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The Case | Euglycemic ketoacidosis in a patient on continuous renal replacement therapy

Stevens, Jacob S; Salazar-Schicchi, John; Radhakrishnan, Jai; Mohan, Sumit
PMID: 34023035
ISSN: 1523-1755
CID: 4887372

Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study

Cummings, Matthew J; Baldwin, Matthew R; Abrams, Darryl; Jacobson, Samuel D; Meyer, Benjamin J; Balough, Elizabeth M; Aaron, Justin G; Claassen, Jan; Rabbani, LeRoy E; Hastie, Jonathan; Hochman, Beth R; Salazar-Schicchi, John; Yip, Natalie H; Brodie, Daniel; O'Donnell, Max R
BACKGROUND:Over 40 000 patients with COVID-19 have been hospitalised in New York City (NY, USA) as of April 28, 2020. Data on the epidemiology, clinical course, and outcomes of critically ill patients with COVID-19 in this setting are needed. METHODS:This prospective observational cohort study took place at two NewYork-Presbyterian hospitals affiliated with Columbia University Irving Medical Center in northern Manhattan. We prospectively identified adult patients (aged ≥18 years) admitted to both hospitals from March 2 to April 1, 2020, who were diagnosed with laboratory-confirmed COVID-19 and were critically ill with acute hypoxaemic respiratory failure, and collected clinical, biomarker, and treatment data. The primary outcome was the rate of in-hospital death. Secondary outcomes included frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal replacement therapy, and time to in-hospital clinical deterioration following admission. The relation between clinical risk factors, biomarkers, and in-hospital mortality was modelled using Cox proportional hazards regression. Follow-up time was right-censored on April 28, 2020 so that each patient had at least 28 days of observation. FINDINGS/RESULTS:Between March 2 and April 1, 2020, 1150 adults were admitted to both hospitals with laboratory-confirmed COVID-19, of which 257 (22%) were critically ill. The median age of patients was 62 years (IQR 51-72), 171 (67%) were men. 212 (82%) patients had at least one chronic illness, the most common of which were hypertension (162 [63%]) and diabetes (92 [36%]). 119 (46%) patients had obesity. As of April 28, 2020, 101 (39%) patients had died and 94 (37%) remained hospitalised. 203 (79%) patients received invasive mechanical ventilation for a median of 18 days (IQR 9-28), 170 (66%) of 257 patients received vasopressors and 79 (31%) received renal replacement therapy. The median time to in-hospital deterioration was 3 days (IQR 1-6). In the multivariable Cox model, older age (adjusted hazard ratio [aHR] 1·31 [1·09-1·57] per 10-year increase), chronic cardiac disease (aHR 1·76 [1·08-2·86]), chronic pulmonary disease (aHR 2·94 [1·48-5·84]), higher concentrations of interleukin-6 (aHR 1·11 [95%CI 1·02-1·20] per decile increase), and higher concentrations of D-dimer (aHR 1·10 [1·01-1·19] per decile increase) were independently associated with in-hospital mortality. INTERPRETATION/CONCLUSIONS:Critical illness among patients hospitalised with COVID-19 in New York City is common and associated with a high frequency of invasive mechanical ventilation, extrapulmonary organ dysfunction, and substantial in-hospital mortality. FUNDING/BACKGROUND:National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, National Institutes of Health, and the Columbia University Irving Institute for Clinical and Translational Research.
PMID: 32442528
ISSN: 1474-547x
CID: 4444752

Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study

Cummings, Matthew J; Baldwin, Matthew R; Abrams, Darryl; Jacobson, Samuel D; Meyer, Benjamin J; Balough, Elizabeth M; Aaron, Justin G; Claassen, Jan; Rabbani, LeRoy E; Hastie, Jonathan; Hochman, Beth R; Salazar-Schicchi, John; Yip, Natalie H; Brodie, Daniel; O'Donnell, Max R
BACKGROUND:Nearly 30,000 patients with coronavirus disease-2019 (COVID-19) have been hospitalized in New York City as of April 14th, 2020. Data on the epidemiology, clinical course, and outcomes of critically ill patients with COVID-19 in this setting are needed. METHODS:We prospectively collected clinical, biomarker, and treatment data on critically ill adults with laboratory-confirmed-COVID-19 admitted to two hospitals in northern Manhattan between March 2nd and April 1st, 2020. The primary outcome was in-hospital mortality. Secondary outcomes included frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal-replacement-therapy, and time to clinical deterioration following hospital admission. The relationship between clinical risk factors, biomarkers, and in-hospital mortality was modeled using Cox-proportional-hazards regression. Each patient had at least 14 days of observation. RESULTS:Of 1,150 adults hospitalized with COVID-19 during the study period, 257 (22%) were critically ill. The median age was 62 years (interquartile range [IQR] 51-72); 170 (66%) were male. Two-hundred twelve (82%) had at least one chronic illness, the most common of which were hypertension (63%; 162/257) and diabetes mellitus (36%; 92/257). One-hundred-thirty-eight patients (54%) were obese, and 13 (5%) were healthcare workers. As of April 14th, 2020, in-hospital mortality was 33% (86/257); 47% (122/257) of patients remained hospitalized. Two-hundred-one (79%) patients received invasive mechanical ventilation (median 13 days [IQR 9-17]), and 54% (138/257) and 29% (75/257) required vasopressors and renal-replacement-therapy, respectively. The median time to clinical deterioration following hospital admission was 3 days (IQR 1-6). Older age, hypertension, chronic lung disease, and higher concentrations of interleukin-6 and d-dimer at admission were independently associated with in-hospital mortality. CONCLUSIONS:Critical illness among patients hospitalized with COVID-19 in New York City is common and associated with a high frequency of invasive mechanical ventilation, extra-pulmonary organ dysfunction, and substantial in-hospital mortality.
PMID: 32511638
ISSN: n/a
CID: 4477932

Association of patient-provider communication domains with lung cancer treatment

Lin, Jenny J; Lake, Jessica; Wall, Melanie M; Berman, Andrew R; Salazar-Schicchi, John; Powell, Charles; Keller, Steven M; Halm, Ethan A; Leventhal, Howard; Wisnivesky, Juan P
BACKGROUND: Patient-physician communication is critical for helping patients understand and complete the complex steps needed to diagnose stage and treat lung cancer. We assessed which domains of patient-physician communication about lung cancer and its treatment are associated with receipt of disease-directed, stage-appropriate treatment. METHODS: Patients with recently diagnosed lung cancer were recruited from four medical centers in New York City from 2008 to 2011. Participants were surveyed about discussions with physicians regarding treatment, symptoms, and needs. Multiple regression analysis and structural equation modeling were used to assess which communication factors were associated with disease treatment. RESULTS: Of the 352 participants, 191 (54%) received disease-directed, stage-appropriate treatment. Unadjusted associations between communication items and treatment found that participants who felt that their physicians explained the risks and disadvantages of lung cancer treatment (p < 0.01), discussed their chances of cure (p = 0.02), discussed goals of treatment (p < 0.01), or who were warm and friendly (p = 0.04) were more likely to undergo treatment. Three communication domains were identified: treatment information, physician support, and patient symptoms/needs. After adjusting for known determinants of lung cancer treatment, increased treatment information was associated with higher probability of cancer-directed treatment (p = 0.003). Other communication domains (physician support or patient symptoms/needs) were not independent predictors of treatment (p > 0.05 for both comparisons). CONCLUSION: These data suggest that treatment information is particularly important for increasing the probability of cancer-directed therapy among lung cancer patients. Clinicians should ensure that they clearly discuss treatment goals and options with patients while maintaining empathy, supporting patient needs, and addressing symptoms.
PMCID:4133738
PMID: 25122421
ISSN: 1556-0864
CID: 1141882

Cultural Factors Associated with Racial Disparities in Lung Cancer Care

Lin, Jenny J; Mhango, Grace; Wall, Melanie M; Lurslurchachai, Linda; Bond, Keosha T; Nelson, Judith E; Berman, Andrew R; Salazar-Schicchi, John; Powell, Charles; Keller, Steven M; Halm, Ethan A; Leventhal, Howard; Wisnivesky, Juan P
Rationale: Minority patients with lung cancer are less likely to receive stage-appropriate treatment. Along with access to care and provider factors, cultural factors such as patients' lung cancer beliefs, fatalism, and medical mistrust, may help explain this disparity. Objectives: To determine cultural factors associated with disparities in lung cancer treatment. Methods: Patients with newly-diagnosed lung cancer were recruited from four medical centers in New York City from 2008 to 2011. Participants were surveyed about their beliefs regarding lung cancer, fatalism, and medical mistrust using validated tools. Rates of stage-appropriate treatment were compared among blacks, Hispanics and non-minority patients. Multiple regression analyses and structural equation modeling were used to assess if cultural factors are associated with or mediate disparities in care. Measurements and Main Results: Of the 352 lung cancer patients in the study, 21% were black and 20% were Hispanic. Blacks were less likely to receive stage-appropriate treatment (odds ratio [OR]: 0.50, 95% confidence interval [CI]: 0.27-0.93) compared with whites, even after adjusting for age, gender, marital status, insurance, income, comorbidities and performance status. No differences in treatment rates were observed among Hispanics (OR: 1.05, 95% CI: 0.53-2.07). Structural equation modeling showed that cultural factors (negative surgical beliefs, fatalism and medical mistrust) partially mediated the relationship between black race and lower rates of stage-appropriate treatment (total effect -0.43, indirect effect = -0.13, 30% of total effect explained by cultural factors). Conclusions: Negative surgical beliefs, fatalism, and mistrust are more prevalent among minorities and appear to explain almost a third of the observed disparities in lung cancer treatment among black patients. Interventions targeting cultural factors may help reduce undertreatment of minorities.
PMCID:5469392
PMID: 24701981
ISSN: 2325-6621
CID: 890612

Racial and ethnic differences in beliefs about lung cancer care

Jonnalagadda, Sirisha; Lin, Jenny J; Nelson, Judith E; Powell, Charles A; Salazar-Schicchi, John; Berman, Andrew R; Keller, Steven M; Smith, Cardinale B; Lurslurchachai, Linda; Halm, Ethan A; Leventhal, Howard; Wisnivesky, Juan P
BACKGROUND: Disparities in lung cancer treatment and palliative care are well documented. However,the mechanisms underlying these disparities are not fully understood. In this study, we evaluated racial and ethnic differences in beliefs and attitudes about lung cancer treatment and palliative care among patients receiving a new diagnosis of lung cancer. METHODS: Patients were recruited from four medical centers in New York City and surveyed about their beliefs regarding lung cancer care, including disease-directed treatments, palliative and end-of-life care, and fatalistic and spiritual beliefs. We used univariate and multiple regression analyses to compare the distribution of beliefs among minority (black and Hispanic) and nonminority patients. RESULTS: Of the 335 patients, 21% were black, 20% were Hispanic, and 59% were nonminority. Beliefs about chemotherapy and radiotherapy were similar across the three groups ( P > .05),whereas black patients were more likely to believe that surgery might cause lung cancer to spread( P =.008). Fatalistic beliefs potentially affecting cancer treatment were more common among both minority groups ( P .05). However, both blacks and Hispanics were more likely to have misconceptions about advance directives and hospice care ( P
PMCID:3494476
PMID: 22700777
ISSN: 0012-3692
CID: 890602

Combined pulmonary fibrosis and emphysema [Case Report]

Dodda, Venkata R; Salazar-Schicchi, John; Spiro, Peter
PMID: 22004839
ISSN: 0020-1324
CID: 890592

Patients rate physician communication about lung cancer

Nelson, Judith E; Gay, Elizabeth B; Berman, Andrew R; Powell, Charles A; Salazar-Schicchi, John; Wisnivesky, Juan P
BACKGROUND: High-quality lung cancer care includes physician-patient communication about the disease and treatment, patient needs/preferences, and care goals. In this study, the authors evaluated communication with patients at all stages across multiple topics. METHODS: A standardized questionnaire asked patients with lung cancer to rate (on 5-point, verbal descriptor scale) the extent of communication with physicians on symptoms, spiritual concerns, practical needs, proxy appointment, living will preparation, prognosis, care goals, potential complications of therapy, life support preferences, and hospice. Communication was defined as inadequate if the patient reported discussing >/=5 of 11 questionnaire topics "not at all" or "a little bit." Multivariate logistic regression was used to evaluate the factors associated with inadequate communication. RESULTS: In total, 276 of 348 (79%) eligible patients were enrolled (mean age [+/-standard deviation], 65 +/- 10 years; 55% white, 21% black, and 19% Hispanic; all disease stages). For most topics, the majority of respondents reported that physicians communicated "not at all" or "a little bit." Low ratings were frequent for discussion of emotional symptoms (56%; 95% confidence interval [CI], 49%-62%), practical needs (71%; 95% CI, 65%-76%), spiritual concerns (80%; 95% CI, 75%-85%), proxy appointment (63%; 95% CI, 57%-69%), living will preparation (90%; 95% CI, 85%-93%), life support preferences (80%; 95% CI, 75%-84%), and hospice (88%; 95% CI, 86%-94%). Communication was inadequate for patients of different ages, stages, and races, although Hispanics were less likely than non-Hispanic whites and blacks to report inadequate communication (odds ratio, 0.31; 95% CI, 0.15-0.65). CONCLUSIONS: Across all stages, patients with lung cancer reported low rates of physician-patient communication on key topics, which may increase patient distress, impair decision-making, and compromise clinical outcomes and use patterns.
PMCID:3267549
PMID: 21495028
ISSN: 0008-543x
CID: 890582

Increasing incidence of mycobacterium xenopi at bellevue hospital : An emerging pathogen or a product of improved laboratory methods? [In Process Citation]

Donnabella V; Salazar-Schicchi J; Bonk S; Hanna B; Rom WN
Study objectives: To investigate the dramatic rise in number of Mycobacterium xenopi isolates identified in our mycobacteriology laboratory, and to determine if this increase was due to emerging clinical pathology or to changes in culture technique. DESIGN: Retrospective chart and laboratory review. SETTING: University-affiliated tertiary-care city hospital. PATIENTS: Eighty-one patients with a single culture positive for M xenopi from 1975 to 1994 (period 1), and 47 patients with two or more cultures positive from 1994 to 1998 (period 2). INTERVENTIONS: The Bellevue mycobacteriology laboratory changed the culture medium from solid Lowenstein-Jensen medium (used from 1975 to 1990) to the Septi-Check AFB System (Becton-Dickinson; Glencoe, MD; used from 1991 to 1994), to the Mycobacteria Growth Indication Tube (MGIT; Becton-Dickinson; used from 1995 to 1998). Measurements and results: We recovered 29 M xenopi isolates from 1975 to 1990, 12 isolates from 1991 to 1994, and 381 isolates from 1995 to 1998. We subsequently identified and reviewed the medical records of all 81 patients who were culture positive for M xenopi from 1975 to 1994 (period 1), and 46 patients who had two or more isolates culture positive for M xenopi from 1995 to 1998 (period 2). For period 1, 75% of the subjects were male, 80% were minority, and at least 43% were HIV positive. Only one patient had clinical M xenopi lung disease during this period. For period 2, 79% of the subjects were male, 83% were minority, and at least 58% were HIV positive; two additional patients were identified who had clinical M xenopi lung disease. CONCLUSIONS: The dramatic increase in M xenopi isolates noted in our hospital was due to a more sensitive laboratory isolation technique, rather than a true increase in clinical disease. Other hospitals utilizing MGIT systems for mycobacterial recovery should interpret positive M xenopi cultures with caution
PMID: 11083687
ISSN: 0012-3692
CID: 15396

Crack-cocaine is a significant risk factor in the development of asthma

Haas, F; Burschtin, O E; Marfatia, A; Dominelli, F; Schicchi, J Salazar
BIOSIS:200100006604
ISSN: 0903-1936
CID: 15777