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1. Iatrogenic esophageal dysmotility as a barrier to transplantation in pulmonary arterial hypertension

Author

Michael S. Miller, Shelsey W. Johnson, Alexander R. Opotowsky, Michael J. Landzberg, Nirmal S. Sharma, Hilary J. Goldberg, Alexandra K. Wong, Alison S. Witkin, Josanna Rodriguez-Lopez, Ronald H. Goldstein, Bradley A. Maron, and Bradley M. Wertheim

Subjects
pulmonary arterial hypertension, phosphodiesterase-type 5 inhibitor, esophageal dysmotility, lung transplantation, Surgery, RD1-811, Specialties of internal medicine, RC581-951
Abstract

Esophageal dysmotility is identified as a contraindication to lung transplantation at some centers due to increased risks of acute rejection, pulmonary infection, and chronic lung allograft dysfunction. Phosphodiesterase-type 5 inhibitors (PDE5i) are a cornerstone pharmacotherapy for pulmonary arterial hypertension (PAH) and are known to exert off-target effects that may impact lung transplant candidacy, including impaired esophageal contractility and decreased lower esophageal sphincter tone. We report 2 patients with PAH who were initially declined listing for lung transplantation due to iatrogenic esophageal dysmotility induced by PDE5is. Upon discontinuation of PDE5i therapy, these patients experienced significant improvement in esophageal motility within 14 days and met the criteria for transplant listing at their centers. Recognizing and mitigating the off-target effects of PDE5i medications is critical for maximizing access to transplant for patients with PAH.

Published
2024
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2. Cluster analysis identifies novel real-world lung disease–pulmonary hypertension subphenotypes: implications for treatment response

Author

Shelsey W. Johnson, Rui-Sheng Wang, Michael R. Winter, Kari R. Gillmeyer, Katarina Zeder, Elizabeth S. Klings, Ronald H. Goldstein, Renda Soylemez Wiener, and Bradley A. Maron

Subjects
Medicine
Abstract

Background Clinical trials repurposing pulmonary arterial hypertension (PAH) therapies to patients with lung disease- or hypoxia-pulmonary hypertension (PH) (classified as World Health Organization Group 3 PH) have failed to show a consistent benefit. However, Group 3 PH clinical heterogeneity suggests robust phenotyping may inform detection of treatment-responsive subgroups. We hypothesised that cluster analysis would identify subphenotypes with differential responses to oral PAH therapy. Methods Two k-means analyses were performed on a national cohort of US veterans with Group 3 PH; an inclusive model (I) of all treated patients (n=196) and a haemodynamic model (H) limited to patients with right heart catheterisations (n=112). The primary outcome was organ failure or all-cause mortality by cluster. An exploratory analysis evaluated within-cluster treatment effects. Results Three distinct clusters of Group 3 PH patients were identified. In the inclusive model (C1I n=43, 21.9%; C2I n=102, 52.0%; C3I n=51, 26.0%), lung disease and spirometry drove cluster assignment. By contrast, in the haemodynamic model (C1H n=44, 39.3%; C2H n=43, 38.4%; C3H n=25, 22.3%), right heart catheterisation data surpassed the importance of lung disease and spirometry. In the haemodynamic model, compared to C3H, C1H experienced the greatest hazard for respiratory failure or death (HR 6.1, 95% CI 3.2–11.8). In an exploratory analysis, cluster determined treatment response (p=0.006). Conclusions regarding within-cluster treatment responses were limited by significant differences between select variables in the treated and untreated groups. Conclusions Cluster analysis identifies novel real-world subphenotypes of Group 3 PH patients with distinct clinical trajectories. Future studies may consider this methodological approach to identify subgroups of heterogeneous patients that may be responsive to existing pulmonary vasodilatory therapies.

Published
2024
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3. Socioeconomically disadvantaged veterans experience treatment delays for pulmonary arterial hypertension

Author

Kari R. Gillmeyer, Seppo T. Rinne, Shirley X. Qian, Bradley A. Maron, Shelsey W. Johnson, Elizabeth S. Klings, and Renda S. Wiener

Subjects
pulmonary arterial hypertension, racial, ethnic, or social disparities in lung disease and treatment, research design/program evaluation/statistical models, Diseases of the circulatory (Cardiovascular) system, RC666-701, Diseases of the respiratory system, RC705-779
Abstract

Abstract Prompt initiation of therapy after pulmonary arterial hypertension (PAH) diagnosis is critical to improve outcomes; yet delays in PAH treatment are common. Prior research demonstrates that individuals with PAH belonging to socially disadvantaged groups experience worse clinical outcomes. Whether these poor outcomes are mediated by delays in care or other factors is incompletely understood. We sought to examine the association between race/ethnicity and socioeconomic status and time‐to‐PAH treatment. We conducted a retrospective cohort study of Veterans diagnosed with incident PAH between 2006 and 2019 and treated with PAH therapy. Our outcome was time‐to‐PAH treatment. Our primary exposures were race/ethnicity, annual household income, health insurance status, education, and housing insecurity. We calculated time‐to‐treatment using multivariable mixed‐effects Cox proportional hazard models. Of 1827 Veterans with PAH, 27% were Black, 4% were Hispanic, 22.1% had an income

Published
2022
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4. Real‐world use of inhaled treprostinil for lung disease‐pulmonary hypertension: A protocol for patient evaluation and prescribing

Author

Shelsey W. Johnson, Lauren Finlay, Stephen C. Mathai, Ronald H. Goldstein, and Bradley A. Maron

Subjects
Group 3 pulmonary hypertension, inhaled treprostinil, interstitial lung disease, pulmonary hypertension, Diseases of the circulatory (Cardiovascular) system, RC666-701, Diseases of the respiratory system, RC705-779
Abstract

Abstract Inhaled treprostinil was approved recently for interstitial lung disease‐pulmonary hypertension; however, efficacy in “real‐world” populations is not known. We designed a protocol and report our experience evaluating 10 patients referred for therapy. Misdiagnosis at presentation was common; ultimately, three patients (30%) were prescribed drug. This protocol offers an opportunity to standardize longitudinal assessment of inhaled treprostinil in clinical practice.

Published
2022
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5. 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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6. Variation in Use of Repurposed Medications Among Patients With Coronavirus Disease 2019. From The Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 Registry Investigator Group

Author

Michael A. Garcia, MD, Shelsey W. Johnson, MD, Nicholas A. Bosch, MD, MSc, Emily K. Sisson, MA, Christopher R. Sheldrick, PhD, Vishakha K. Kumar, MD, MBA, Karen Boman, BS, Scott Bolesta, PharmD, Vikas Bansal, MBBS, MPH, Neha Deo, BS, J. P. Domecq, MD, Amos Lal, MD, Amy B. Christie, MD, Valerie M. Banner-Goodspeed, MPH, Devang Sanghavi, MD, MHA, Girish Vadgaonkar, MBBS, Ognjen Gajic, MD, MSc, Rahul Kashyap, MBBS, MBA, Allan J. Walkey, MD, MSc, for the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study Investigators, Jean-Baptiste Mesland, Pierre Henin, Hélène Petre, Isabelle Buelens, Anne-Catherine Gerard, Philippe Clevenbergh, Dragana Markotić, Ivana Bošnjak, Ruben Garza, Eric Chu, Victoria Chan, Oscar Y Gavidia, Felipe Pachon, Yeimy A Sanchez, Mohamed El Kassas, Mohamed Badr, Ahmed Tawheed, Hend Yahia, Jose Luis Ramos Coello, Guillermo Perez, Ana Karen Vallecillo Lizardo, Gabina María Reyes Guillen, Helin Archaga Soto, Smitha S. Segu, Tuhin Chakraborty, Epcebha Joyce, Girish Vadgaonkar, Rekha Ediga, Shilpa Basety, Shwetha Dammareddy, Phani Sreeharsha Kasumalla, Umamaheswara Raju, Janaki Manduva, Naresh Kolakani, Shreeja Sripathi, Sheetal Chaitanya, Mradul Kumar Daga, Munisha Agarwal, Ishan Rohtagi, Sridhar Papani, Mahesh Kamuram, Kamlesh Kumar Agrawal, Vijendra Baghel, Kirti Kumar Patel, Surapaneni Krishna Mohan, Ekambaram Jyothisree, Wataru Matsuda, Reina Suzuki, Michihito Kyo, Yuki Itagaki, Akira Kodate, Yuki Takahashi, Koyo Moriki, 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, 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, Bojan Kovacevic, Jovana Bojicic, 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 Y. Teruel, Belen C. Martin, Uluhan Sili, Huseyin Bilgin, Pinar Ay, Abhijit A Raval, Andrea Franks, 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, 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, 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, Raghavendra Tirupathi, Alymer Tang, Arshad Safi, Cindy Green, Jackie Newell, Katja M. Gist, Imran A Sayed, John Brinton, Larisa Strom, Steven K. Daugherty, Sam Atkinson, Kelly Shrimpton, David P. Yamane, Ivy Benjenk, Nivedita Prasanna, Norma Smalls, Michael Smith, William Snow, Riley Liptak, Hannah Durant, Valerie Pendleton, Alay Nanavati, Risa Mrozowsk, 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, 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, Abigail La Nou, Marija Bogojevic, Barbara Mullen, Devang Sanghavi, Pablo Moreno Franco, Pramod Guru, 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, Jessica Timmer, Kimberly Welker, Chakradhar Venkata, Miriam Engemann, Annamarie Mantese, Anna Eschler, Mary Hejna, Emily Lewandowski, Kristen Kusmierski, Clare Martin, 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, Brian L. Delmonaco, Anthony Franklin, Mitchell Heath, 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, Paul K Mohabir, Connor G O’Brien, Komal Dasani, Neha Gupta, Tracy L Jones, Shonda C Ayers, Amy B Harrell, Brent R Brown, 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, Mary Barletta, Mary Ferranti, Benjamin J Sines, Thomas J Bice, Patrick W. McGonagill, Colette Galet, Janice Hubbard, David Wang, Lauren Allan, Aditya Badheka, Madhuradhar Chegondi, Usman Nazir, Garrett Rampon, Jake Riggle, Nathan Dismang, Roger A. Alvarez, Amarilys Alarcon-Calderon, Marie Anne Sosa, Sunita K. Mahabir, Mausam J. Patel, Dima Dandachi, Hariharan Regunath, Maraya N. Camazine, Grant. E. Geiger, Abdoulie O. Njai, Baraa M. Saad, 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, 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, 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

IMPORTANCE:. At the start of the coronavirus disease 2019 pandemic, medications repurposed for management of coronavirus disease 2019 were used in the absence of clinical trial evidence. OBJECTIVES:. To describe the variation and evolution in use of repurposed medications for coronavirus disease 2019. DESIGN, SETTING, AND PARTICIPANTS:. Observational cohort study of adults hospitalized with coronavirus disease 2019 between February 15, 2020, and April 12, 2021, across 76 United States and international hospitals within the Society of Critical Care Medicine’s Discovery Viral Infection and Respiratory Illness Universal Study coronavirus disease 2019 registry. MAIN OUTCOMES AND MEASURES:. Hospital variation was quantified using multivariable adjusted random effects logistic regression models and unsupervised clustering. Repurposed medications included antivirals, corticosteroids, hydroxychloroquine, immunomodulators, and therapeutic dose anticoagulants. RESULTS:. Among 7,069 adults hospitalized with coronavirus disease 2019, 1,979 (28%) received antivirals, 2,876 (41%) received corticosteroids, 1,779 (25%) received hydroxychloroquine, 620 (9%) received immunomodulators, and 2,154 (31%) received therapeutic dose anticoagulants. Contribution of hospital site to risk-adjusted variation was 46% for antivirals, 30% for corticosteroids, 48% for hydroxychloroquine, 46% for immunomodulators, and 52% for therapeutic dose anticoagulants. Compared with the early pandemic, the later pandemic practice phenotypes converged with increased use of antivirals (odds ratio, 3.14; 95% CI, 2.40–4.10) and corticosteroids (odds ratio, 5.43; 95% CI, 4.23–6.97), with decreased use of hydroxychloroquine (odds ratio, 0.02; 95% CI, 0.01–0.04) and immunomodulators (odds ratio, 0.49; 95% CI, 0.34–0.70). There was no clinically significant change in the use of therapeutic dose anticoagulants (odds ratio, 1.01; 95% CI, 1.01–1.02). There were no differences in risk-adjusted mortality between hospitals with high rates of repurposed medication use compared with hospitals with low rates of use. CONCLUSIONS AND RELEVANCE:. Hospital variation in the use of repurposed medications varied widely across hospitals early in the pandemic and later converged with the emergence of randomized clinical trials. Platforms developed for rapid activation and enrollment in clinical trials of repurposed medications are needed prior to the next pandemic to expedite effective, evidence-based practice.

Published
2021
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7. Polymicrobial empyema; a novel case of Actinomyces turicensis

Author

Shelsey W. Johnson and Ehab Billatos

Subjects
Diseases of the respiratory system, RC705-779
Abstract

Empyema or infection of the pleural space is a well described complication of pneumonia, however knowledge of culprit pathogens is still evolving. We report a novel case of empyema due to Actinomyces turicensis, a commensal of the oropharynx and female urogenital tract but previously undescribed cause of empyema. We additionally review general pathogenesis of Actinomyces species within the pleural space. Familiarity with this unique pleural infection pathogen is important for selection of adequate antimicrobial therapy given the propensity of anaerobes such as Actinomyces species to disobey anatomic boundaries and recrudescence of infection in the absence of appropriate therapy.

Published
2021
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8. Room for improvement in pulmonary capillary wedge pressure reporting: a review of hemodynamic tracings at a large academic medical center

Author

Shelsey W. Johnson, Alison Witkin, Josanna Rodriguez-Lopez, and Richard Channick

Subjects
Diseases of the circulatory (Cardiovascular) system, RC666-701, Diseases of the respiratory system, RC705-779
Abstract

To describe the frequency with which pulmonary capillary wedge pressure measurements, obtained during right heart catheterization, are falsely elevated and to educate operators on techniques to improve accuracy of pulmonary capillary wedge pressure reporting. Failure to completely occlude pulmonary artery branch vessels during balloon inflation can lead to falsely elevated, “incomplete” pulmonary capillary wedge pressures. Balloon deflation prior to catheter retraction may result in catheter advancement into smaller branch vessels, yielding an inadvertent but more accurate alternative pulmonary capillary wedge pressure. We hypothesized that this phenomenon can be identified on retrospective review of right heart catheterization tracings, which occurs commonly and goes unrecognized by operators. We conducted a retrospective study of patients undergoing right heart catheterization or right heart catheterization and left heart catheterization with computer-generated pulmonary capillary wedge pressure ≥20 from January 2015 to June 2017. Alternative pulmonary capillary wedge pressures were defined as a pulmonary capillary wedge pressure trace during balloon deflation ≥3 mmHg lower than the reported pulmonary capillary wedge pressure. Inter-rater reliability of tracing reviewers was also evaluated. Results showed that, of the 182 tracings reviewed, an alternative pulmonary capillary wedge pressure was identified in 26 or 14.3% of cases. Eleven of these alternative pulmonary capillary wedge pressures were ≤15 mmHg with a calculated pulmonary vascular resistance ≥3 Wood units in 10 patients, re-classifying the etiology of pulmonary hypertension from post-capillary to pre-capillary in 38.5% of cases. For the eight patients for whom left heart catheterization data were available, left ventricular end-diastolic pressure aligned with the alternative pulmonary capillary wedge pressure. In conclusion, inadvertently obtained, but likely more accurate, alternative pulmonary capillary wedge pressures were identified in almost 15% of procedures reviewed from a busy academic institution. As wedge pressures often drive diagnosis and treatment decisions for patients with cardiac and pulmonary pathology, operators should be attuned to balloon deflation as a time when alternative pulmonary capillary wedge pressures may be identified as they are likely more reflective of left ventricular end-diastolic pressure. Additional tools to ensure accuracy of pulmonary capillary wedge pressure reporting are reviewed.

Published
2020
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10. Organization of pulmonary hypertension care in non-expert care settings: Lessons learned from a multi-site study

Author

Kari R. Gillmeyer, Shelsey W. Johnson, Rendelle E. Bolton, Megan B. McCullough, and Renda Soylemez Wiener

Subjects
Health Policy
Abstract

To examine how select Veterans Health Administration (VA) sites organized care for patients with pulmonary hypertension (PH), with a focus on describing existing practices and identifying unmet needs within the sites.Semi-structured interviews across seven diverse VA sites.Qualitative multiple-site study.We interviewed 54 key informants including pulmonologists, cardiologists, primary care providers, advanced care practitioners, pharmacists, and clinical leaders to assess the structures and processes of PH care delivery. We analyzed transcripts using directed content analysis and constructed site profiles for each site, comparing profiles to existing guidelines for PH expert centers.Sites varied considerably in how they organized PH care, with wide variation in the availability of structures and processes recommended for expert centers, including availability of PH expertise and PH-specific resources, multidisciplinary approach to care, establishment of clear referral pathways, and presence of PH education. Further, participants identified three areas of unmet need not directly addressed within current guidelines, including better integration of pharmacists into multidisciplinary teams, early and routine involvement of palliative care, and improved care coordination efforts.The rising prevalence of PH and evolution of treatments for common PH subgroups underscore the need to standardize PH care delivery in non-expert care settings to improve care quality and patient outcomes. The insight gained from this study may inform the development of guidance appropriate for care settings outside of expert centers.

Published
2022

12. Predictors to forgo resuscitative effort during Covid-19 critical illness at the height of the pandemic : A retrospective cohort study

Author

Shelsey W. Johnson, Alexandra Fischman, Michael A Garcia, Nathan Mesfin, Renda Soylemez Wiener, and Raj Parikh

Subjects
Adult, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Critical Illness, Ethnic group, Code status, Pandemic, medicine, Ethnicity, Humans, Pandemics, Minority Groups, Resuscitation Orders, Retrospective Studies, business.industry, SARS-CoV-2, Do not resuscitate, COVID-19, Family meetings, Retrospective cohort study, General Medicine, Intensive Care Units, Anesthesiology and Pain Medicine, Family medicine, Critical illness, business
Abstract

Background: Early in the Covid-19 pandemic, there was uncertainty regarding critical illness prognosis and challenges to traditional face-to-face family meetings. Ethnic minority populations have suffered disproportionately worse outcomes during the pandemic, which may in part relate to differences in end-of-life decision-making. Aim: Characterize patterns of and factors associated with decisions to forgo resuscitative efforts, as measured by do-not-resuscitate orders, during critical illness with Covid-19. Design: Retrospective cohort with medical record abstraction. Setting/participants: Adult patients diagnosed with SARS-Cov-2 virus via polymerase chain reaction and admitted to the intensive care unit at an academic hospital, which cares for the city’s underserved communities, between March 1 and June 7, 2020 who underwent invasive mechanical ventilation for at least 48 hours. Results: In this cohort ( n = 155), 45% were black people, and 51% spoke English as their primary language. Median time to first goals-of-care conversation was 3.9 days (IQR 1.9–7.6) after intensive care unit admission. Overall 61/155 patients (39%) transitioned to do-not-resuscitate status, and 50/62 (82%) patients who died had do-not-resuscitate orders. Multivariate analysis shows age and palliative care involvement as the strongest predictors of decision to instate do-not-resuscitate order. There was no association between race, ethnicity, or language and decisions to forego resuscitation. Conclusions: During this time of crisis and uncertainty with limited resources and strained communication, time to first goals of care conversation was shorter than in pre-pandemic studies, but rates of foregoing resuscitation remained similar, with no differences observed by race, ethnicity, or language. This study suggests that early palliative care involvement and non-traditional communications, including videoconferencing, to facilitate goals of care conversations could have mitigated potential disparities in end-of-life decision making patterns during the pandemic.

Published
2021

13. Rebuttal From Drs Johnson and Maron

Author

Shelsey W. Johnson and Bradley A. Maron

Subjects
Pulmonary and Respiratory Medicine, Cardiology and Cardiovascular Medicine, Critical Care and Intensive Care Medicine
Published
2021

14. Patterns of Pulmonary Consultation for Veterans with Incident Chronic Obstructive Pulmonary Disease

Author

Eduardo R. Nunez, W. Ryan Powell, Renda Soylemez Wiener, Allan J. Walkey, Shirley Qian, Seppo T. Rinne, and Shelsey W. Johnson

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, business.industry, Pulmonary disease, Hospitalization, Pulmonary Disease, Chronic Obstructive, Text mining, medicine, Humans, Letters, Intensive care medicine, business, Referral and Consultation, Veterans
Published
2021

15. Polymicrobial empyema; a novel case of Actinomyces turicensis

Author

Ehab Billatos and Shelsey W. Johnson

Subjects
Pulmonary and Respiratory Medicine, lcsh:RC705-779, biology, business.industry, Pleural infection, Case Report, lcsh:Diseases of the respiratory system, respiratory system, medicine.disease, biology.organism_classification, Antimicrobial, Empyema, Microbiology, respiratory tract diseases, 03 medical and health sciences, Pneumonia, 0302 clinical medicine, 030228 respiratory system, 030220 oncology & carcinogenesis, medicine, Actinomyces turicensis, Complication, business, Pathogen, Actinomyces
Abstract

Empyema or infection of the pleural space is a well described complication of pneumonia, however knowledge of culprit pathogens is still evolving. We report a novel case of empyema due to Actinomyces turicensis, a commensal of the oropharynx and female urogenital tract but previously undescribed cause of empyema. We additionally review general pathogenesis of Actinomyces species within the pleural space. Familiarity with this unique pleural infection pathogen is important for selection of adequate antimicrobial therapy given the propensity of anaerobes such as Actinomyces species to disobey anatomic boundaries and recrudescence of infection in the absence of appropriate therapy.

Published
2021

16. ICU outcomes in Covid-19 patients with obesity

Author

Nathan Mesfin, Shelsey W. Johnson, Christine C. Reardon, Janice Weinberg, Raj Parikh, Michael A Garcia, and Iniya Rajendran

Subjects
Pulmonary and Respiratory Medicine, Adult, Male, medicine.medical_specialty, ARDS, 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Critical Care, Pneumonia, Viral, 030209 endocrinology & metabolism, Coronavirus-2019, 03 medical and health sciences, Betacoronavirus, 0302 clinical medicine, Pandemic, Medicine, Humans, Pharmacology (medical), 030212 general & internal medicine, Hospital Mortality, Obesity, Pandemics, Letter to the Editor, Aged, Proportional Hazards Models, Retrospective Studies, lcsh:RC705-779, biology, business.industry, Proportional hazards model, SARS-CoV-2, COVID-19, Retrospective cohort study, lcsh:Diseases of the respiratory system, Length of Stay, Middle Aged, medicine.disease, biology.organism_classification, Logistic Models, Treatment Outcome, Emergency medicine, Female, business, Coronavirus Infections
Abstract

The reviews of this paper are available via the supplemental material section.

Published
2020

18. Room for improvement in pulmonary capillary wedge pressure reporting: a review of hemodynamic tracings at a large academic medical center

Author

Alison S. Witkin, Richard N. Channick, Shelsey W Johnson, and Josanna Rodriguez-Lopez

Subjects
Pulmonary and Respiratory Medicine, Right heart catheterization, lcsh:RC705-779, medicine.medical_specialty, lcsh:Diseases of the circulatory (Cardiovascular) system, left ventricular end diastolic pressure, business.industry, nutritional and metabolic diseases, Hemodynamics, lcsh:Diseases of the respiratory system, medicine.disease, Pulmonary hypertension, nervous system diseases, lcsh:RC666-701, Internal medicine, pulmonary hypertension, medicine, Ventricular pressure, Cardiology, right heart catheterization, Pulmonary wedge pressure, business, Research Article
Abstract

To describe the frequency with which pulmonary capillary wedge pressure measurements, obtained during right heart catheterization, are falsely elevated and to educate operators on techniques to improve accuracy of pulmonary capillary wedge pressure reporting. Failure to completely occlude pulmonary artery branch vessels during balloon inflation can lead to falsely elevated, “incomplete” pulmonary capillary wedge pressures. Balloon deflation prior to catheter retraction may result in catheter advancement into smaller branch vessels, yielding an inadvertent but more accurate alternative pulmonary capillary wedge pressure. We hypothesized that this phenomenon can be identified on retrospective review of right heart catheterization tracings, which occurs commonly and goes unrecognized by operators. We conducted a retrospective study of patients undergoing right heart catheterization or right heart catheterization and left heart catheterization with computer-generated pulmonary capillary wedge pressure ≥20 from January 2015 to June 2017. Alternative pulmonary capillary wedge pressures were defined as a pulmonary capillary wedge pressure trace during balloon deflation ≥3 mmHg lower than the reported pulmonary capillary wedge pressure. Inter-rater reliability of tracing reviewers was also evaluated. Results showed that, of the 182 tracings reviewed, an alternative pulmonary capillary wedge pressure was identified in 26 or 14.3% of cases. Eleven of these alternative pulmonary capillary wedge pressures were ≤15 mmHg with a calculated pulmonary vascular resistance ≥3 Wood units in 10 patients, re-classifying the etiology of pulmonary hypertension from post-capillary to pre-capillary in 38.5% of cases. For the eight patients for whom left heart catheterization data were available, left ventricular end-diastolic pressure aligned with the alternative pulmonary capillary wedge pressure. In conclusion, inadvertently obtained, but likely more accurate, alternative pulmonary capillary wedge pressures were identified in almost 15% of procedures reviewed from a busy academic institution. As wedge pressures often drive diagnosis and treatment decisions for patients with cardiac and pulmonary pathology, operators should be attuned to balloon deflation as a time when alternative pulmonary capillary wedge pressures may be identified as they are likely more reflective of left ventricular end-diastolic pressure. Additional tools to ensure accuracy of pulmonary capillary wedge pressure reporting are reviewed.

Published
2019

19. Rules Imposed by Providers on Medical and Surgical Inpatients With Substance Use Disorders

Author

Shilpa Sharma, Rachel Wallwork, Rachel C. Frank, Shelsey W Johnson, Yasmin F. K. Islam, Theodore A. Stern, and Bradley Lander

Subjects
Adult, Inpatients, Substance-Related Disorders, business.industry, Comorbidity, General Medicine, Nursing Staff, Hospital, medicine.disease, Hospitalization, Practice Guidelines as Topic, Medical Staff, Hospital, Humans, Medicine, Patient Safety, Medical emergency, Substance use, business
Published
2018
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20. Spontaneous coronary artery dissection masquerading as Takotsubo cardiomyopathy: a case report

Author

Pradeep Natarajan, Nandita S. Scott, Shelsey W Johnson, and Sandeep Hedgire

Subjects
medicine.medical_specialty, Cardiomyopathy, Case Reports, 030204 cardiovascular system & hematology, Chest pain, Coronary artery disease, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Coronary CT angiogram, Case report, medicine, 030212 general & internal medicine, Myocardial infarction, cardiovascular diseases, medicine.diagnostic_test, business.industry, Spontaneous coronary artery dissection, medicine.disease, 3. Good health, Angiography, Cardiology, Etiology, Takotsubo cardiomyopathy, medicine.symptom, Differential diagnosis, Cardiology and Cardiovascular Medicine, business, Scad
Abstract

Background Although obstructive coronary artery disease (CAD) is the most likely cause of acute coronary syndromes (ACS), nearly one in 20 individuals with clinical myocardial infarction (MI) do not have obstructive CAD. For many such individuals, presentation of Takotsubo cardiomyopathy frequently mimics presentation of MI, though spontaneous coronary artery dissection (SCAD) is an increasingly recognized aetiology of MI in women. Case summary This case report describes a woman with chest pain, found to have non-obstructive CAD on angiogram and left ventricular apical dysfunction on echocardiogram raising suspicion for Takotsubo cardiomyopathy. Additional suspicion for SCAD led to coronary CT angiogram (CCTA) which ultimately confirmed this diagnosis. Discussion Familiarity with a differential diagnosis for non-obstructive CAD is less common than that for obstructive coronary disease. This case emphasizes the clinical features that should raise suspicion for SCAD when Takotsubo is presumed and outlines the clinical utility of CCTA in making this diagnosis when angiography is unrevealing.

Published
2018

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