Ventilator-associated events (VAEs) are surveillance paradigms established by the CDC. They denot... more Ventilator-associated events (VAEs) are surveillance paradigms established by the CDC. They denote three categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC), to an infection-related ventilator-associated complication (IVAC), and finally to a ventilator-associated pneumonia (VAP). In a recent study, Gacouin et al., incidentally found that risk of late-onset VAP was higher in patients with a tube size greater than or equal to 7.5 mm. While there has been association found between ventilator associated pneumonia and endotracheal tube (ETT) size, there has not been a study done looking at CDC defined Ventilator Associated Events occurence and ETT size. We wanted to determine if there is an association between endotracheal tube size and the development of VAEs and whether that association is gender base. We retrospectively examined patient data at our institution from May 2013 through August 2016. Our final dataset consisted of 186 patients that met CDC-defined criteria as part of the hospital's daily VAE surveillance routine. We matched 1:1 by age, gender, ventilator days, vasopressors usage, and the size of endotracheal tube used. Our results showed that more males (n=121) developed VAEs than females (n=65). In males, larger tube size was associated with less VAEs; but in the female group, the opposite was noticed. With ETT size less than 8 mm, 73/121 (60.33%) males developed VAE compared to matched controls 47/123 (38.21%); with ETT size 8 mm, 48/121 males (39.66%) had VAE compared to 76/123 (61.79%) in control group; P value 0.000. With ETT size less than 8 mm, 36/65 (55.38%) females developed VAE compared to matched controls 49/63 (77.78%); with ETT size 8 mm, 29/65 females (44.62%) had VAE compared to 14/63 (22.22%) in control group; P value 0.008 CONCLUSIONS: VAEs appeared higher in intubated female patients with a larger ETT size. Clearly, our findings are difficult to explain and needs to be confirmed on a larger scale by others studies CLINICAL IMPLICATIONS: Selection of tube size during intubation does not follow a specific guideline and is left at the discretion of the operateur. We question whether an inappropriate selection of ETT size is a contributing factor in a patient's progression towards VAP on the VAE spectrum. From a patient safety perspective, we question whether physicians are more consistent with ETT size selection among male patients; while among female patients, physicians may take into consideration others factors, such as neck circumference and other anatomical measurements, and select a larger ETT size. A definite answer on the role of ETT size in the genesis of VAEs including VAP will help develop safe practices and guidelines to prevent VAEs and their complications.
PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppr... more PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppressive regimens used in solid organ transplant. However, sirolimus has been associated with a spectrum of lung toxicities, including interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia and diffuse alveolar hemorrhage, with estimated incidence 4.3-10%. Drugs' direct toxicity and immunological toxicity have been proposed as possible pathophysiology of sirolimus-associated lung toxicity. We aim to characterize chest X-ray and computed tomographic (CT) scan features and add to the scant body of knowledge of role of imaging modalities in diagnosis of sirolimus-associated lung toxicity following solid organ transplant. We identified patients on sirolimus as part of immunosuppressive regimen for solid organ transplant at our center between January 1999 and March 2013. Thirteen patients developed lung toxicity. We retrospectively screened patients with suspected sirolimus-associated lung toxicity and reviewed their chest X-rays and CT scans for characteristic diagnostic features. RESULTS: Thirteen patients with solid organ transplant were identified with suspected sirolimus-associated lung injury (10 kidneys, 1 kidney-pancreas, 1 liver and 1 heart). The mean age of patients was 62.4AE10.9 years with male predominance (69%). Chest X-rays findings were normal in 31% of patients (n=4/13). 69% of patients (n=9/13) demonstrated interstitial infiltrates (4 bilateral, 4 left sided and 1 right sided) with predilection of lower lobes (Figure ). Chest CT scans demonstrated interstitial infiltrates accompanied with ground-glass opacities. 53% of patients (n=7/13) had bilateral lower lobes involvement (Figure ), 31% of patients (n=4/13) had left lower lobe involvement and 8% of patient (n=1/13) had right lower lobe involvement and 8% of patient (n=1/13) had right middle lobe involvement. CONCLUSIONS: Features of interstitial infiltrates and ground-glass opacities favoring lower lung lobes are suggestive of sirolimus-associated lung toxicity in solid organ transplant patients on sirolimus as part of their immunosuppressive regimen. Predilection of lower lung lobes favors direct drug toxicity as the mechanism of pneumonitis associated with mTOR inhibitors. Imaging findings may not be detectable in conventional chest X-rays and chest CT scan is recommended in solid organ transplant patients on sirolimus presenting with respiratory symptoms. CLINICAL IMPLICATIONS: Development of sirolimus associated-lung toxicity in solid organ transplant patients highlights the need for diagnostic criteria that results in early diagnosis and management, in order to avoid compromising patients' allografts long-term survival at the expense of inducing a devastating lung disease that patients and physicians would end up regretting. Pulmonologists need to be more familiar with characteristics CT scan findings in patients with sirolimus-associated lung toxicity.
PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppr... more PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppressive regimens used in solid organ transplant. However, sirolimus has been associated with a spectrum of lung toxicities, including interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia and diffuse alveolar hemorrhage, with estimated incidence 4.3-10%. Drugs' direct toxicity and immunological toxicity have been proposed as possible pathophysiology of sirolimus-associated lung toxicity. We aim to characterize chest X-ray and computed tomographic (CT) scan features and add to the scant body of knowledge of role of imaging modalities in diagnosis of sirolimus-associated lung toxicity following solid organ transplant. We identified patients on sirolimus as part of immunosuppressive regimen for solid organ transplant at our center between January 1999 and March 2013. Thirteen patients developed lung toxicity. We retrospectively screened patients with suspected sirolimus-associated lung toxicity and reviewed their chest X-rays and CT scans for characteristic diagnostic features. RESULTS: Thirteen patients with solid organ transplant were identified with suspected sirolimus-associated lung injury (10 kidneys, 1 kidney-pancreas, 1 liver and 1 heart). The mean age of patients was 62.4AE10.9 years with male predominance (69%). Chest X-rays findings were normal in 31% of patients (n=4/13). 69% of patients (n=9/13) demonstrated interstitial infiltrates (4 bilateral, 4 left sided and 1 right sided) with predilection of lower lobes (Figure ). Chest CT scans demonstrated interstitial infiltrates accompanied with ground-glass opacities. 53% of patients (n=7/13) had bilateral lower lobes involvement (Figure ), 31% of patients (n=4/13) had left lower lobe involvement and 8% of patient (n=1/13) had right lower lobe involvement and 8% of patient (n=1/13) had right middle lobe involvement. CONCLUSIONS: Features of interstitial infiltrates and ground-glass opacities favoring lower lung lobes are suggestive of sirolimus-associated lung toxicity in solid organ transplant patients on sirolimus as part of their immunosuppressive regimen. Predilection of lower lung lobes favors direct drug toxicity as the mechanism of pneumonitis associated with mTOR inhibitors. Imaging findings may not be detectable in conventional chest X-rays and chest CT scan is recommended in solid organ transplant patients on sirolimus presenting with respiratory symptoms. CLINICAL IMPLICATIONS: Development of sirolimus associated-lung toxicity in solid organ transplant patients highlights the need for diagnostic criteria that results in early diagnosis and management, in order to avoid compromising patients' allografts long-term survival at the expense of inducing a devastating lung disease that patients and physicians would end up regretting. Pulmonologists need to be more familiar with characteristics CT scan findings in patients with sirolimus-associated lung toxicity.
Establishing whether there is a correlation or not between volume overload and ventilator associa... more Establishing whether there is a correlation or not between volume overload and ventilator associated events (VAE). The least layer in the spectrum of VAE is Ventilator Associated Condition (VAC). VAC needs one of two criteria; either an increase in Fraction of Inspired Oxygen (FiO2) or Positive End Exipratory Pressure (PEEP) for two days. We suspected prior to gathering the data that some patients qualify for VAC due to volume overload resulting in hypoxia. This study investigated if VAE patients had a higher CVP than match controls. METHODS: Data was gathered from May 2013 to August 2016, which was collected by the Infection Prevention Department at our university hospital as part of their responsibility for VAE surveillance. 2400 ventilated patients were screened. 186 VAE cases were identified during the time period. VAE cases were matched 1:1 with controls based on age, gender, unit of intubation, use of vasopressors while intubated, and total ventilator days. Controls were randomly selected among patients that were mechanically ventilated for at least 3 days to meet VAE definitions. Central Venous Pressures (CVPs) were gathered for each group, which resulted in 123 patients in the VAE group, while 123 were among the controls. CVPs for each group was compared using Student t-test and a p-value of 0.05 or less was considered statistically significant. For the VAC group, 16 patients (21.05%) had a CVP of 15 or greater compared to 50 patients having a CVP less than 15. While for the IVAC group, 8 patients (24.2%) had a CVP of 15 or greater compared to 25 patients having a CVP less than 15. For the possible VAP group, 5 patients (19.2%) had a CVP of 15 or greater compared to 21 patients having a CVP less than 50. The p-value was 0.865 showing that CVP levels at day 3 of intubation did not significantly differ between subgroups of VAE. Among all VAE patients, 29 had a CVP greater than 15 (23.2%) compared to 29 patients (23.96%) in the control group. The Odds ratio was 0.958 (95% CI 0.509-1.804) with a p value of 1.00. In our population, CVP per si did not correlate with the development of VAE. Although this measurement can be affected by many factors such as pulmonary hypertension, tricuspid regurgitation and others, it cannot be directly attributed for the development of VAE in reflection to volume overload which was our initial suspicion. Based on our data of 372 ventilated patients, CVP is an insensitive test in correlating with volume overload induced hypoxemia. CLINICAL IMPLICATIONS: Based on our data of 372 ventilated patients, clinicians and quality improvement staff need to disregard high CVP as a biasing factor when applying CDC criteria for VAEs. Other measures of volume status might clarify the blur but subjective variation in physical examination and chest radiography restricts these methods.
Electronic cigarettes (e cigarettes) are battery operated devices that produce aerosol by heating... more Electronic cigarettes (e cigarettes) are battery operated devices that produce aerosol by heating a solution typically made up of nicotine, propylene glycol, glycerin and flavoring agents. The use of e cigarettes has risen dramatically in recent years especially among adolescents and young adults. These devices have been marketed as safer alternatives to tobacco smoking by their manufactures despite lack of adequate safety data. We present a case of 40-year-old female patient who developed significant pulmonary toxicity secondary to e cigarette use and searched existing literature relevant to the case. To our knowledge this is the second reported case of organizing pneumonia and tenth reported case of pulmonary toxicity related to e cigarette use. Our patient presented with symptoms of worsening dyspnea and intermittent chest pain for past 1 month. She reported increased use of e cigarettes during this time period to help her quit smoking. Patient developed acute hypoxemic respirato...
Ventilator-associated events (VAE) are surveillance paradigms established by the CDC, and they de... more Ventilator-associated events (VAE) are surveillance paradigms established by the CDC, and they denote three categories of increasing progression from a ventilator-associated condition (VAC), to an infection-related ventilator-associated condition (IVAC), and finally to ventilator-associated pneumonia (VAP). Moreover, the first criteria for VAC can only be met after 2 days of stable daily values (PEEP or FiO 2 ). Following a period of two days of more of instability, additional specific criteria, such as WBCs, temperature, antimicrobial therapy, and a positive culture, would need to be met to move through the remaining categories. Considering VAEs are rather new in critical care, there has been a growing interest in quantifying these definitions for practical application. While a distinction exists between an early onset (the first 4 days) and a late onset (after the 4th day) of VAP, very little information exists on the duration of intubation before a VAE. Furthermore, some studies have looked at the incidence of early onset VAP in the ICU, found that the highest observed number of cases occurred in day 3 and 4 after admission and that the incidence increases with the duration of mechanical ventilation and the median time from ICU admission to the onset of the first episodes was 6 days. We retrospectively examined patients' data admitted to intensive care units (ICUs) at our institution from May 2013 through December 2015 with an emphasis on the numbers of days from intubation to the onset of any of the three categories of VAE. Total of 858 patients were included. Our final dataset consisted of 152 patients that met CDC-defined criteria as part of the hospital's daily VAE surveillance routine. We found the following: Days to VAC: number of patients 82, median time to first episode 5.50, IQR 7.0. The days to IVAC: number of patients 38, median time to first episode 5.50, IQR 4.0. And the days to VAP: number of patients 32, median time to first episode 5.00, IQR 4.5 CONCLUSIONS: Although we used the time from intubation rather than the time from admission to the ICU as a starting point, the median values are very similar. Between 3-5 days from intubation, 50% of patients developed VAC and IVAC, while 60% developed VAP. Fewer cases occurred after 12 days in all three categories. Conversely, the majority of VAEs (61.8%) did occur after the 4 th day. Our data highlights the need for prevention and control methods between day 3 and 9 of mechanical intubation to prevent most of these conditions. CLINICAL IMPLICATIONS: This study suggests to clinicians the peak time of developing VAP. Infection control measures need to be maximized throughout ICU stay and especially around the peak of incidence which was found to be around the 4th day of intubation.
Hermann Simo* Aahd Kubbara William Barnett Kevin Qin Wail Alamoudi Madiha Fida Nawaf Almashal Asi... more Hermann Simo* Aahd Kubbara William Barnett Kevin Qin Wail Alamoudi Madiha Fida Nawaf Almashal Asif Iqbal Amala Ambati Ajit Ramadugu Christopher Marino Faisal Khateeb Fadi Safi and Ragheb Assaly University of Toledo Medical Center, Toledo, OH IO N , R E S E A R C H , A N D Q U A L IT Y IM P R O V E M E N T PURPOSE: Ventilator-associated events (VAEs) are surveillance paradigms established by the CDC. They denote three categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC), to an infection-related ventilator-associated complication (IVAC), and finally to a ventilator-associated pneumonia (VAP). In a recent study, Gacouin et al., incidentally found that risk of late-onset VAP was higher in patients with a tube size greater than or equal to 7.5 mm. While there has been association found between ventilator associated pneumonia and endotracheal tube (ETT) size, there has not been a study done looking at CDC defined Ventilator ...
Just-in-Time (JIT) supply calls for frequent, small deliveries, which arrive on time, with the qu... more Just-in-Time (JIT) supply calls for frequent, small deliveries, which arrive on time, with the quantity and quality required. For JIT to be effective there should be a cooperative relationship between the buyer and the supplier. They should work together to enhance their competitive positions in the market place. This study extends the quantitative models published in the literature to provide more realistic models for JIT operations and evaluates the costs and benefits o f JIT partnerships to help in the negotiation process between the partners. We provide a new model for the optimization of the joint total relevant cost o f the buyer and supplier in the typical JIT scenario where the buyer’s order is delivered in multiple shipments and the supplier’s production lot size is an integer multiple o f the shipment size. The new model provides more flexibility and cost saving for a JIT environment. It determines jointly the optimal values o f the three decision variables: the shipment s...
To evaluate retrievable IVC filters in our institution and assess their retrieval following a wel... more To evaluate retrievable IVC filters in our institution and assess their retrieval following a well-structured follow up program. Retrospective cohort study. The medical records of patients implanted with retrievable IVC filters were reviewed. All retrievable filter insertions between July 2007 and August 2011 at our institution were reviewed. Data was analyzed for age, gender, indication, complications, retrieval rate, and brand of filter inserted. Statistical analysis was done using SPSS software v19. Chi-square was used to compare discrete data and t-test for continuous data. P < 0.05 was significant. A total of 484 patients were reviewed of which 258 (53.1%) had a complete medical record. And 96 (37.2%) filters were placed as permanent at the time of insertion. An additional 40 (15.5%) filters were converted to permanent (total permanent filters 136; 52.7%). Death was reported in 26 (10%) patients and 96 (37.2%) out of the remaining 232 patients presented for potential retriev...
BACKGROUND Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United... more BACKGROUND Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United States contains levamisole. It is a synthetic imidazothiazole derivative which was previously used as an immunomodulating agent for treatment of various connective tissue disorders and colorectal carcinoma. However, it was withdrawn later from the market due to significant toxicity associated with it. CASE REPORT We present the case of a 59-year-old male patient with a history of active cocaine use who presented to the hospital with febrile neutropenia and agranulocytosis. He underwent extensive work-up for neutropenia and was suspected to have it secondary to levamisole-adulterated cocaine. He was treated with antibiotics and granulocyte-stimulating factor. His white cell count improved and he was discharged home. He continued to use cocaine after discharge from the hospital. He returned to the hospital 3 weeks later with recurrent neutropenia and agranulocytosis complicated by septic ...
Ventilator-associated events (VAEs) are surveillance paradigms established by the CDC. They denot... more Ventilator-associated events (VAEs) are surveillance paradigms established by the CDC. They denote three categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC), to an infection-related ventilator-associated complication (IVAC), and finally to a ventilator-associated pneumonia (VAP). In a recent study, Gacouin et al., incidentally found that risk of late-onset VAP was higher in patients with a tube size greater than or equal to 7.5 mm. While there has been association found between ventilator associated pneumonia and endotracheal tube (ETT) size, there has not been a study done looking at CDC defined Ventilator Associated Events occurence and ETT size. We wanted to determine if there is an association between endotracheal tube size and the development of VAEs and whether that association is gender base. We retrospectively examined patient data at our institution from May 2013 through August 2016. Our final dataset consisted of 186 patients that met CDC-defined criteria as part of the hospital's daily VAE surveillance routine. We matched 1:1 by age, gender, ventilator days, vasopressors usage, and the size of endotracheal tube used. Our results showed that more males (n=121) developed VAEs than females (n=65). In males, larger tube size was associated with less VAEs; but in the female group, the opposite was noticed. With ETT size less than 8 mm, 73/121 (60.33%) males developed VAE compared to matched controls 47/123 (38.21%); with ETT size 8 mm, 48/121 males (39.66%) had VAE compared to 76/123 (61.79%) in control group; P value 0.000. With ETT size less than 8 mm, 36/65 (55.38%) females developed VAE compared to matched controls 49/63 (77.78%); with ETT size 8 mm, 29/65 females (44.62%) had VAE compared to 14/63 (22.22%) in control group; P value 0.008 CONCLUSIONS: VAEs appeared higher in intubated female patients with a larger ETT size. Clearly, our findings are difficult to explain and needs to be confirmed on a larger scale by others studies CLINICAL IMPLICATIONS: Selection of tube size during intubation does not follow a specific guideline and is left at the discretion of the operateur. We question whether an inappropriate selection of ETT size is a contributing factor in a patient's progression towards VAP on the VAE spectrum. From a patient safety perspective, we question whether physicians are more consistent with ETT size selection among male patients; while among female patients, physicians may take into consideration others factors, such as neck circumference and other anatomical measurements, and select a larger ETT size. A definite answer on the role of ETT size in the genesis of VAEs including VAP will help develop safe practices and guidelines to prevent VAEs and their complications.
PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppr... more PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppressive regimens used in solid organ transplant. However, sirolimus has been associated with a spectrum of lung toxicities, including interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia and diffuse alveolar hemorrhage, with estimated incidence 4.3-10%. Drugs' direct toxicity and immunological toxicity have been proposed as possible pathophysiology of sirolimus-associated lung toxicity. We aim to characterize chest X-ray and computed tomographic (CT) scan features and add to the scant body of knowledge of role of imaging modalities in diagnosis of sirolimus-associated lung toxicity following solid organ transplant. We identified patients on sirolimus as part of immunosuppressive regimen for solid organ transplant at our center between January 1999 and March 2013. Thirteen patients developed lung toxicity. We retrospectively screened patients with suspected sirolimus-associated lung toxicity and reviewed their chest X-rays and CT scans for characteristic diagnostic features. RESULTS: Thirteen patients with solid organ transplant were identified with suspected sirolimus-associated lung injury (10 kidneys, 1 kidney-pancreas, 1 liver and 1 heart). The mean age of patients was 62.4AE10.9 years with male predominance (69%). Chest X-rays findings were normal in 31% of patients (n=4/13). 69% of patients (n=9/13) demonstrated interstitial infiltrates (4 bilateral, 4 left sided and 1 right sided) with predilection of lower lobes (Figure ). Chest CT scans demonstrated interstitial infiltrates accompanied with ground-glass opacities. 53% of patients (n=7/13) had bilateral lower lobes involvement (Figure ), 31% of patients (n=4/13) had left lower lobe involvement and 8% of patient (n=1/13) had right lower lobe involvement and 8% of patient (n=1/13) had right middle lobe involvement. CONCLUSIONS: Features of interstitial infiltrates and ground-glass opacities favoring lower lung lobes are suggestive of sirolimus-associated lung toxicity in solid organ transplant patients on sirolimus as part of their immunosuppressive regimen. Predilection of lower lung lobes favors direct drug toxicity as the mechanism of pneumonitis associated with mTOR inhibitors. Imaging findings may not be detectable in conventional chest X-rays and chest CT scan is recommended in solid organ transplant patients on sirolimus presenting with respiratory symptoms. CLINICAL IMPLICATIONS: Development of sirolimus associated-lung toxicity in solid organ transplant patients highlights the need for diagnostic criteria that results in early diagnosis and management, in order to avoid compromising patients' allografts long-term survival at the expense of inducing a devastating lung disease that patients and physicians would end up regretting. Pulmonologists need to be more familiar with characteristics CT scan findings in patients with sirolimus-associated lung toxicity.
PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppr... more PURPOSE: mTOR inhibitors play an integral role in induction and long-term maintenance immunosuppressive regimens used in solid organ transplant. However, sirolimus has been associated with a spectrum of lung toxicities, including interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia and diffuse alveolar hemorrhage, with estimated incidence 4.3-10%. Drugs' direct toxicity and immunological toxicity have been proposed as possible pathophysiology of sirolimus-associated lung toxicity. We aim to characterize chest X-ray and computed tomographic (CT) scan features and add to the scant body of knowledge of role of imaging modalities in diagnosis of sirolimus-associated lung toxicity following solid organ transplant. We identified patients on sirolimus as part of immunosuppressive regimen for solid organ transplant at our center between January 1999 and March 2013. Thirteen patients developed lung toxicity. We retrospectively screened patients with suspected sirolimus-associated lung toxicity and reviewed their chest X-rays and CT scans for characteristic diagnostic features. RESULTS: Thirteen patients with solid organ transplant were identified with suspected sirolimus-associated lung injury (10 kidneys, 1 kidney-pancreas, 1 liver and 1 heart). The mean age of patients was 62.4AE10.9 years with male predominance (69%). Chest X-rays findings were normal in 31% of patients (n=4/13). 69% of patients (n=9/13) demonstrated interstitial infiltrates (4 bilateral, 4 left sided and 1 right sided) with predilection of lower lobes (Figure ). Chest CT scans demonstrated interstitial infiltrates accompanied with ground-glass opacities. 53% of patients (n=7/13) had bilateral lower lobes involvement (Figure ), 31% of patients (n=4/13) had left lower lobe involvement and 8% of patient (n=1/13) had right lower lobe involvement and 8% of patient (n=1/13) had right middle lobe involvement. CONCLUSIONS: Features of interstitial infiltrates and ground-glass opacities favoring lower lung lobes are suggestive of sirolimus-associated lung toxicity in solid organ transplant patients on sirolimus as part of their immunosuppressive regimen. Predilection of lower lung lobes favors direct drug toxicity as the mechanism of pneumonitis associated with mTOR inhibitors. Imaging findings may not be detectable in conventional chest X-rays and chest CT scan is recommended in solid organ transplant patients on sirolimus presenting with respiratory symptoms. CLINICAL IMPLICATIONS: Development of sirolimus associated-lung toxicity in solid organ transplant patients highlights the need for diagnostic criteria that results in early diagnosis and management, in order to avoid compromising patients' allografts long-term survival at the expense of inducing a devastating lung disease that patients and physicians would end up regretting. Pulmonologists need to be more familiar with characteristics CT scan findings in patients with sirolimus-associated lung toxicity.
Establishing whether there is a correlation or not between volume overload and ventilator associa... more Establishing whether there is a correlation or not between volume overload and ventilator associated events (VAE). The least layer in the spectrum of VAE is Ventilator Associated Condition (VAC). VAC needs one of two criteria; either an increase in Fraction of Inspired Oxygen (FiO2) or Positive End Exipratory Pressure (PEEP) for two days. We suspected prior to gathering the data that some patients qualify for VAC due to volume overload resulting in hypoxia. This study investigated if VAE patients had a higher CVP than match controls. METHODS: Data was gathered from May 2013 to August 2016, which was collected by the Infection Prevention Department at our university hospital as part of their responsibility for VAE surveillance. 2400 ventilated patients were screened. 186 VAE cases were identified during the time period. VAE cases were matched 1:1 with controls based on age, gender, unit of intubation, use of vasopressors while intubated, and total ventilator days. Controls were randomly selected among patients that were mechanically ventilated for at least 3 days to meet VAE definitions. Central Venous Pressures (CVPs) were gathered for each group, which resulted in 123 patients in the VAE group, while 123 were among the controls. CVPs for each group was compared using Student t-test and a p-value of 0.05 or less was considered statistically significant. For the VAC group, 16 patients (21.05%) had a CVP of 15 or greater compared to 50 patients having a CVP less than 15. While for the IVAC group, 8 patients (24.2%) had a CVP of 15 or greater compared to 25 patients having a CVP less than 15. For the possible VAP group, 5 patients (19.2%) had a CVP of 15 or greater compared to 21 patients having a CVP less than 50. The p-value was 0.865 showing that CVP levels at day 3 of intubation did not significantly differ between subgroups of VAE. Among all VAE patients, 29 had a CVP greater than 15 (23.2%) compared to 29 patients (23.96%) in the control group. The Odds ratio was 0.958 (95% CI 0.509-1.804) with a p value of 1.00. In our population, CVP per si did not correlate with the development of VAE. Although this measurement can be affected by many factors such as pulmonary hypertension, tricuspid regurgitation and others, it cannot be directly attributed for the development of VAE in reflection to volume overload which was our initial suspicion. Based on our data of 372 ventilated patients, CVP is an insensitive test in correlating with volume overload induced hypoxemia. CLINICAL IMPLICATIONS: Based on our data of 372 ventilated patients, clinicians and quality improvement staff need to disregard high CVP as a biasing factor when applying CDC criteria for VAEs. Other measures of volume status might clarify the blur but subjective variation in physical examination and chest radiography restricts these methods.
Electronic cigarettes (e cigarettes) are battery operated devices that produce aerosol by heating... more Electronic cigarettes (e cigarettes) are battery operated devices that produce aerosol by heating a solution typically made up of nicotine, propylene glycol, glycerin and flavoring agents. The use of e cigarettes has risen dramatically in recent years especially among adolescents and young adults. These devices have been marketed as safer alternatives to tobacco smoking by their manufactures despite lack of adequate safety data. We present a case of 40-year-old female patient who developed significant pulmonary toxicity secondary to e cigarette use and searched existing literature relevant to the case. To our knowledge this is the second reported case of organizing pneumonia and tenth reported case of pulmonary toxicity related to e cigarette use. Our patient presented with symptoms of worsening dyspnea and intermittent chest pain for past 1 month. She reported increased use of e cigarettes during this time period to help her quit smoking. Patient developed acute hypoxemic respirato...
Ventilator-associated events (VAE) are surveillance paradigms established by the CDC, and they de... more Ventilator-associated events (VAE) are surveillance paradigms established by the CDC, and they denote three categories of increasing progression from a ventilator-associated condition (VAC), to an infection-related ventilator-associated condition (IVAC), and finally to ventilator-associated pneumonia (VAP). Moreover, the first criteria for VAC can only be met after 2 days of stable daily values (PEEP or FiO 2 ). Following a period of two days of more of instability, additional specific criteria, such as WBCs, temperature, antimicrobial therapy, and a positive culture, would need to be met to move through the remaining categories. Considering VAEs are rather new in critical care, there has been a growing interest in quantifying these definitions for practical application. While a distinction exists between an early onset (the first 4 days) and a late onset (after the 4th day) of VAP, very little information exists on the duration of intubation before a VAE. Furthermore, some studies have looked at the incidence of early onset VAP in the ICU, found that the highest observed number of cases occurred in day 3 and 4 after admission and that the incidence increases with the duration of mechanical ventilation and the median time from ICU admission to the onset of the first episodes was 6 days. We retrospectively examined patients' data admitted to intensive care units (ICUs) at our institution from May 2013 through December 2015 with an emphasis on the numbers of days from intubation to the onset of any of the three categories of VAE. Total of 858 patients were included. Our final dataset consisted of 152 patients that met CDC-defined criteria as part of the hospital's daily VAE surveillance routine. We found the following: Days to VAC: number of patients 82, median time to first episode 5.50, IQR 7.0. The days to IVAC: number of patients 38, median time to first episode 5.50, IQR 4.0. And the days to VAP: number of patients 32, median time to first episode 5.00, IQR 4.5 CONCLUSIONS: Although we used the time from intubation rather than the time from admission to the ICU as a starting point, the median values are very similar. Between 3-5 days from intubation, 50% of patients developed VAC and IVAC, while 60% developed VAP. Fewer cases occurred after 12 days in all three categories. Conversely, the majority of VAEs (61.8%) did occur after the 4 th day. Our data highlights the need for prevention and control methods between day 3 and 9 of mechanical intubation to prevent most of these conditions. CLINICAL IMPLICATIONS: This study suggests to clinicians the peak time of developing VAP. Infection control measures need to be maximized throughout ICU stay and especially around the peak of incidence which was found to be around the 4th day of intubation.
Hermann Simo* Aahd Kubbara William Barnett Kevin Qin Wail Alamoudi Madiha Fida Nawaf Almashal Asi... more Hermann Simo* Aahd Kubbara William Barnett Kevin Qin Wail Alamoudi Madiha Fida Nawaf Almashal Asif Iqbal Amala Ambati Ajit Ramadugu Christopher Marino Faisal Khateeb Fadi Safi and Ragheb Assaly University of Toledo Medical Center, Toledo, OH IO N , R E S E A R C H , A N D Q U A L IT Y IM P R O V E M E N T PURPOSE: Ventilator-associated events (VAEs) are surveillance paradigms established by the CDC. They denote three categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC), to an infection-related ventilator-associated complication (IVAC), and finally to a ventilator-associated pneumonia (VAP). In a recent study, Gacouin et al., incidentally found that risk of late-onset VAP was higher in patients with a tube size greater than or equal to 7.5 mm. While there has been association found between ventilator associated pneumonia and endotracheal tube (ETT) size, there has not been a study done looking at CDC defined Ventilator ...
Just-in-Time (JIT) supply calls for frequent, small deliveries, which arrive on time, with the qu... more Just-in-Time (JIT) supply calls for frequent, small deliveries, which arrive on time, with the quantity and quality required. For JIT to be effective there should be a cooperative relationship between the buyer and the supplier. They should work together to enhance their competitive positions in the market place. This study extends the quantitative models published in the literature to provide more realistic models for JIT operations and evaluates the costs and benefits o f JIT partnerships to help in the negotiation process between the partners. We provide a new model for the optimization of the joint total relevant cost o f the buyer and supplier in the typical JIT scenario where the buyer’s order is delivered in multiple shipments and the supplier’s production lot size is an integer multiple o f the shipment size. The new model provides more flexibility and cost saving for a JIT environment. It determines jointly the optimal values o f the three decision variables: the shipment s...
To evaluate retrievable IVC filters in our institution and assess their retrieval following a wel... more To evaluate retrievable IVC filters in our institution and assess their retrieval following a well-structured follow up program. Retrospective cohort study. The medical records of patients implanted with retrievable IVC filters were reviewed. All retrievable filter insertions between July 2007 and August 2011 at our institution were reviewed. Data was analyzed for age, gender, indication, complications, retrieval rate, and brand of filter inserted. Statistical analysis was done using SPSS software v19. Chi-square was used to compare discrete data and t-test for continuous data. P < 0.05 was significant. A total of 484 patients were reviewed of which 258 (53.1%) had a complete medical record. And 96 (37.2%) filters were placed as permanent at the time of insertion. An additional 40 (15.5%) filters were converted to permanent (total permanent filters 136; 52.7%). Death was reported in 26 (10%) patients and 96 (37.2%) out of the remaining 232 patients presented for potential retriev...
BACKGROUND Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United... more BACKGROUND Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United States contains levamisole. It is a synthetic imidazothiazole derivative which was previously used as an immunomodulating agent for treatment of various connective tissue disorders and colorectal carcinoma. However, it was withdrawn later from the market due to significant toxicity associated with it. CASE REPORT We present the case of a 59-year-old male patient with a history of active cocaine use who presented to the hospital with febrile neutropenia and agranulocytosis. He underwent extensive work-up for neutropenia and was suspected to have it secondary to levamisole-adulterated cocaine. He was treated with antibiotics and granulocyte-stimulating factor. His white cell count improved and he was discharged home. He continued to use cocaine after discharge from the hospital. He returned to the hospital 3 weeks later with recurrent neutropenia and agranulocytosis complicated by septic ...
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