomic, Radhika Patel, Rafael Garza-Castillon, Ravi Kalhan, Richard G. Wunderink, Rogan A. Grant, Romy Lawrence, Ruben J. Mylvaganam, Samuel S. Kim, Sanket Thakkar, Sean B. Smith, SeungHye Han, Sharon R. Rosenberg, Susan R. Russell, Sydney M. Hyder, Taylor A. Poor, Theresa A. Lombardo, and Zasu M. Klug

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

Objectives:. Determine the variation in outcomes and respiratory mechanics between the subjects who are intubated earlier versus later in their coronavirus disease 2019 course. Design:. Retrospective cohort study. Setting:. Northwestern Memorial Hospital ICUs. Patients:. All patients intubated for coronavirus disease 2019 between March 2020 and June 2020. Interventions:. Patients were stratified by time to intubation: 30 subjects were intubated 4–24 hours after presentation and 24 subjects were intubated 5–10 days after presentation. Baseline characteristics, hospitalization, ventilator mechanics, and outcomes were extracted and analyzed. Ten clinically available CT scans were manually reviewed to identify evidence of pulmonary vascular thrombosis and intussusceptive angiogenesis. Measurements and Main Results:. Median time from symptom onset to intubation was significantly different between the early and late intubation cohorts, with the latter being intubated later in the course of their illness (7.9 vs 11.8 d; p = 0.04). The early intubation cohort had a lower mortality rate than the late intubation cohort (6% vs 30%, p < 0.001) without significantly different respiratory mechanics at the time of intubation. The late intubation cohort was noted to have higher dead space ratio (0.40 vs 0.52; p = 0.03). On review of CT scans, the late intubation cohort also had more dilated peripheral segments on imaging (two segments vs five segments). Conclusions:. The question as to whether delaying intubation is beneficial or harmful for patients with coronavirus disease 2019-induced hypoxemic respiratory failure has yet to be answered. As our approaches to coronavirus disease 2019 continue to evolve, the decision of timing of intubation remains paramount. Although noninvasive ventilation may allow for delaying intubation, it is possible that there are downstream effects of delayed intubation that should be considered, including the potential for pulmonary vascular thrombosis and intussusceptive angiogenesis with delayed intubation.

Published
2021
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4. Bacterial Superinfection Pneumonia in Patients Mechanically Ventilated for COVID-19 Pneumonia

Author

Chiagozie O. Pickens, Catherine A. Gao, Michael J. Cuttica, Sean B. Smith, Lorenzo L. Pesce, Rogan A. Grant, Mengjia Kang, Luisa Morales-Nebreda, Avni A. Bavishi, Jason M. Arnold, Anna Pawlowski, Chao Qi, G. R. Scott Budinger, Benjamin D. Singer, Richard G. Wunderink, A. Christine Argento, Ajay A. Wagh, Alexander V. Misharin, Alexandra C. McQuattie-Pimentel, Alexis Rose Wolfe, Alvaro Donayre, Ankit Bharat, Anne R. Levenson, Anthony M. Joudi, Betty Tran, Chitaru Kurihara, Clara J Schroedl, Daniel Meza, Daniel Schneider, David A. Kidd, David D. Odell, David W. Kamp, Elizabeth S. Malsin, Emily M. Leibenguth, Eric P. Cantey, Gabrielle Y. Liu, Helen K. Donnelly, Isaac A. Goldberg, Jacob I. Sznajder, Jacqueline M. Kruser, James M. Walter, Jane E. Dematte, John Coleman, Joseph I. Bailey, Joseph S. Deters, Justin A. Fiala, Katharine Secunda, Kaitlyn Vitale, Khalilah L. Gates, Kristy Todd, Lindsey D. Gradone, Lindsey N. Textor, Lisa F. Wolfe, Madeline L. Rosenbaum, Manu Jain, Marc A. Sala, Mary Carns, Marysa V. Leya, Michael J. Alexander, Michelle Hinsch Prickett, Natalie Jensema, Nicole Borkowski, Nikolay S. Markov, Orlyn R. Rivas, Paul A. Reyfman, Peter H. S. Sporn, Prasanth Nannapaneni, Rachel B. Kadar, Rachel M. Kaplan, Rade Tomic, Radhika Patel, Rafael Garza-Castillon, Ravi Kalhan, Romy Lawrence, Ruben J. Mylvaganam, Samuel S. Kim, Sanket Thakkar, SeungHye Han, Sharon R. Rosenberg, Susan R. Russell, Sydney M. Hyder, Taylor A. Poor, Theresa A. Lombardo, and Zasu M. Klug

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, community-acquired pneumonia, medicine.drug_class, viruses, medicine.medical_treatment, Antibiotics, Critical Care and Intensive Care Medicine, ventilator-associated pneumonia, Community-acquired pneumonia, Internal medicine, guideline therapy, medicine, bronchoalveolar lavage, Humans, Intubation, COVID-19/Pulmonary Infections, Mechanical ventilation, Bacteria, medicine.diagnostic_test, SARS-CoV-2, business.industry, Incidence (epidemiology), Ventilator-associated pneumonia, COVID-19, Original Articles, medicine.disease, respiratory tract diseases, Pneumonia, Bronchoalveolar lavage, Superinfection, business
Abstract

Rationale: Current guidelines recommend patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia receive empirical antibiotics for suspected bacterial superinfection on the basis of weak evidence. Rates of ventilator-associated pneumonia (VAP) in clinical trials of patients with SARS-CoV-2 pneumonia are unexpectedly low. Objectives: We conducted an observational single-center study to determine the prevalence and etiology of bacterial superinfection at the time of initial intubation and the incidence and etiology of subsequent bacterial VAP in patients with severe SARS-CoV-2 pneumonia. Methods: Bronchoscopic BAL fluid samples from all patients with SARS-CoV-2 pneumonia requiring mechanical ventilation were analyzed using quantitative cultures and a multiplex PCR panel. Actual antibiotic use was compared with guideline-recommended therapy. Measurements and Main Results: We analyzed 386 BAL samples from 179 patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. Bacterial superinfection within 48 hours of intubation was detected in 21% of patients. Seventy-two patients (44.4%) developed at least one VAP episode (VAP incidence rate = 45.2/1,000 ventilator days); 15 (20.8%) initial VAPs were caused by difficult-to-treat pathogens. The clinical criteria did not distinguish between patients with or without bacterial superinfection. BAL-based management was associated with significantly reduced antibiotic use compared with guideline recommendations. Conclusions: In patients with SARS-CoV-2 pneumonia requiring mechanical ventilation, bacterial superinfection at the time of intubation occurs in

Published
2021

5. Treatment of newly diagnosed sarcoid-associated pulmonary hypertension with ambrisentan and tadalafil combination therapy

Author

Eric, Abston, Stephanie, Hon, Romy, Lawrence, Jeffrey, Berman, Praveen, Govender, and Harrison W, Farber

Subjects
Adult, Male, ambrisentan, Endothelin A Receptor Antagonists, Hypertension, Pulmonary, Pulmonary Artery, Tadalafil, Sarcoidosis, Pulmonary, pulmonary hypertension, Humans, Arterial Pressure, Case Series, sarcoidosis, Antihypertensive Agents, Aged, Retrospective Studies, Ambition Protocol, Phenylpropionates, Sarcoid associated pulmonary hypertension, Middle Aged, Phosphodiesterase 5 Inhibitors, Pyridazines, Treatment Outcome, Drug Therapy, Combination, Female, Lung Transplantation
Abstract

Sarcoid Associated Pulmonary Hypertension (SAPH) is a common complication of sarcoidosis and is associated with poor prognosis. SAPH can be due to multiple synergistic mechanisms and current therapeutic strategies treat systemic sarcoidosis and pulmonary hypertension separately. Several studies have been performed to develop an effective therapy for SAPH but have been met with mixed results. The AMBITION trial successfully treated incident patients with pulmonary arterial hypertension (PAH) with the upfront combination of ambrisentan and tadalafil; however combination therapy has not yet been studied in patients with SAPH. Here we report a cohort of patients with newly diagnosed SAPH who were treated with upfront combination therapy per the AMBITION study protocol. We report three subjects with newly diagnosed SAPH who were treated with combination ambrisentan and tadalafil. Baseline hemodynamics were compared with those from surveillance right heart catheterization while on therapy. Mean follow up period was 17 months. Each subject demonstrated clinical and hemodynamic improvement with combination therapy. This series is the first to evaluate upfront combination ambrisentan and tadalafil therapy for treatment of newly diagnosed SAPH. Despite the impressive clinical and hemodynamic improvement, the study is limited by its small size and retrospective nature. While these initial results are promising, further work is needed to fully evaluate this regimen for treatment of SAPH. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 234-238)

Published
2020

6. Single-center experience of antifungal prophylaxis for coccidioidomycosis in heart transplant recipients within an endemic area

Author

Romy Lawrence, D. Vucicevic, Shimon Kusne, Graham M. Lohrmann, Robert L. Scott, Janis E. Blair, and D. Eric Steidley

Subjects
medicine.medical_specialty, Antifungal Agents, Endemic Diseases, 030230 surgery, Single Center, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, medicine, Humans, Contraindication, Retrospective Studies, Voriconazole, Transplantation, Coccidioidomycosis, business.industry, Incidence (epidemiology), Arizona, Surgery, Regimen, Infectious Diseases, Cohort, Heart Transplantation, 030211 gastroenterology & hepatology, business, Fluconazole, medicine.drug
Abstract

In endemic regions, coccidioidomycosis causes substantial morbidity and mortality for patients receiving solid organ transplants. We aimed to demonstrate the effect of antifungal coccidioidal prophylaxis in heart transplant (HT) recipients. We retrospectively reviewed the electronic health records of all patients who received HTs between October 19, 2005, and December 13, 2014. We collected information regarding antifungal regimens and determined whether patients subsequently developed infections. Our 174-person cohort all received antifungal prophylaxis for at least 6 months (mean follow-up, 53.8 months). One proven and one probable coccidioidal infection (each, 0.6%) occurred during the study period. The incidence of coccidioidomycosis was 0.6% at 1 year and 2.3% at 5 years. No cases of proven coccidioidomycosis occurred within 2 years after transplantation. No patients developed disseminated disease, and no sentinel events were attributed to coccidioidomycosis. Both fluconazole and voriconazole were well tolerated. In the absence of intolerance or contraindication, we suggest continuing a universal antifungal prophylactic regimen with fluconazole for at least 6-12 months in HT recipients residing in a coccidioidomycosis-endemic area. This article is protected by copyright. All rights reserved.

Published
2016

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