Myopathy is a rare complication that arises during management of status asthmaticus that may be r... more Myopathy is a rare complication that arises during management of status asthmaticus that may be related to administration of corticosteroids and neuromuscular blocking agents. We present 4 patients with myopathy and a review of the 31 previously reported patients in the literature. All patients received corticosteroids, and 33 of the 35 patients received neuromuscular blocking agents. Muscle weakness was often diffuse and, in several patients, involved the muscles of respiration. Creatine kinase values ranged from normal to markedly elevated. Diagnosis was obtained by electromyogram and muscle biopsy in most patients. Resolution of the muscle weakness occurred over a period of days to months. Patients in whom myopathy developed required mechanical ventilation for longer periods than patients intubated for status asthmaticus without myopathy.
The obstetric patient, pregnant or puerperal, is significantly different from the average patient... more The obstetric patient, pregnant or puerperal, is significantly different from the average patient who enters an intensive care unit. These patients have a unique pathophysiology and present specific disorders; in addition, there is the presence of the fetus, an alteration of the pharmacokinetics, diseases that may be aggravated by pregnancy and the scenario of a birth. The pregnant patient undergoes dramatic physiological changes at the cardiovascular, respiratory, renal, endocrinological, and hematological levels, which make her a different patient [1]. Post-partum hemorrhages, pre-eclampsia, acute fatty liver of pregnancy, and post-partum endometrial infections are unique conditions in an obstetric patient. The management challenge of these patients increases with the presence of the fetus. Publications report that there is a prevalence of critical obstetric patients of 100-900/100,000 gestations (0.1-0.9%) [2, 3], but these statistics are usually from medium-and high-resource countries. Statistical data from lowincome countries reach much higher values and often patients do not even manage to be treated in intensive care units. The mortality ratio is also very different between rich and low-income countries, with statistics of 6-24/100,000 live births (LB) in the highest-income countries, and 55-920/100,000 LB in poor countries [4]. It is estimated that 75% of hospitalizations of obstetric patients to intensive care units occur in the puerperium [3], because it is a period susceptible to complications such as pulmonary edema (due to a reduction in oncotic pressure) and a high frequency of hemorrhages, such as uterine atony. In the ICNARC study in UK 2007, 81.5% of patients were reported as recently pregnant (within 42 days of admission to the ICU) [5], either post-partum or post-abortion. There are vulnerable populations where the risk of maternal death is multiplied, such as ethnic minorities, extreme maternal ages, and low socioeconomic status [6].
Results. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 h... more Results. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 hours. Of 690 patients, 312 (45%) received palliative consultation and median time was 3.9 hours; 378 (55%) without palliative consultation had median time of 3.6 hours (not statistically significantly different). There was no statistically significant difference in time from WLST orders to death between the three mutually exclusive groups: orders by palliative provider and palliative consult, orders by nonpalliative provider and palliative consult, and orders by nonpalliative provider and no palliative consult.
PURPOSE: Critically ill patients with acute respiratory failure are often in positive fluid balan... more PURPOSE: Critically ill patients with acute respiratory failure are often in positive fluid balance. Positive fluid balance may be related to comorbidities as well as treatment of the acute disorder, as emphasized in the fluid resuscitation for sepsis. We investigated fluid balance and use of diuretics among patients in the medical intensive care unit (MICU), undergoing ventilator weaning trials. METHODS: Retrospective cohort of 55 consecutive patients admitted to the MICU. We included patients who required mechanical ventilation for > 24 hours. Exclusion criteria was end-stage renal disease. We reviewed electronic medical records to collect demographic data, comorbidities, reason for ICU admission, daily spontaneous breathing trials (SBT), fluid balance and diuretic administration 24 hours before and after each SBT, duration of mechanical ventilation and ICU length of stay. Results were analyzed with SPPS version 16; Fisher exact test was used for statistical significance. RESULTS: 55 subjects were studied, 28 men (51%), and 27 women (49%). Mean age was 67.25 years (SDAE16.36). Main comorbidities included: diastolic heart failure 21 (38%), COPD 16 (29%), CKD 11 (20%) and systolic heart failure 9 (16%). The most common admitting diagnosis was sepsis in 29 (49%), with 19 subjects in septic shock, followed by COPD exacerbation 5 (9%), status asthmaticus 4 (7%), cardiac arrest 4 (7%) and status epilepticus 4 (7%). Median time to first weaning trial was 3 days (IQR:2.5), and the median number of weaning trials prior to extubation was 2 (IQR:3.5). On the day of a successful weaning trial, 24 subjects had negative fluid balance (21 extubated) and 30 subjects had a positive fluid balance (26 extubated), Fisher's exact test p¼1.000. Furosemide was administered to 24 (43%) subjects before or after a ventilator weaning trial. Of those, 13 subjects (24%) achieved a negative or even fluid balance (11 extubated), Fisher's exact test p¼1.000, while 11 subjects had positive fluid balance (8 extubated), Fisher's exact test p¼0.335. CONCLUSIONS: In our study of mechanically ventilated MICU patients, we found that diuretics are commonly administered before or right after a weaning trial. Patients who received furosemide and had successful weaning trials often did not achieve a negative fluid balance. We did not find a difference in successful SBT and extubation between patients with negative fluid balance compared to patients with positive fluid balance. CLINICAL IMPLICATIONS: Negative fluid balance is a goal in patients with ARDS. In this first subset of MICU patients without ARDS in our ongoing study, we found that diuretics are commonly administered around the time of extubation. We could not, however, find a correlation between diuretic use, negative fluid balance and successful weaning. Further investigation may shed light on the value of including fluid balance and diuretics in the daily weaning assessment.
ABSTRACT Fatal lactic acidosis and hepatic steatosis developed in a patient who was receiving com... more ABSTRACT Fatal lactic acidosis and hepatic steatosis developed in a patient who was receiving combination nucleoside analog therapy for human immunodeficiency virus infection.
A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah&amp... more A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah's Witness, she was not willing to accept thrombolysis because of the potential risk of bleeding requiring blood transfusion. The patient was successfully treated with catheter thrombectomy, using rheolytic and fragmentation devices. (CHEST 2000; 117:594-597)
A 45-year-old woman with HIV infection presented with thrombotic microangiopathy 1 week after ini... more A 45-year-old woman with HIV infection presented with thrombotic microangiopathy 1 week after initiating therapy with the nucleoside analogue abacavir. She was successfully treated with plasmapheresis and corticosteroids.
Necrotizing pleuropulmonary infection in a patient with acquired immunodeficiency syndrome develo... more Necrotizing pleuropulmonary infection in a patient with acquired immunodeficiency syndrome developed due to Corynebacterium afermentans subspecies lipophilum. Long-term combination antibiotic therapy was successful in eradicating the infection without surgery.
Myopathy is a rare complication that arises during management of status asthmaticus that may be r... more Myopathy is a rare complication that arises during management of status asthmaticus that may be related to administration of corticosteroids and neuromuscular blocking agents. We present 4 patients with myopathy and a review of the 31 previously reported patients in the literature. All patients received corticosteroids, and 33 of the 35 patients received neuromuscular blocking agents. Muscle weakness was often diffuse and, in several patients, involved the muscles of respiration. Creatine kinase values ranged from normal to markedly elevated. Diagnosis was obtained by electromyogram and muscle biopsy in most patients. Resolution of the muscle weakness occurred over a period of days to months. Patients in whom myopathy developed required mechanical ventilation for longer periods than patients intubated for status asthmaticus without myopathy.
The obstetric patient, pregnant or puerperal, is significantly different from the average patient... more The obstetric patient, pregnant or puerperal, is significantly different from the average patient who enters an intensive care unit. These patients have a unique pathophysiology and present specific disorders; in addition, there is the presence of the fetus, an alteration of the pharmacokinetics, diseases that may be aggravated by pregnancy and the scenario of a birth. The pregnant patient undergoes dramatic physiological changes at the cardiovascular, respiratory, renal, endocrinological, and hematological levels, which make her a different patient [1]. Post-partum hemorrhages, pre-eclampsia, acute fatty liver of pregnancy, and post-partum endometrial infections are unique conditions in an obstetric patient. The management challenge of these patients increases with the presence of the fetus. Publications report that there is a prevalence of critical obstetric patients of 100-900/100,000 gestations (0.1-0.9%) [2, 3], but these statistics are usually from medium-and high-resource countries. Statistical data from lowincome countries reach much higher values and often patients do not even manage to be treated in intensive care units. The mortality ratio is also very different between rich and low-income countries, with statistics of 6-24/100,000 live births (LB) in the highest-income countries, and 55-920/100,000 LB in poor countries [4]. It is estimated that 75% of hospitalizations of obstetric patients to intensive care units occur in the puerperium [3], because it is a period susceptible to complications such as pulmonary edema (due to a reduction in oncotic pressure) and a high frequency of hemorrhages, such as uterine atony. In the ICNARC study in UK 2007, 81.5% of patients were reported as recently pregnant (within 42 days of admission to the ICU) [5], either post-partum or post-abortion. There are vulnerable populations where the risk of maternal death is multiplied, such as ethnic minorities, extreme maternal ages, and low socioeconomic status [6].
Results. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 h... more Results. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 hours. Of 690 patients, 312 (45%) received palliative consultation and median time was 3.9 hours; 378 (55%) without palliative consultation had median time of 3.6 hours (not statistically significantly different). There was no statistically significant difference in time from WLST orders to death between the three mutually exclusive groups: orders by palliative provider and palliative consult, orders by nonpalliative provider and palliative consult, and orders by nonpalliative provider and no palliative consult.
PURPOSE: Critically ill patients with acute respiratory failure are often in positive fluid balan... more PURPOSE: Critically ill patients with acute respiratory failure are often in positive fluid balance. Positive fluid balance may be related to comorbidities as well as treatment of the acute disorder, as emphasized in the fluid resuscitation for sepsis. We investigated fluid balance and use of diuretics among patients in the medical intensive care unit (MICU), undergoing ventilator weaning trials. METHODS: Retrospective cohort of 55 consecutive patients admitted to the MICU. We included patients who required mechanical ventilation for > 24 hours. Exclusion criteria was end-stage renal disease. We reviewed electronic medical records to collect demographic data, comorbidities, reason for ICU admission, daily spontaneous breathing trials (SBT), fluid balance and diuretic administration 24 hours before and after each SBT, duration of mechanical ventilation and ICU length of stay. Results were analyzed with SPPS version 16; Fisher exact test was used for statistical significance. RESULTS: 55 subjects were studied, 28 men (51%), and 27 women (49%). Mean age was 67.25 years (SDAE16.36). Main comorbidities included: diastolic heart failure 21 (38%), COPD 16 (29%), CKD 11 (20%) and systolic heart failure 9 (16%). The most common admitting diagnosis was sepsis in 29 (49%), with 19 subjects in septic shock, followed by COPD exacerbation 5 (9%), status asthmaticus 4 (7%), cardiac arrest 4 (7%) and status epilepticus 4 (7%). Median time to first weaning trial was 3 days (IQR:2.5), and the median number of weaning trials prior to extubation was 2 (IQR:3.5). On the day of a successful weaning trial, 24 subjects had negative fluid balance (21 extubated) and 30 subjects had a positive fluid balance (26 extubated), Fisher's exact test p¼1.000. Furosemide was administered to 24 (43%) subjects before or after a ventilator weaning trial. Of those, 13 subjects (24%) achieved a negative or even fluid balance (11 extubated), Fisher's exact test p¼1.000, while 11 subjects had positive fluid balance (8 extubated), Fisher's exact test p¼0.335. CONCLUSIONS: In our study of mechanically ventilated MICU patients, we found that diuretics are commonly administered before or right after a weaning trial. Patients who received furosemide and had successful weaning trials often did not achieve a negative fluid balance. We did not find a difference in successful SBT and extubation between patients with negative fluid balance compared to patients with positive fluid balance. CLINICAL IMPLICATIONS: Negative fluid balance is a goal in patients with ARDS. In this first subset of MICU patients without ARDS in our ongoing study, we found that diuretics are commonly administered around the time of extubation. We could not, however, find a correlation between diuretic use, negative fluid balance and successful weaning. Further investigation may shed light on the value of including fluid balance and diuretics in the daily weaning assessment.
ABSTRACT Fatal lactic acidosis and hepatic steatosis developed in a patient who was receiving com... more ABSTRACT Fatal lactic acidosis and hepatic steatosis developed in a patient who was receiving combination nucleoside analog therapy for human immunodeficiency virus infection.
A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah&amp... more A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah's Witness, she was not willing to accept thrombolysis because of the potential risk of bleeding requiring blood transfusion. The patient was successfully treated with catheter thrombectomy, using rheolytic and fragmentation devices. (CHEST 2000; 117:594-597)
A 45-year-old woman with HIV infection presented with thrombotic microangiopathy 1 week after ini... more A 45-year-old woman with HIV infection presented with thrombotic microangiopathy 1 week after initiating therapy with the nucleoside analogue abacavir. She was successfully treated with plasmapheresis and corticosteroids.
Necrotizing pleuropulmonary infection in a patient with acquired immunodeficiency syndrome develo... more Necrotizing pleuropulmonary infection in a patient with acquired immunodeficiency syndrome developed due to Corynebacterium afermentans subspecies lipophilum. Long-term combination antibiotic therapy was successful in eradicating the infection without surgery.
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Papers by Janet Shapiro