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Papers by Mazen Yazan Kherallah

Annals of Pharmacotherapy, Mar 20, 2014

Objective: To evaluate the available evidence regarding the efficacy and safety of rifampicin, as... more Objective: To evaluate the available evidence regarding the efficacy and safety of rifampicin, as adjunct to colistin, in the treatment of multidrug resistant Acinetobacter baumannii (MDR-AB). Data Sources: We searched MEDLINE (1966 to January 2014) using the following search terms: A baumannii, drug resistance, treatment, colistin, and rifampicin and combinations. In addition, the bibliographies of relevant articles were searched for additional citations. Study Selection and Data Extraction: The search was limited to English-language references and adults. Studies in which colistin was not administered intravenously were excluded. In addition, we excluded meeting abstracts and single case reports. Data Synthesis: The search strategy identified 5 observational studies and 2 randomized controlled trials that evaluated the combination of intravenous colistin and rifampicin for the treatment of MDR-AB. All observational studies included a small sample size, and the microbiological clearance associated with the combination therapy ranged from 60% to 100%. The randomized controlled trials reported reduced time to microbiological clearance and higher microbiological eradication rate in the colistin/rifampicin group compared with colistin alone. However, there was no difference between both groups in the overall mortality, infection-related mortality, and the length of stay. Furthermore, rifampicin was associated with a higher incidence of hepatotoxicity. Conclusions: Studies evaluating the combination of rifampicin and colistin in the treatment of MDR-AB are limited. The currently available evidence does not support the addition of rifampicin to colistin because of the lack of improved clinical outcomes with the combination therapy and the risk of rifampicin-induced hepatotoxicity.

Avicenna journal of medicine, Jul 1, 2012

Annals of the American Thoracic Society, Feb 1, 2016

The Syrian crisis, now in its fifth year, has created an unprecedented strain on health services ... more The Syrian crisis, now in its fifth year, has created an unprecedented strain on health services and systems due to the protracted nature of the warfare, the targeting of medics and health care infrastructure, the exodus of physicians and nurses, the shortage of medical supplies and medications, and the disruption of medical education and training. Within a few short years, the life expectancy of resident Syrians has declined by 20 years. Over the first 4 years of the conflict, more than 75,000 civilians died from injuries incurred in the violence. More than twice as many civilians, including many women and children, have died prematurely of infectious and noninfectious chronic diseases for want of adequate health care. Doctors, local administrators, and nongovernmental organizations are struggling to manage the consequences of the conflict under substandard conditions, often using unorthodox methods of health care delivery in field hospitals and remotely by telehealth communication. Much-needed medical supplies are channeled through dangerous routes across the borders from Lebanon, Jordan, and Turkey. Physicians in the United States and other western nations have helped Syrian physicians make the most of the situation by providing training on introducing innovations in technology and treatment. Portable ultrasound machines have been introduced and are being used extensively in the management of trauma and shock. This report, prepared by members of the Syrian American Medical Society, documents current needs for health care relief within Syria, focusing on pulmonary, critical care, and sleep medicine, and some of the efforts currently underway to meet those needs.

Avicenna journal of medicine, Apr 1, 2012

Critical Care Medicine, 2018

Anaesthesia, 2007

PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in pat... more PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in patients with severe sepsis.

HFOV is a rescue mode of ventilation. Our objective was to assess usage and mortality predictors ... more HFOV is a rescue mode of ventilation. Our objective was to assess usage and mortality predictors of HFOV. Observational study of ARDS patients, with data extracted from an ICU database. Analysis was carried out using SPSS version 20.0. Of 136 ARDS patients, 29.4% (40) were placed on HFOV. Use of HFOV correlated with age (38.7±14.8 vs 49.7±19.4 years, p=0.002, 95% CI 4.2, 17.8) and pulmonary insults (Chi 2 value 44.3, p<0.001). Earlier placement was associated with levels of support on conventional ventilation (PIP-0.343, p=0.029, PEEP-0.322, p=0.043, FiO2-0.404, p=0.010, tidal volumes-0.4, p=0.009). ICU mortality was 58.8% (80) with 53% in patients on conventional ventilation and 72.5% (29) in patients on HFOV. Multivariate regression identifi ed APACHE IV (score≤70 OR 0.97, 95% CI 0.96, 0.98, p<0.001) and use of HFOV (OR 2.4, 95% CI 1.05, 5.5, p=0.038) as independent predictors of mortality. Baseline PaO2/FiO2 ratio (p=0.006), concurrent iNO (p=0.001), tidal volumes on conventional ventilation (p=0.016) and improved oxygenation (p=0.001) correlated signifi cantly with survival. HFOV is associated with increased ICU mortality in patients with ARDS.

Critical Care, 2009

Introduction There is considerable uncertainty about the reproducibility of the various instrumen... more Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Chest, Oct 1, 2008

... RATIOS OF ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II AND IV SCORING SYSTEMS. ... more ... RATIOS OF ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II AND IV SCORING SYSTEMS. Mazen Kherallah, MD*, Talal Dahhan, MBBS, Mouhamad G. Jamil, MD, Nabil Abouchala, MD and Ashraf Al-tarifi, MD King Faisal Specialist Hospital And ...

Chest, Oct 1, 2008

PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in pat... more PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in patients with severe sepsis.

Introduction Mortality rates from severe sepsis /shock have declined with implementation of the S... more Introduction Mortality rates from severe sepsis /shock have declined with implementation of the Surviving Sepsis Guidelines in the western world. Unfortunately, lesser developed countries continue to exhibit high death rates. We hypothesized that this is because of poor adherence to the guidelines and we carried out this study to determine compliance and to identify variables that relate to improved compliance. Materials and Methods Critical care providers were asked to fill out a survey instrument designed to assess compliance with the 2012 Surviving Sepsis Guidelines. Providers from countries located in the Eastern Mediterranean Region were sampled. The study protocol was approved by the Hospital Research Ethics committee. Results 175 responses from 11 countries were received; 95 high-income (Saudi Arabia, Bahrain), 8 mid-income (Lebanon, Jordan, Turkey, Iran, Libya), 72 low-income (Pakistan, Syria, West Bank & Gaza, Sudan). Compliance with the Resuscitation bundle was 66% and 47% with the Management bundle. Amongst the individual components, 84% (148) routinely measured lactate, 51% (89) give antibiotics within the first hour of sepsis, 36% (64) measure procalcitonin, 7% (12) routinely use colloidal fluids for resuscitation. 32% (56) do not use lung protective ventilation for patients with acute respiratory distress syndrome and 22% (39) use no stress ulcer prophylaxis. Compliance was significantly associated with 24 hour intensivist coverage, p=0.004; 1:1 nurse: patient ratio, p= 0.000; a rapid response service, p=0.001 and routine measurement of critical care performance indicators, p=0.029. Conclusion Poor compliance with key recommendations may be responsible for the continued high mortality observed from severe sepsis and shock in these countries. Any effort to improve outcomes will need to address these knowledge and practice deficiencies.

Critical Care, 2009

Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon d... more Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon dioxide during respiratory distress in field emergency care D Lain, S Bourn P7 Cardiogenic oscillations extracted from spontaneous breathing airway pressure and flow signal are related to chest wall motility and continuous positive airway pressure

Critical Care, 2009

Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon d... more Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon dioxide during respiratory distress in field emergency care D Lain, S Bourn P7 Cardiogenic oscillations extracted from spontaneous breathing airway pressure and flow signal are related to chest wall motility and continuous positive airway pressure

CHEST Journal, 2008

PURPOSE:Our ICU bloodstream infection (BSI) rates were hovering at the National Nosocomial Infect... more PURPOSE:Our ICU bloodstream infection (BSI) rates were hovering at the National Nosocomial Infection Surveillance (NNIS) 50th percentile (3-7.2) infections per 1,000 CVC days from January through June 2006; necessitating a performance improvement (PI) initiative designated to decrease the incidence of BSI.

Critical Care, 2009

Introduction There is considerable uncertainty about the reproducibility of the various instrumen... more Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Avicenna Journal of Medicine, 2012

Avicenna Journal of Medicine, 2012

Avicenna Journal of Medicine, 2012

Objective: Implementation of ventilator associated pneumonia (VAP) bundle as a performance improv... more Objective: Implementation of ventilator associated pneumonia (VAP) bundle as a performance improvement project in the critical care units for all mechanically ventilated patients aiming to decrease the VAP rates. Materials and Methods: VAP bundle was implemented in 4 teaching hospitals after educational sessions and compliance rates along with VAP rates were monitored using statistical process control charts. Results: VAP bundle compliance rates were steadily increasing from 33 to 80% in hospital 1, from 33 to 86% in hospital 2 and from 83 to 100% in hospital 3 during the study period. The VAP bundle was not applied in hospital 4 therefore no data was available. A target level of 95% was reached only in hospital 3. This correlated with a decrease in VAP rates from 30 to 6.4 per 1000 ventilator days in hospital 1, from 12 to 4.9 per 1000 ventilator days in hospital 3, whereas VAP rate failed to decrease in hospital 2 (despite better compliance) and it remained high around 33 per 1000...

Journal of Critical Care, 2010

Because the pharmacies continue to stock and dispense mainly those medicines (branded and/or gene... more Because the pharmacies continue to stock and dispense mainly those medicines (branded and/or generic) that are more profitable for them, a new policy should be applied to control the dispensing pattern. 2. To overcome the limited patient choice and escalating drug expenditure, reference pricing is one of the recommended solutions.

Annals of Pharmacotherapy, Mar 20, 2014

Objective: To evaluate the available evidence regarding the efficacy and safety of rifampicin, as... more Objective: To evaluate the available evidence regarding the efficacy and safety of rifampicin, as adjunct to colistin, in the treatment of multidrug resistant Acinetobacter baumannii (MDR-AB). Data Sources: We searched MEDLINE (1966 to January 2014) using the following search terms: A baumannii, drug resistance, treatment, colistin, and rifampicin and combinations. In addition, the bibliographies of relevant articles were searched for additional citations. Study Selection and Data Extraction: The search was limited to English-language references and adults. Studies in which colistin was not administered intravenously were excluded. In addition, we excluded meeting abstracts and single case reports. Data Synthesis: The search strategy identified 5 observational studies and 2 randomized controlled trials that evaluated the combination of intravenous colistin and rifampicin for the treatment of MDR-AB. All observational studies included a small sample size, and the microbiological clearance associated with the combination therapy ranged from 60% to 100%. The randomized controlled trials reported reduced time to microbiological clearance and higher microbiological eradication rate in the colistin/rifampicin group compared with colistin alone. However, there was no difference between both groups in the overall mortality, infection-related mortality, and the length of stay. Furthermore, rifampicin was associated with a higher incidence of hepatotoxicity. Conclusions: Studies evaluating the combination of rifampicin and colistin in the treatment of MDR-AB are limited. The currently available evidence does not support the addition of rifampicin to colistin because of the lack of improved clinical outcomes with the combination therapy and the risk of rifampicin-induced hepatotoxicity.

Avicenna journal of medicine, Jul 1, 2012

Annals of the American Thoracic Society, Feb 1, 2016

The Syrian crisis, now in its fifth year, has created an unprecedented strain on health services ... more The Syrian crisis, now in its fifth year, has created an unprecedented strain on health services and systems due to the protracted nature of the warfare, the targeting of medics and health care infrastructure, the exodus of physicians and nurses, the shortage of medical supplies and medications, and the disruption of medical education and training. Within a few short years, the life expectancy of resident Syrians has declined by 20 years. Over the first 4 years of the conflict, more than 75,000 civilians died from injuries incurred in the violence. More than twice as many civilians, including many women and children, have died prematurely of infectious and noninfectious chronic diseases for want of adequate health care. Doctors, local administrators, and nongovernmental organizations are struggling to manage the consequences of the conflict under substandard conditions, often using unorthodox methods of health care delivery in field hospitals and remotely by telehealth communication. Much-needed medical supplies are channeled through dangerous routes across the borders from Lebanon, Jordan, and Turkey. Physicians in the United States and other western nations have helped Syrian physicians make the most of the situation by providing training on introducing innovations in technology and treatment. Portable ultrasound machines have been introduced and are being used extensively in the management of trauma and shock. This report, prepared by members of the Syrian American Medical Society, documents current needs for health care relief within Syria, focusing on pulmonary, critical care, and sleep medicine, and some of the efforts currently underway to meet those needs.

Avicenna journal of medicine, Apr 1, 2012

Critical Care Medicine, 2018

Anaesthesia, 2007

PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in pat... more PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in patients with severe sepsis.

HFOV is a rescue mode of ventilation. Our objective was to assess usage and mortality predictors ... more HFOV is a rescue mode of ventilation. Our objective was to assess usage and mortality predictors of HFOV. Observational study of ARDS patients, with data extracted from an ICU database. Analysis was carried out using SPSS version 20.0. Of 136 ARDS patients, 29.4% (40) were placed on HFOV. Use of HFOV correlated with age (38.7±14.8 vs 49.7±19.4 years, p=0.002, 95% CI 4.2, 17.8) and pulmonary insults (Chi 2 value 44.3, p<0.001). Earlier placement was associated with levels of support on conventional ventilation (PIP-0.343, p=0.029, PEEP-0.322, p=0.043, FiO2-0.404, p=0.010, tidal volumes-0.4, p=0.009). ICU mortality was 58.8% (80) with 53% in patients on conventional ventilation and 72.5% (29) in patients on HFOV. Multivariate regression identifi ed APACHE IV (score≤70 OR 0.97, 95% CI 0.96, 0.98, p<0.001) and use of HFOV (OR 2.4, 95% CI 1.05, 5.5, p=0.038) as independent predictors of mortality. Baseline PaO2/FiO2 ratio (p=0.006), concurrent iNO (p=0.001), tidal volumes on conventional ventilation (p=0.016) and improved oxygenation (p=0.001) correlated signifi cantly with survival. HFOV is associated with increased ICU mortality in patients with ARDS.

Critical Care, 2009

Introduction There is considerable uncertainty about the reproducibility of the various instrumen... more Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Chest, Oct 1, 2008

... RATIOS OF ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II AND IV SCORING SYSTEMS. ... more ... RATIOS OF ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II AND IV SCORING SYSTEMS. Mazen Kherallah, MD*, Talal Dahhan, MBBS, Mouhamad G. Jamil, MD, Nabil Abouchala, MD and Ashraf Al-tarifi, MD King Faisal Specialist Hospital And ...

Chest, Oct 1, 2008

PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in pat... more PURPOSE: Determination of the APACHE IV score that is associated with higher risk of death in patients with severe sepsis.

Introduction Mortality rates from severe sepsis /shock have declined with implementation of the S... more Introduction Mortality rates from severe sepsis /shock have declined with implementation of the Surviving Sepsis Guidelines in the western world. Unfortunately, lesser developed countries continue to exhibit high death rates. We hypothesized that this is because of poor adherence to the guidelines and we carried out this study to determine compliance and to identify variables that relate to improved compliance. Materials and Methods Critical care providers were asked to fill out a survey instrument designed to assess compliance with the 2012 Surviving Sepsis Guidelines. Providers from countries located in the Eastern Mediterranean Region were sampled. The study protocol was approved by the Hospital Research Ethics committee. Results 175 responses from 11 countries were received; 95 high-income (Saudi Arabia, Bahrain), 8 mid-income (Lebanon, Jordan, Turkey, Iran, Libya), 72 low-income (Pakistan, Syria, West Bank & Gaza, Sudan). Compliance with the Resuscitation bundle was 66% and 47% with the Management bundle. Amongst the individual components, 84% (148) routinely measured lactate, 51% (89) give antibiotics within the first hour of sepsis, 36% (64) measure procalcitonin, 7% (12) routinely use colloidal fluids for resuscitation. 32% (56) do not use lung protective ventilation for patients with acute respiratory distress syndrome and 22% (39) use no stress ulcer prophylaxis. Compliance was significantly associated with 24 hour intensivist coverage, p=0.004; 1:1 nurse: patient ratio, p= 0.000; a rapid response service, p=0.001 and routine measurement of critical care performance indicators, p=0.029. Conclusion Poor compliance with key recommendations may be responsible for the continued high mortality observed from severe sepsis and shock in these countries. Any effort to improve outcomes will need to address these knowledge and practice deficiencies.

Critical Care, 2009

Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon d... more Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon dioxide during respiratory distress in field emergency care D Lain, S Bourn P7 Cardiogenic oscillations extracted from spontaneous breathing airway pressure and flow signal are related to chest wall motility and continuous positive airway pressure

Critical Care, 2009

Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon d... more Quality assurance report on the use of continuous positive airway pressure and end-tidal carbon dioxide during respiratory distress in field emergency care D Lain, S Bourn P7 Cardiogenic oscillations extracted from spontaneous breathing airway pressure and flow signal are related to chest wall motility and continuous positive airway pressure

CHEST Journal, 2008

PURPOSE:Our ICU bloodstream infection (BSI) rates were hovering at the National Nosocomial Infect... more PURPOSE:Our ICU bloodstream infection (BSI) rates were hovering at the National Nosocomial Infection Surveillance (NNIS) 50th percentile (3-7.2) infections per 1,000 CVC days from January through June 2006; necessitating a performance improvement (PI) initiative designated to decrease the incidence of BSI.

Critical Care, 2009

Introduction There is considerable uncertainty about the reproducibility of the various instrumen... more Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Avicenna Journal of Medicine, 2012

Avicenna Journal of Medicine, 2012

Avicenna Journal of Medicine, 2012

Objective: Implementation of ventilator associated pneumonia (VAP) bundle as a performance improv... more Objective: Implementation of ventilator associated pneumonia (VAP) bundle as a performance improvement project in the critical care units for all mechanically ventilated patients aiming to decrease the VAP rates. Materials and Methods: VAP bundle was implemented in 4 teaching hospitals after educational sessions and compliance rates along with VAP rates were monitored using statistical process control charts. Results: VAP bundle compliance rates were steadily increasing from 33 to 80% in hospital 1, from 33 to 86% in hospital 2 and from 83 to 100% in hospital 3 during the study period. The VAP bundle was not applied in hospital 4 therefore no data was available. A target level of 95% was reached only in hospital 3. This correlated with a decrease in VAP rates from 30 to 6.4 per 1000 ventilator days in hospital 1, from 12 to 4.9 per 1000 ventilator days in hospital 3, whereas VAP rate failed to decrease in hospital 2 (despite better compliance) and it remained high around 33 per 1000...

Journal of Critical Care, 2010

Because the pharmacies continue to stock and dispense mainly those medicines (branded and/or gene... more Because the pharmacies continue to stock and dispense mainly those medicines (branded and/or generic) that are more profitable for them, a new policy should be applied to control the dispensing pattern. 2. To overcome the limited patient choice and escalating drug expenditure, reference pricing is one of the recommended solutions.