Rashmi Sahay - Academia.edu (original) (raw)

Papers by Rashmi Sahay

Hospital Pediatrics, 2017

BACKGROUND AND OBJECTIVES: Adoption of clinical respiratory scoring as a quality improvement (QI)... more BACKGROUND AND OBJECTIVES: Adoption of clinical respiratory scoring as a quality improvement (QI) tool in bronchiolitis has been temporally associated with decreased bronchodilator usage. We sought to determine whether documented use of a clinical respiratory score at the patient level was associated with a decrease in either the physician prescription of any dose of bronchodilator or the number of doses, if prescribed, in a multisite QI collaborative. METHODS: We performed a secondary analysis of data from a QI collaborative involving 22 hospitals. The project enrolled patients aged 1 month to 2 years with a primary diagnosis of acute viral bronchiolitis and excluded those with prematurity, other significant comorbid diseases, and those needing intensive care. We assessed for an association between documentation of any respiratory score use during an episode of care, as well as the method in which scores were used, and physician prescribing of any bronchodilator and number of doses...

American Journal of Physiology-Heart and Circulatory Physiology, 2000

Oxidative stress may increase production of superoxide and nitric oxide, leading to formation of ... more Oxidative stress may increase production of superoxide and nitric oxide, leading to formation of prooxidant peroxynitrite to cause vascular dysfunction. Having found nitrotyrosine residues, a marker of peroxynitrite action, in placental vessels of preeclamptic and diabetic pregnancies, we determined whether vasoreactivity is altered in these placentas and treatment with peroxynitrite produces vascular dysfunction. The responses of diabetic, preeclamptic, and normal placentas to increasing concentrations of the vasoconstrictors U-46619 (10− 9–10− 7M) and ANG II (10− 9–10− 7M) and the vasodilators glyceryl trinitrate (10− 9–10− 7M) and prostacyclin (PGI2; 10− 8–10− 6M) were compared as were responses to these agents in normal placentas before and after treatment with 3.16 × 10− 4 M peroxynitrite for 30 min. Responses to both vasoconstrictors and vasodilators were significantly attenuated in diabetic and preeclamptic placentas compared with controls. Similarly, responses to U-46619, ni...

Critical Care Medicine, 2019

Pediatric dentistry, 2021

Purpose: The purpose of this study was to assess changes in medical student knowledge, skills, an... more Purpose: The purpose of this study was to assess changes in medical student knowledge, skills, and beliefs in oral health after participating in an oral health curriculum that included an online learning module, shadowing pediatric dental residents, and applying fluoride varnish. Methods: Third-year medical students completed a precurriculum questionnaire. After completing the online module and clinical experience, students completed a postcurriculum questionnaire. Data were analyzed via descriptive statistics, and outcomes were assessed. Results: There was an improvement in knowledge and oral health-related skills questions postcurriculum. All questions on beliefs toward oral health showed a more agreeable response following the oral health curriculum. Conclusion: Interprofessional collaboration and oral health curriculum integration lead to positively changing the knowledge, attitudes, and skills of medical students.

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2020

INTRODUCTION Simulation is a core aspect of training and assessment; however, simulation laborato... more INTRODUCTION Simulation is a core aspect of training and assessment; however, simulation laboratories are limited in their ability to visually represent mental, respiratory, and perfusion status. Augmented reality (AR) represents a potential adjunct to address this gap. METHODS A prospective, observational pilot of interprofessional simulation assessing a decompensating patient was conducted from April to June 2019. Teams completed 2 simulations: (1) traditional training (TT) using a manikin (Laerdal SimJunior) and (2) AR-enhanced training (ART) using a manikin plus an AR patient. The primary outcome was self-assessed effectiveness at the assessment of patient decompensation. Secondary outcomes were attitudes toward and adverse effects during the AR training. RESULTS Twenty-one simulation sessions included 84 participants in headsets. Participants reported improved ability to assess the patient's mental status, respiratory status, and perfusion status (all P < 0.0001) during ART in comparison to TT. Similar findings were noted for recognition of hypoxemia, shock, apnea, and decompensation (all P ≤ 0.0003) but not for recognition of cardiac arrest (P = 0.06). Most participants agreed or strongly agreed that ART accurately depicted a decompensating patient (89%), reinforced key components of the patient assessment (88%), and will impact how they care for patients (68%). Augmented reality-enhanced training was rated more effective than manikin training and standardized patients and equally as effective as bedside teaching. CONCLUSIONS This novel application of AR to enhance the realism of manikin simulation demonstrated improvement in self-assessed recognition of patient decompensation. Augmented reality may represent a viable modality for increasing the clinical impact of training.

Hospital Pediatrics, 2021

OBJECTIVE Resident physicians are expected to recognize patients requiring escalation of care on ... more OBJECTIVE Resident physicians are expected to recognize patients requiring escalation of care on day 1 of residency, as outlined by the Association of American Medical Colleges. Opportunities for medical students to assess patients at the bedside or through traditional simulation-based medical education have decreased because of coronavirus disease 2019 restrictions. Virtual reality (VR) delivered remotely via video teleconferencing may address this educational gap. METHODS A prospective pilot study targeting third-year pediatric clerkship students at a large academic children’s hospital was conducted from April to December 2020. Groups of 6 to 15 students participated in a 1.5-hour video teleconferencing session with a physician facilitator donning a VR headset and screen sharing interactive VR cases of a hospitalized infant with respiratory distress. Students completed surveys assessing the immersion and tolerability of the virtual experience and reported its perceived effectivene...

Academic Pediatrics, 2021

Objective The Association of American Medical Colleges defines recognition of the need for urgent... more Objective The Association of American Medical Colleges defines recognition of the need for urgent or emergent escalation of care as a key Entrustable Professional Activity (EPA) for entering residency (EPA#10). This study pilots the use of an immersive virtual reality (VR) platform for defining objective observable behaviors as standards for evaluation of medical student recognition of impending respiratory failure. Methods A cross-sectional observational study was conducted from July 2018-December 2019, evaluating student performance during a VR scenario of an infant in impending respiratory failure using the OculusRift™ VR platform. Video recordings were rated by two pair of physician reviewers blinded to student identity. One pair provided a consensus global assessment of performance (not competent, borderline, or competent) while the other used a checklist of observable behaviors to rate performance. Binary discriminant analysis was used to identify the observable behaviors that predicted the global assessment rating. Results Twenty-six fourth year medical students participated. Student performance of eight observable behaviors was found to be most predictive of a rating of competent, with a 91% probability. Correctly stating that the patient required an escalation of care had the largest contribution towards predicting a rating of competent, followed by commenting on the patient's increased heart rate, low oxygen saturation, increased respiratory rate, and stating that the patient was in respiratory distress. Conclusions This study demonstrates that VR can be used to establish objective and observable performance standards for assessment of EPA attainment – a key step in moving towards competency based medical education.

Blood Purification, 2021

Introduction: We aimed to characterize acute kidney injury (AKI), fluid overload (FO), and renal ... more Introduction: We aimed to characterize acute kidney injury (AKI), fluid overload (FO), and renal replacement therapy (RRT) utilization by diagnostic categories and examine associations between these complications and mortality by category. Methods: To test our hypotheses, we conducted a retrospective multicenter, cohort study including 446 neonates (categories: 209 with cardiac disease, 114 with congenital diaphragmatic hernia [CDH], 123 with respiratory disease) requiring extracorporeal membrane oxygenation (ECMO) between January 1, 2007, and December 31, 2011. Results: AKI, FO, and RRT each varied by diagnostic category. AKI and RRT receipt were most common in those neonates with cardiac disease. Subjects with CDH had highest peak %FO (51% vs. 28% cardiac vs. 32% respiratory; p < 0.01). Hospital survival was 55% and varied by diagnostic category (45% cardiac vs. 48% CDH vs. 79% respiratory; p < 0.001). A significant interaction suggested risk of mortality differed by diagnos...

American Journal of Respiratory Cell and Molecular Biology, 2020

Neutrophils are vital to both the inflammatory cascade and tissue repair following injury. Neutro... more Neutrophils are vital to both the inflammatory cascade and tissue repair following injury. Neutrophil heterogeneity is well established, but there is less evidence for significant different functional roles for neutrophil subsets. Olfactomedin 4 (OLFM4) is expressed by a subset of neutrophils and high expression of OLFM4 is associated with worse outcomes in patients with sepsis and acute respiratory distress syndrome. We hypothesized that increased number of OLFM4+ neutrophils would occur in trauma patients with worse clinical outcomes. To test this, we prospectively enrolled patients who suffered blunt traumatic injury. Blood was collected at the time of admission, day three, and day seven and analyzed for percentage of neutrophils expressing OLFM4. We found that a subset of patients who suffered blunt traumatic injury upregulated their percentage of OLFM4 positive neutrophils. Those who upregulated their OLFM4 had increased length of stay, days in the intensive care unit, and ventilator days. A majority of these patients also suffered from hemorrhagic shock. To establish a potential role for OLFM4+ neutrophils we used a murine model of hemorrhagic shock because mice also express OLFM4 in a subset of neutrophils. These studies demonstrated that wild-type mice had higher levels of cytokines in the plasma and myeloperoxidase in the lungs compared to OLFM4 null mice. Additionally, we used anti-OLFM4 antibody, which when given to wild-type mice, led to the reduction of myeloperoxidase in the lungs of mice. These findings suggest that OLFM4+ neutrophils are a unique subset of neutrophils that affect the inflammatory response following tissue injury.

Journal of Pediatric Intensive Care, 2020

We conducted a candidate gene association study to test the hypothesis that different gene polymo... more We conducted a candidate gene association study to test the hypothesis that different gene polymorphisms will be associated with corticosteroid responsiveness and study outcomes among children undergoing congenital heart surgery. This is a prospective observational cohort study at a large, tertiary pediatric cardiac center on children undergoing corrective or palliative congenital heart surgery. A total of 83 children were enrolled. DNA was isolated for three polymorphisms of interest namely N363 (rs56149945) and 9β (rs6198) associated with increased sensitivity to corticosteroids and BclI (rs41423247) associated with decreased sensitivity to corticosteroids. Duration of inotropic use, low cardiac output scores (LCOS), and vasoactive inotrope scores were examined in relation to these three polymorphisms. Using Kaplan–Meier analysis, heterozygous individuals showed longer transcriptional intermediary factor (TIF) compared with wild type for N363 polymorphism (p = 0.05). In multivaria...

Pediatric Critical Care Medicine, 2020

Objective: To determine whether exposure to an immersive virtual reality curriculum on pediatric ... more Objective: To determine whether exposure to an immersive virtual reality curriculum on pediatric respiratory distress improves medical students’ recognition of impending respiratory failure. Design: Randomized, controlled, prospective study conducted from July 2017 to June 2018. Evaluators blinded to student groupings. Setting: Academic, free-standing children’s hospital. Participants: All third-year medical students (n = 168) were eligible. The standard curriculum was delivered to all students during their pediatric rotation with optional inclusion of research data per Institutional Review Board review. A randomized selection of students was exposed to the virtual reality curriculum. Intervention: All students received standard training on respiratory distress through didactics and high-fidelity mannequin simulation. Intervention students underwent an additional 30-minute immersive virtual reality curriculum, experienced through an OculusRift headset, with three simulations of an infant with 1) no distress, 2) respiratory distress, and 3) impending respiratory failure. Measurements and Main Results: The impact of the virtual reality curriculum on recognition/interpretation of key examination findings, assignment of an appropriate respiratory status assessment, and recognition of the need for escalation of care for patients in impending respiratory failure was assessed via a free response clinical assessment of video vignettes at the end of the pediatric rotation. Responses were scored on standardized rubrics by physician experts. All eligible students participated (78 intervention and 90 control). Significant differences between intervention and control were demonstrated for consideration/interpretation of mental status (p < 0.01), assignment of the appropriate respiratory status assessment (p < 0.01), and recognition of a need for escalation of care (p = 0.0004). Conclusions: Exposure to an immersive virtual reality curriculum led to improvement in objective competence at the assessment of respiratory distress and recognition of the need for escalation of care for patients with signs of impending respiratory failure. This study represents a novel application of immersive virtual reality and suggests that it may be effective for clinical assessment training.

The Joint Commission Journal on Quality and Patient Safety, 2020

Current Treatment Options in Pediatrics, 2019

Purpose of Review: Acute kidney injury (AKI) and fluid overload affect a large number of children... more Purpose of Review: Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations. Recent Findings: Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload. Summary: Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Jan 19, 2018

Postoperative administration of corticosteroids is common practice for managing catecholamine ref... more Postoperative administration of corticosteroids is common practice for managing catecholamine refractory low cardiac output syndrome. Since corticosteroid activity is dependent on the glucocorticoid receptor, we sought to characterize glucocorticoid receptor levels in children undergoing cardiac surgery and examined the association between glucocorticoid receptor levels and cardiovascular dysfunction. Prospective observational cohort study. Large, tertiary pediatric cardiac center. Children undergoing corrective or palliative cardiac surgery. None. A prospective observational cohort study was conducted in 83 children with congenital heart disease. Total glucocorticoid receptor levels were measured in the peripheral WBCs using flow cytometry. In addition, blood samples were collected for total cortisol levels. The primary outcome studied was the time to being inotrope free. An increase in glucocorticoid receptor level from postoperative day 1 to postoperative day 3 was associated wit...

Pediatric Critical Care Medicine, 2017

Pediatric cardiology, Jan 23, 2016

The aim of the study is to determine the utility of echocardiography in the assessment of diastol... more The aim of the study is to determine the utility of echocardiography in the assessment of diastolic function in children and young adults with restrictive cardiomyopathy (RCM). RCM is a rare disease with high mortality requiring frequent surveillance. Accurate, noninvasive echocardiographic measures of diastolic function may reduce the need for invasive catheterization. Single-center, prospective, observational study of pediatric and young adult RCM patients undergoing assessment of diastolic parameters by simultaneous transthoracic echocardiogram (TTE) and invasive catheterization. Twenty-one studies in 15 subjects [median (IQR) = 13.8 years (7.0-19.2), 60% female] were acquired with median left ventricular end-diastolic pressure (LVEDP) 21 (IQR 18-25) mmHg. TTE parameters of diastolic function, including pulmonary vein A wave duration (r s = 0.79) and indexed left atrial volume (r s = 0.49), demonstrated significant positive correlation, while mitral valve A (r s = -0.44), late...

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Jan 13, 2016

In a population of neonatal and pediatric patients on extracorporeal membrane oxygenation; to des... more In a population of neonatal and pediatric patients on extracorporeal membrane oxygenation; to describe the prevalence and timing of acute kidney injury utilizing a consensus acute kidney injury definition and investigate the association of acute kidney injury with outcomes (length of extracorporeal membrane oxygenation and mortality). Multicenter retrospective observational cohort study. Six pediatric extracorporeal membrane oxygenation centers. Pediatric patients (age, < 18 yr) on extracorporeal membrane oxygenation at six centers during a period of January 1, 2007, to December 31, 2011. None. Complete data were analyzed for 832 patients on extracorporeal membrane oxygenation. Sixty percent of patients had acute kidney injury utilizing the serum creatinine Kidney Disease Improving Global Outcomes criteria (AKI) and 74% had acute kidney injury using the full Kidney Disease Improving Global Outcomes criteria including renal support therapy (AKI). Of those who developed acute kidne...

Critical Care Medicine, 2012

In pediatric patients, fluid overload at continuous renal replacement therapy initiation is assoc... more In pediatric patients, fluid overload at continuous renal replacement therapy initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at continuous renal replacement therapy initiation, fluid removal during continuous renal replacement therapy, the kinetics of fluid removal and mortality in a large pediatric population receiving continuous renal replacement therapy while on extracorporeal membrane oxygenation. Design: Retrospective chart review. Setting: Tertiary children's hospital. Patients: Extracorporeal membrane oxygenation patients requiring continuous renal replacement therapy from July 2006 to September 2010. Interventions: None. Measurements and Main Results: Overall intensive care unit survival was 34% for 53 patients that were initiated on continuous renal replacement therapy while on extracorporeal membrane oxygenation during the study period. Median fluid overload at continuous renal replacement therapy initiation was significantly lower in survivors compared to nonsurvivors (24.5% vs. 38%, p = .006). Median fluid overload at continuous renal replacement therapy discontinuation was significantly lower in survivors compared to nonsurvivors (7.1% vs. 17.5%, p = .035). After adjusting for percent fluid overload at continuous renal replacement therapy initiation, age, and severity of illness, the change in fluid overload at continuous renal replacement therapy discontinuation was not significantly associated with mortality (p = .212). Models investigating the rates of fluid removal in different periods, age, severity of illness, and fluid overload at continuous renal replacement therapy initiation found that fluid overload at continuous renal replacement therapy initiation was the most consistent predictor of survival. Conclusions: Our data demonstrate an association between fluid overload at continuous renal replacement therapy initiation and mortality in pediatric patients receiving extracorporeal membrane oxygenation. The degree of fluid overload at continuous renal replacement therapy discontinuation is also associated with mortality, but appears to reflect the effect of fluid overload at initiation. Furthermore, correction of fluid overload to ≤10% was not associated with improved survival. These results suggest that intervening prior to the development of significant fluid overload may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of continuous renal replacement therapy in this population, and warrant further clinical studies.

Pediatric Research

d-TGA, d-transposition of great arteries; GA, gestational age; HC, head circumference. All values... more d-TGA, d-transposition of great arteries; GA, gestational age; HC, head circumference. All values are medians (interquartile range). a Wilcoxon rank-sum test was used to examine significant differences between groups.

Collegium antropologicum, 2015

The objective of the study was to examine the association between fish and shellfish intake and d... more The objective of the study was to examine the association between fish and shellfish intake and diabetes in an island population, and the design of the study was Cross-sectional. Two independent population-based field surveys were conducted in Hvar Island of the eastern Adriatic coast of Croatia in May 2007 and May 2008, with a total of 1,379 adult participants. In multivariable logistic regression models, total fish intake was positively associated with diabetes prevalence in the total population (OR(Q4 vs. Q1) = 1.64; 95% CI = 1.01-2.66; p-trend = 0.09). Oily fish intake also exhibited a positive association with diabetes prevalence in the total population (OR(Q4 vs. Q1) = 2.22; 95% CI = 1.35-3.64; p-trend = 0.01) and in analyses stratified by body mass index, males and those with a high waist circumference. The study suggests an association between oily fish intake and diabetes in the population of the Hvar Island in Croatia. Longitudinal studies incorporating measures of persist...