Clinical Assistant Professor, Neurology & Neurological Sciences
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Current research interest is stroke recovery, including use of virtual reality and robotics for post-stroke rehabilitation.
To describe practices for preventing venous thromboembolism in critically ill medical patients and to identify associations between prophylactic measures and survival.We reviewed the records of all medical admissions to the intensive care units of a university hospital and an affiliated Veterans Affairs hospital over a 1-year period. We recorded patients' demographic characteristics, risk factors for venous thromboembolism, methods of prophylaxis, and in-hospital deaths.We identified 272 critically ill medical patients who received intensive care for at least 24 hours. Some form of prophylaxis was used in 205 patients (75%), including pharmacologic prophylaxis alone in 55 (20%), mechanical prophylaxis alone in 102 (38%), and both methods in 48 (18%). In-hospital mortality rates were 23% (24/103) for patients who received pharmacologic prophylaxis, and 36% (61/169) for those who received mechanical prophylaxis alone or no prophylaxis (P=.03). After adjusting for demographic characteristics, risk factors for thrombosis and severity of illness, the odds of death were 55% lower in patients who received pharmacologic prophylaxis (odds ratio [OR]=0.45; 95% confidence interval (CI): 0.22 to 0.93; P=.03). Similar results were obtained in propensity-adjusted and propensity-stratified analyses. Use of mechanical prophylaxis was not associated with survival (OR=0.88; 95% CI 0.44 to 1.77; P=.73).In this cohort of critically ill medical patients, pharmacologic but not mechanical thromboprophylaxis was associated with reduced risk of in-hospital death. This hypothesis must be tested in randomized trials.
View details for DOI 10.1016/j.amjmed.2005.12.025
View details for Web of Science ID 000234157700013
View details for PubMedID 16378781
To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients.Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU.The medical-surgical ICUs of two teaching hospitals.Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group.Implementation of an evidence-based ICU nutritional management protocol.Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (+/- SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 +/- 31.3 vs 11.2 +/- 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007).An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.
View details for Web of Science ID 000221793700042
View details for PubMedID 15078758
To describe the variation in clinical practice strategies for the treatment of suspected ventilator-associated pneumonia (VAP) in a population of critically ill patients, and to determine whether initial empiric treatment with certain antibiotics, monotherapy vs combination antibiotic therapy, or appropriate vs inappropriate antibiotic therapy is associated with survival, length of hospital stay, or days free of antibiotics.Prospective, observational cohort study.Medical-surgical ICUs of two university-affiliated tertiary medical centers.Between May 1, 1998, and August 1, 2000, we screened 7,030 ICU patients and identified 156 patients with clinically suspected VAP. Patients were followed up until death or discharge from the hospital.The mean age was 62 years, mean APACHE (acute physiology and chronic health evaluation) II score was 14, and mortality was 34%. Combination antibiotic therapy was used in 53% of patients. Piperacillin-tazobactam, fluoroquinolones, vancomycin, cephalosporins, and aminoglycosides were the most commonly employed antibiotics. Initial empiric antibiotics were deemed appropriate in 92% of patients. The predominant organisms isolated from respiratory secretions included Pseudomonas aeruginosa and Staphylococcus aureus. Patients had lower in-hospital mortality rates if their initial treatment regimen included an antipseudomonal penicillin plus beta-lactamase inhibitor (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.21 to 0.80; p = 0.009). There was also a strong trend toward reduced mortality rates in patients treated with aminoglycosides (HR, 0.43; 95% CI, 0.16 to 1.11; p = 0.08). Specific antibiotic therapy was not associated with length of hospital stay or days free of antibiotics. Outcomes were similar for patients treated with monotherapy vs combination therapy, and for patients who received initial appropriate vs inappropriate therapy.Patients with clinically suspected VAP who receive initial empiric therapy with antipseudomonal penicillins plus beta-lactamase inhibitors, and possibly aminoglycosides, have lower in-hospital mortality rates when compared with those who are not treated with these antibiotics. These agents should be considered for the initial empiric therapy of VAP.
View details for Web of Science ID 000181536500035
View details for PubMedID 12628886