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Browsing by Author "Williams, Mark"
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Item Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial(Elsevier, 2020) Douglas, Ivor S.; Alapat, Philip M.; Corl, Keith A.; Exline, Matthew C.; Forni, Lui G.; Holder, Andre L.; Kaufman, David A.; Khan, Akram; Levy, Mitchell M.; Martin, Gregory S.; Sahatjian, Jennifer A.; Seeley, Eric; Self, Wesley H.; Weingarten, Jeremy A.; Williams, Mark; Hansell, Douglas M.; Medicine, School of MedicineBackground: Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. Research question: Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes? Study design and methods: We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first. Results: In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37 L favoring the intervention arm; 0.65 ± 2.85 L intervention arm vs 2.02 ± 3.44 L usual care arm; P = .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P = .04) or mechanical ventilation (17.7% vs 34.1%; P = .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals. Interpretation: Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care.Item International Normalized Ratio Relevance to the Observed Coagulation Abnormalities in Warfarin Treatment and Disseminated Intravascular Coagulation(SAGE Publications, 2018-10-01) Walborn, Amanda; Williams, Mark; Fareed, Jawed; Hoppensteadt, Debra; Medicine, School of MedicineThe development of coagulation abnormalities is common in patients with sepsis. Sepsis-associated coagulopathy (SAC) is typically diagnosed by prothrombin time (PT) prolongation or elevated international normalized ratio (INR) in conjunction with reduced platelet count. INR is also used to monitor warfarin-treated patients. However, due to the different natures of SAC and warfarin anticoagulation, it is likely that the same INR value provides different information in these two patient populations. The purpose of this study was to compare measures of coagulation function and clotting factor levels in patients with SAC to those observed in patients receiving warfarin anticoagulation. Deidentified plasma samples were collected at baseline from patients diagnosed with SAC and from patients receiving warfarin. These plasma samples were evaluated for PT/INR, activated partial thromboplastin time (aPTT), fibrinogen, and functional and immunologic levels of factors VII, IX, and X. Both aPTT and fibrinogen correlated with INR in patients with SAC, but not in patients treated with warfarin. Factors VII, IX, and X showed an inverse relationship with INR in the anticoagulated patients; however, no relationship between factor level and INR was observed in patients with SAC. Distinct patterns of coagulopathy were observed in patients with SAC and patients receiving warfarin anticoagulation, and equivalent INR values were associated with distinct coagulation profiles in the two patient groups. These results suggest that an abnormal INR provides different information about the coagulation status in patients with disseminated intravascular coagulation than in patients receiving warfarin. This may indicate that an equivalently increased INR predicts different bleeding risks in these two patient groups.Item Novel Presentation of Pulmonary Atypical Carcinoid Tumor as Acute Pancreatitis(Cureus Inc, 2020-10) Bharat, Anchit; Duncan, Francesca; Williams, Mark; Medicine, School of MedicinePulmonary neuroendocrine tumors (NETs) are a group of rare tumors that pose a high financial burden on patients and the United States healthcare system. The usual presenting symptoms include cough or wheezing, hemoptysis, or chest pain. Due to bronchial obstruction, patients may also present with recurrent pneumonia. Acute pancreatitis has yet to be documented as the initial manifestation of this disease. Atypical carcinoids - a subtype of NETs - are heterogeneous regarding their site of origin, biological behavior, and malignant potential. Studies show that the most common primary tumor site varies by race, with the lung being the most common in white patients and the rectum being the most common in Asian/Pacific Islander, American Indian/Alaskan Native, and African American patients. Certain carcinoid tumors, such as those of the rectum, are over-represented among the Black and Asian populations within the United States, suggesting the role of genetics in the development of this intriguing disease. Furthermore, the pancreas is not a usual site of metastasis for primary lung NET. Our case study describes the rare occurrence of a primary pulmonary NET (atypical carcinoid) metastasizing to the pancreas and presenting as acute pancreatitis.