Showing papers by "Lena M. Napolitano published in 2016"

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Abstract: It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Whole-Exome Sequencing Reveals Mutations in Genes Linked to Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome in Fatal Cases of H1N1 Influenza

Abstract: Background. Severe H1N1 influenza can be lethal in otherwise healthy individuals and can have features of reactive hemophagocytic lymphohistiocytosis (HLH). HLH is associated with mutations in lymphocyte cytolytic pathway genes, which have not been previously explored in H1N1 influenza. Methods. Sixteen cases of fatal influenza A(H1N1) infection, 81% with histopathologic hemophagocytosis, were identified and analyzed for clinical and laboratory features of HLH, using modified HLH-2004 and macrophage activation syndrome (MAS) criteria. Fourteen specimens were subject to whole-exome sequencing. Sequence alignment and variant filtering detected HLH gene mutations and potential disease-causing variants. Cytolytic function of the PRF1 p.A91V mutation was tested in lentiviral-transduced NK-92 natural killer (NK) cells. Results. Despite several lacking variables, cases of influenza A(H1N1) infection met 44% and 81% of modified HLH-2004 and MAS criteria, respectively. Five subjects (36%) carried one of 3 heterozygous LYST mutations, 2 of whom also possessed the p.A91V PRF1 mutation, which was shown to decrease NK cell cytolytic function. Several patients also carried rare variants in other genes previously observed in MAS. Conclusions. This cohort of fatal influenza A(H1N1) infections confirms the presence of hemophagocytosis and HLH pathology. Moreover, the high percentage of HLH gene mutations suggests they are risk factors for mortality among individuals with influenza A(H1N1) infection.

Outcome of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) ECMO.

Abstract: Objective:To examine the outcomes of prolonged (≥14 days) extracorporeal membrane oxygenation (P-ECMO) for adult severe respiratory failure and to assess characteristics associated with survival.Background:The use of ECMO for treatment of severe respiratory adult patients is associated with overall

Incidence, risk factors, and mortality associated with acute respiratory distress syndrome in combat casualty care.

Abstract: BACKGROUND The overall incidence and mortality of acute respiratory distress syndrome (ARDS) in civilian trauma settings have decreased over the past four decades; however, the epidemiology and impact of ARDS on modern combat casualty care are unknown. We sought to determine the incidence, risk factors, resource utilization, and mortality associated with ARDS in current combat casualty care. METHODS This was a retrospective review of mechanically ventilated US combat casualties within the Department of Defense Trauma Registry (formerly the Joint Theater Trauma Registry) during Operation Iraqi Freedom/Enduring Freedom (October 2001 to August 2008) for ARDS development, resource utilization, and mortality. RESULTS Of 18,329 US Department of Defense Trauma Registry encounters, 4,679 (25.5%) required mechanical ventilation; ARDS was identified in 156 encounters (3.3%). On multivariate logistic regression, ARDS was independently associated with female sex (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.21-5.71; p = 0.02), higher military-specific Injury Severity Score (Mil ISS) (OR, 4.18; 95% CI, 2.61-6.71; p < 0.001 for Mil ISS ≥25 vs. <15), hypotension (admission systolic blood pressure <90 vs. ≥90 mm Hg; OR, 1.76; 95% CI, 1.07-2.88; p = 0.03), and tachycardia (admission heart rate ≥90 vs. <90 beats per minute; OR, 1.53; 95% CI, 1.06-2.22; p = 0.02). Explosion injury was not associated with increased risk of ARDS. Critical care resource utilization was significantly higher in ARDS patients as was all-cause hospital mortality (ARDS vs. no ARDS, 12.8% vs. 5.9%; p = 0.002). After adjustment for age, sex, injury severity, injury mechanism, Mil ISS, hypotension, tachycardia, and admission Glasgow Coma Scale score, ARDS remained an independent risk factor for death (OR, 1.99; 95% CI, 1.12-3.52; p = 0.02). CONCLUSIONS In this large cohort of modern combat casualties, ARDS risk factors included female sex, higher injury severity, hypotension, and tachycardia, but not explosion injury. Patients with ARDS also required more medical resources and were at greater risk of death compared with patients without ARDS. Thus, ARDS remains a significant complication in current combat casualty care. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

General surgery resident rotations in surgical critical care, trauma, and burns: what is optimal for residency training?

Abstract: Background There are no specific Accreditation Council for Graduate Medical Education General Surgery Residency Program Requirements for rotations in surgical critical care (SCC), trauma, and burn. We sought to determine the experience of general surgery residents in SCC, trauma, and burn rotations. Methods Data analysis of surgical rotations of American Board of Surgery general surgery resident applicants (n = 7,299) for the last 8 years (2006 to 2013, inclusive) was performed through electronic applications to the American Board of Surgery Qualifying Examination. Duration (months) spent in SCC, trauma, and burn rotations, and postgraduate year (PGY) level were examined. Results The total months in SCC, trauma and burn rotations was mean 10.2 and median 10.0 (SD 3.9 months), representing approximately 16.7% (10 of 60 months) of a general surgery resident's training. However, there was great variability (range 0 to 29 months). SCC rotation duration was mean 3.1 and median 3.0 months (SD 2, min to max: 0 to 15), trauma rotation duration was mean 6.3 and median 6.0 months (SD 3.5, min to max: 0 to 24), and burn rotation duration was mean 0.8 and median 1.0 months (SD 1.0, min to max: 0 to 6). Of the total mean 10.2 months duration, the longest exposure was 2 months as PGY-1, 3.4 months as PGY-2, 1.9 months as PGY-3, 2.2 months as PGY-4 and 1.1 months as PGY-5. PGY-5 residents spent a mean of 1 month in SCC, trauma, and burn rotations. PGY-4/5 residents spent the majority of this total time in trauma rotations, whereas junior residents (PGY-1 to 3) in SCC and trauma rotations. Conclusions There is significant variability in total duration of SCC, trauma, and burn rotations and PGY level in US general surgery residency programs, which may result in significant variability in the fund of knowledge and clinical experience of the trainee completing general surgery residency training. As acute care surgery programs have begun to integrate emergency general surgery with SCC, trauma, and burn rotations, it is an ideal time to determine the optimal curriculum and duration of these important rotations for general surgery residency training.

Hemoglobin-Based Oxygen Carrier for Traumatic Hemorrhagic Shock Treatment in a Jehovah's Witness.

Abstract: Introduction: Treatment of severe hemorrhagic shock due to acute blood loss from traumatic injuries in a Jehovah’s witness (JW) trauma patient is very challenging since hemostatic blood product resuscitation is limited by refusal of the transfusion of allogeneic blood products. Case Presentation: We describe a multifaceted approach to the clinical care of a severely anemic JW trauma patient including the early administration of a bovine hemoglobin-based oxygen carrier (HBOC) as a bridge to resolution of critical anemia (nadir hemoglobin 3.9 g/dL). HBOC infusions were used to supplement oxygen delivery until endogenous erythropoiesis could restore adequate red blood cell mass. Subsequent endogenous bone marrow recovery was supported by early administration of high-dose erythropoiesis-stimulating agents and iron supplementation. Conclusions: Early HBOC administration can be used in the treatment of severe hemorrhagic shock in trauma patients who refuse allogeneic blood.

Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection

Abstract: Background: Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. Methods: Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in ...

Anemia in the Surgical ICU

Abstract: Anemia is common in critically ill and it is associated with worsening of outcomes and increased risk of transfusion. Various compensatory mechanisms are activated to mitigate the negative effects of reduced oxygen-carrying capacity of blood in anemia, but these adaptations have limits and as the limits are reached, tissue oxygen delivery will no longer be adequate to meet the demand and ischemia and tissue injury may occur. Anemia is often multifactorial and in critically ill patients, it can be caused by blood loss, impaired erythropoiesis, and reduced life span of red blood cells, iron deficiency (absolute or functional), and hemodilution. Various management strategies are available to address these etiologies. Given the risks of transfusion, allogeneic blood should be used judiciously and only when clearly indicated and alongside other management and preventive strategies to reduce unnecessary and avoidable transfusions.

Source Control and Supporting Therapeutics: Integrating Bacterial Invasion, Host Defense, and Clinical Interventions with Source Control Procedures

Abstract: While the concept of source control is not new and is in widespread practice, some of the underpinning that defines the practice has evolved. While source control is commonly interpreted as the drainage of purulent material, removal of infected medical devices, control of GI tract perforation, and debridement of devitalized tissue, all of those elements are reactionary in nature and are accompanied by adjunctive antibiotics for variable courses. Over the last decade, major advances have occurred in understanding the molecular basis of disease pathogenesis as well as the host response to injury, inflammation, and infection. These advances may enable proactive measures to be undertaken that target specific elements of host defense to optimize patient outcome in the emergency department (ED), operating room (OR), intensive care unit (ICU), or general ward. This chapter will address how one may integrate standard source control practices with recent data on potentially controllable elements that may enable host defense success.

Scholarly Activity Requirements for Critical Care Fellowship Program Directors: What Should It Be? How Should We Measure it?

Abstract: s/presentations/ posters No. of abstracts, posters, and presentations given at international, national, or regional meetings Other presentations No. of other presentations given (grand rounds and invited professorships), materials developed, or other work presented in non–peer-review publication, including peer reviewed but not recognized by NLM Chapters No. of chapters or textbooks published Grants No. of grants for which faculty member had leadership role (principal investigator, coprincipal investigator, or site director) Leadership role Had an active leadership role (such as serving on committees or governing boards in national medical organizations or served as a reviewer or an editorial board member for a peer-reviewed journal Education leadership/ materials Held teaching responsibility for seminar, conference series, or course coordination (such as arrangement of materials and assessment of participants’ performance) for any didactic training within the sponsoring institution or program (note: this is not a single presentation or lecture) NLM = National Library of Medicine.