Allan Walkey

• MD, MSc
• Professor (Assistant) at Boston University

Importance The impact of awake prone positioning (APP) on clinical outcomes in patients with COVID-19 and acute hypoxemic respiratory failure (AHRF) remains uncertain. Objective To assess the association of APP with improved clinical outcomes among patients with COVID-19 and AHRF, and to identify potential effect modifiers. Data Sources PubMed, E...

Background Corticosteroids improve survival in hospitalized COVID-19 patients needing supplemental oxygen. However, concern exists about increased risk of secondary infections. This study investigated the impact of early corticosteroids use on these infections. Methods Data from the Society of Critical Care Medicine Discovery Viral Infection and R...

Importance Chronic obstructive pulmonary disease (COPD) is often undiagnosed. Although genetic risk plays a significant role in COPD susceptibility, its utility in guiding spirometry testing and identifying undiagnosed cases is unclear. Objective To determine whether a COPD polygenic risk score (PRS) enhances the identification of undiagnosed COPD...

Background: Acute chest syndrome (ACS) causes significant morbidity and mortality for patients with sickle cell disease (SCD), and often develops during a hospitalization for acute SCD pain due to chest wall splinting, hypoventilation, and atelectasis due to prior rib infarcts, pain and opioid use. While incentive spirometry is an important compone...

Background Screening for cognitive impairment in primary care is important, yet primary care physicians (PCPs) report conducting routine cognitive assessments for less than half of patients older than 60 years of age. Linus Health’s Core Cognitive Evaluation (CCE), a tablet-based digital cognitive assessment, has been used for the detection of cogn...

Rationale: Uncertainty remains regarding the risks associated with single-dose use of etomidate. Objectives: To assess the use of etomidate in critically ill patients and compare outcomes for patients who received etomidate versus ketamine. Methods: We assessed patients who received invasive mechanical ventilation (IMV) and were admitted to an ICU...

Background High‐intensity end‐of‐life (EOL) care, marked by admission to intensive care units (ICUs) or in‐hospital death, can be costly and burdensome. Recent trends in use of ICUs, life‐sustaining treatments (LSTs), and noninvasive ventilation (NIV) during EOL hospitalizations among older adults with advanced cancer and patterns of in‐hospital de...

IMPORTANCE The opioid crisis is impacting people across the country and deserves attention to be able to curb the rise in opioid-related deaths. OBJECTIVES To evaluate practice patterns in opioid infusion administration and dosing for patients with acute respiratory failure receiving invasive mechanical ventilation. DESIGN Retrospective cohort st...

Background Chronic inflammation may increase susceptibility to pneumonia. Research question To explore associations between clinical comorbidities, serum protein immunoassays, and long-term pneumonia risk. Methods Framingham Heart Study Offspring Cohort participants ≥65 years were linked to their Centers for Medicare Services claims data. Clinica...

Rationale Acute chest syndrome (ACS) often develops during hospitalizations for sickle cell disease (SCD) vaso‐occlusive episodes and may be triggered by a combination of chest wall splinting, opioid use, hypoventilation, and atelectasis. In 2017, Boston Medical Center's general pediatric inpatient unit instituted the novel use of bi‐level positive...

Importance Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and posthospitalization opioid–related outcomes are unclear. Objective To evaluate associations between an intravenous opioid dose received during mechanical ventilation and...

Importance In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Prior studies have reported higher in-hospital mortality among patients with sepsis at safety-net hospitals compared with non–safety-net hospitals; however, in critically ill patients, in-hospital mortality rates a...

Background: New-onset atrial fibrillation (AF) during sepsis is common, but models designed to stratify stroke risk excluded patients with secondary AF. We assessed the predictive validity of CHA2DS2VASc scores among patients with new-onset AF during sepsis and developed a novel stroke prediction model incorporating presepsis and intrasepsis chara...

Background Large‐scale observational studies have summarized transfusion practice using traditional measures of central tendency (e.g., the mean hemoglobin concentration at the time of transfusion). However, the mean hemoglobin concentration fails to identify specific hemoglobin concentration thresholds that drive practice. In the following brief r...

Objectives To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients. Design Retrospective, multicenter, observational study using the Premier AI Healthcare Database. Setting The study was conducted in U.S. ICUs. Patients Adult (≥ 18 yr old) patients with a history of opioid u...

Objective: To determine the epidemiological effect-magnitude and outcomes of patients with cancer vs those without cancer who are hospitalized with acute respiratory failure (ARF). Patients and Methods: We reviewed hospitalizations within the National Inpatient Sample (NIS) database between January 1, 2016, and December 31, 2018. Patients were clas...

BACKGROUND Providing analgesia and sedation is an essential component of caring for many mechanically ventilated patients. The selection of analgesic and sedative medications during the COVID-19 pandemic, and the impact of these sedation practices on patient outcomes, remain incompletely characterized. RESEARCH QUESTION What were the hospital patt...

Rationale: The use of hydrocortisone in adult septic shock is controversial, and effectiveness of adding fludrocortisone to hydrocortisone remains uncertain. Objective: To assess comparative effectiveness and safety of fludrocortisone plus hydrocortisone, hydrocortisone alone and placebo/usual care in adults with septic shock. Methods: Systema...

Rationale The comparative effectiveness of biologics used as add-on therapy in the management of difficult-to-control asthma is unclear. Objective To compare the effectiveness of dupilumab, mepolizumab and benralizumab among patients with difficult-to-control asthma. Methods Retrospective multicenter cohort study of adult patients with difficult-to...

Most prior studies on the prognostic significance of newly-diagnosed atrial fibrillation (AF) in COVID-19 did not differentiate newly-diagnosed AF from pre-existing AF. To determine the association between newly-diagnosed AF and in-hospital and 30-day mortality among regular users of Veterans Health Administration using data linked to Medicare. We...

Rationale: Potassium repletion is common in critically ill patients. However, practice patterns and outcomes related to different intensive care unit (ICU) potassium repletion strategies are unclear. Objectives: (1) Describe potassium repletion practices in critically ill adults, (2) compare the effectiveness of potassium repletion strategies, a...

Background Chronic inflammation may increase susceptibility to pneumonia. Research Question To explore associations between clinical comorbidities, serum protein immunoassays, and long-term pneumonia risk. Methods Framingham Heart Study Offspring Cohort participants ≥65 years were linked to their Centers for Medicare Services claims data. Clinical...

Background: Acute chest syndrome (ACS), the second most common cause of hospitalization and leading cause of death in children with sickle cell disease (SCD), often develops during a hospitalization for acute SCD in the setting of chest wall splinting, hypoventilation, and atelectasis from pain and opioid use. While incentive spirometry is an impor...

Importance Long-term acute care hospitals (LTCHs) are common sites of postacute care for patients recovering from severe respiratory failure requiring mechanical ventilation (MV). However, federal payment reform led to the closure of many LTCHs in the US, and it is unclear how closure of LTCHs may have affected upstream care patterns at short-stay...

Rationale: One quarter of Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) die within 1 year. Although overall mortality rates are higher among White patients with COPD, racial and ethnic differences in the vulnerable period following hospitalization are unknown.Objectives: To determine the association between ra...

Background Although corticosteroids have become the standard of care for patients with coronavirus disease-2019 (COVID-19) on supplemental oxygen, there is growing evidence of differential treatment response. This study aimed to evaluate if there was an association between biomarker-concordant corticosteroid treatment and COVID-19 outcomes. Method...

Background The gold standard for gathering data from electronic health records (EHR) has been manual data extraction; however, this requires vast resources and personnel. Automation of this process reduces resource burdens and expands research opportunities. Objective This study aimed to determine the feasibility and reliability of automated data...

PURPOSE: Code status orders are of high impact and reflect end-of-life (EoL) care preferences. During the COVID-19 pandemic, documenting code status was paramount due to the limited resource availability. We examined hospital variations in admission code status for patients admitted with COVID-19 infection. METHODS: This study used the Society of...

Rationale Rapid respiratory viral panel (RVP) testing has become widely used to aid in the diagnosis and treatment of acute respiratory failure. However, the impact of RVP on antibiotic stewardship in critically ill patients is unclear. Objective To assess if adoption of RVP testing at hospitals was associated with changes in antibiotic duration in...

IMPORTANCE:. Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes. OBJECTIVES:. The Structured Team-based Optimal Pati...

Rationale: Acute respiratory failure (ARF) is the leading cause of death in critically ill patients with cancer. A diagnosis of ARF in those with cancer often portends a dire prognosis, but a contemporary real-world understanding of the epidemiology and prognosis of such patients is lacking. Moreover, we have limited knowledge about the utilization...

Rationale: There have been conflicting results on the association of asthma with the severity ofCOVID-19. Metabolic syndrome has been previously associated with both severe COVID-19 andsevere asthma. We aimed to examine effect modification of metabolic syndrome on the associationbetween asthma and COVID-19 outcomes.Methods: We performed a secondary...

Background Cumulative research show association of neutrophils and neutrophil extracellular traps (NETs) with poor outcomes in severe COVID-19. However, to date, there is no curative intent therapy able to block neutrophil/NETs-mediated progression of multi-organ dysfunction. Because of emerging neutrophil heterogeneity, the study of subsets of cir...

Unlabelled: The COVID-19 pandemic led to rapid changes in care delivery for critically ill patients, due to factors including increased numbers of ICU patients, shifting staff roles, and changed care locations. As these changes may have impacted the care of patients without COVID-19, we assessed changes in common ICU practices for mechanically ven...

Importance: Thyroid storm is the most severe form of thyrotoxicosis, with high mortality, and is treated with propylthiouracil and methimazole. Some guidelines recommend propylthiouracil over methimazole, although the difference in outcomes associated with each treatment is unclear. Objective: To compare outcomes associated with use of propylthi...

Background: In the absence of evidence-based strategies to improve patient outcomes, the management of patients with severe idiopathic pulmonary fibrosis (IPF) exacerbations may vary widely across centres. We assessed between-hospital variation in practices and mortality for patients with severe IPF exacerbations. Methods: Using the Premier Heal...

Importance: Patients with septic shock may benefit from the initiation of corticosteroids. However, the comparative effectiveness of the 2 most studied corticosteroid regimens (hydrocortisone with fludrocortisone vs hydrocortisone alone) is unclear. Objective: To compare the effectiveness of adding fludrocortisone to hydrocortisone vs hydrocorti...

Background The COVID-19 pandemic produced unprecedented demands and rapidly changing evidence and practices within critical care settings. The purpose of this study was to identify factors and strategies that hindered and facilitated effective implementation of new critical care practices and policies in response to the pandemic. Methods We used a...

Background: Practice patterns and outcomes associated with the use of oral anticoagulation for arterial thromboembolism prevention following a hospitalization with new-onset atrial fibrillation (AF) during sepsis are unclear. Methods: Retrospective, observational cohort study of patients ≥40 years of age discharged alive following hospitalizatio...

Rationale Acute Respiratory Distress Syndrome (ARDS) is associated with significant mortality. Despite the mortality benefits of lung protective ventilation, adherence rates to evidence-based ventilator practice have remained low and ARDS mortality has remained high. Objective Determine variation in ARDS mortality and adherence to low tidal volume...

Background: Cumulative research show association of neutrophils and neutrophil extracellular traps (NETs) with poor outcomes in severe COVID-19. However, to date, no curative intent therapy has been identified to block neutrophil/NETs-mediated progression of multi-organ dysfunction. Because of emerging neutrophil heterogeneity, the study of subsets...

Unlabelled: Troponin I is frequently elevated in sepsis, but optimal clinical approaches to diagnosis and management of troponin I during sepsis are unclear. Objectives: We aimed to describe the variation in troponin I measurement and the cardiovascular diagnostic and therapeutic approach to elevated troponin I among critically ill adults with s...

Purpose: Incidental adrenal masses (IAMs) are common but rarely evaluated. To improve this, we developed a standardized radiology report recommendation template and investigated its implementation and effectiveness. Methods: We prospectively studied implementation of a standardized IAM reporting template as part of an ongoing quality improvement...

ABSTRACT Objective To develop and validate an updated lung injury prediction score (c-LIPS) tailored for predicting acute respiratory distress syndrome (ARDS) in coronavirus disease-2019. Patients and Methods This was a registry-based cohort study using the Viral Infection and Respiratory Illness Universal Study. Hospitalized adult patients betwee...

Importance Undertreatment of older adults with atrial fibrillation with anticoagulation therapy is an important practice gap. It has been posited that the availability of direct oral anticoagulants (DOACs) would improve oral anticoagulant (OAC) initiation in older adults with atrial fibrillation given their superior safety profile compared with war...

Importance There is limited evidence for therapeutic options for pediatric COVID-19 outside of multisystem inflammatory syndrome in children (MIS-C). Objective To determine whether the use of steroids within 2 days of admission for non–MIS-C COVID-19 in children is associated with hospital length of stay (LOS). The secondary objective was to deter...

Septic shock is defined by the need for vasopressor agents to correct hypotension and lactic acidosis resulting from infection, with 30%-40% case fatality rates. The care of patients with worsening septic shock involves multiple treatment decisions involving vasopressor choices and adjunctive treatments. In this edition of "How I Do It", we provide...

Background Better delineation of COVID-19 presentations in different climatological conditions might assist with prompt diagnosis and isolation of patients. Objectives To study the association of latitude and altitude with COVID-19 symptomatology. Methods This observational cohort study included 12267 adult COVID-19 patients hospitalized between...

Background Inhaled vasodilators nitric oxide and epoprostenol may be initiated to improve oxygenation in mechanically ventilated patients with severe acute respiratory failure; however, practice patterns and head-to-head comparisons of effectiveness are unclear. Research Question What are the practice patterns and comparative effectiveness for inh...

Objectives: To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19. Design: Retrospective observational study. Setting: Multicenter, international COVID-19 registry. Subjects: Adult hospitalized COVID-19 patients on antihypertens...

Rationale: Norepinephrine is a first-line agent for the treatment of hypotension in septic shock. However, its frequency of use and potential barriers to its use are unclear. Objectives: To evaluate the frequency of use of norepinephrine in septic shock, to identify potential barriers to its use, and to evaluate trends in use of vasopressors over t...

Background: The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) for hypoxemic respiratory failure secondary to coronavirus disease 2019 (COVID-19) are recommended by critical-care guidelines; however, apprehension about viral particle aerosolization and patient self-inflicted lung injury may have limited use. We aimed to de...

Objectives: Suggested therapeutic options for Multisystem Inflammatory Syndrome in Children (MIS-C) include intravenous immunoglobulins (IVIG) and steroids. Prior studies have shown the benefit of combination therapy with both agents on fever control or the resolution of organ dysfunction. The primary objective of this study was to analyze the imp...

Context: The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19. Objectives: Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) amon...

Background: Describe the incidence and associated outcomes of gastrointestinal (GI) manifestations of acute coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in hospitalized children (MIS-C). Methods: Retrospective review of the Viral Infection and Respiratory Illness Universal Study registry, a prospective observational,...