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van Baarle FLF, van de Weerdt EK, Raasveld SJ, Vlaar APJ, Biemond BJ. Bleeding assessment following central venous catheter placement, a direct comparison of prospective and retrospective analyses. Transfusion 2024. [PMID: 38923611 DOI: 10.1111/trf.17930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Reported bleeding incidences following central venous catheter (CVC) placement highly depend on methods of bleeding assessment. To determine the direction and magnitude of the bias associated with retrospective data collection, we used data from the PACER randomized controlled trial and a previous retrospective cohort study. STUDY DESIGN AND METHODS A patient-level comparison of CVC-related bleeding severity was made among (1) the prospectively collected clinical bleeding assessment of the PACER trial, (2) centralized assessment of CVC insertion site photographs, and (3) retrospective chart review. Interrater reliability for photographic bleeding assessment and retrospective chart review was assessed using Cohen's κ. The magnitude of underreporting of both methods compared to prospective clinical bleeding assessment at different cutoff points of clinically relevant bleeding was assessed using McNemar's test. RESULTS Interrater reliability was acceptable for both methods (κ = 0.583 and κ = 0.481 for photographic assessment and retrospective chart review, respectively). Photographic bleeding assessment led to significant underreporting of bleeding complications at all cutoff points. Retrospective chart review led to significant underreporting of minor bleeding complications, with an odds ratio (95% CI) of 0.17 (0.044-0.51) for the cutoff point grade 1 (i.e., self-limiting or requiring at most 20 min of manual compression) or higher. There was no significant underreporting of major bleeding complications with retrospective chart review. DISCUSSION Centralized photographic bleeding assessment and retrospective chart review lead to biased bleeding assessment compared to prospective clinical bleeding assessment.
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Affiliation(s)
- Floor L F van Baarle
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
| | - Emma K van de Weerdt
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
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2
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Fernández-Barge T, Domínguez-García JJ, Díaz-Santander A, Rivero-Fernández R, Cantera-Estefanía R, Mendez GA, Romón Í. Extended platelet transfusion in bleeding patients with platelet transfusion refractoriness. Transfus Apher Sci 2023; 62:103711. [PMID: 37059653 DOI: 10.1016/j.transci.2023.103711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/11/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023]
Affiliation(s)
| | | | - Alba Díaz-Santander
- Haematology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain
| | | | | | - Gala A Mendez
- Haematology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain
| | - Íñigo Romón
- Haematology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain.
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3
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Zarama V, Revelo-Noguera J, Quintero JA, Manzano R, Uribe-Buriticá FL, Carvajal DF, Ochoa LM, Valencia-Orozco A, Sánchez ÁI, Ospina-Tascón GA. Prophylactic platelet transfusion and risk of bleeding associated with ultrasound-guided central venous access in patients with severe thrombocytopenia. Acad Emerg Med 2023; 30:644-652. [PMID: 36587310 DOI: 10.1111/acem.14651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/23/2022] [Accepted: 12/24/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Reported risk of bleeding complications after central catheter access in patients with thrombocytopenia is highly variable. Current guidelines recommend routine prophylactic platelet (PLT) transfusion before central venous catheter placement in patients with severe thrombocytopenia. Nevertheless, the strength of such recommendations is weak and supported by observational studies including few patients with very low PLT counts (<20 × 109 /L). This study aims to assess the risk of bleeding complications related to using or not using prophylactic PLT transfusion before ultrasound-guided central venous access in patients with very low PLT counts. METHODS This was a retrospective cohort study of patients with very low PLT counts (<20 × 109 /L) subjected to ultrasound-guided central venous catheterization between January 2011 and November 2019 in a university hospital. Bleeding complications were graded according to the Common Terminology Criteria for Adverse Events. A multivariate logistic regression was conducted to assess the risk of major and minor bleeding complications comparing patients who did or did not receive prophylactic PLT transfusion for the procedure. Multiple imputation by chained equations was used to handle missing data. A two-tailed p < 0.05 was considered statistically significant. RESULTS Among 221 patients with very low PLT counts, 72 received prophylactic PLT transfusions while 149 did not. Baseline characteristics were similar between transfused and nontransfused patients. No major bleeding events were identified, while minor bleeding events were recognized in 35.7% of patients. Multivariate logistic regression analysis showed no significant differences in bleeding complications between patients who received prophylactic PLT transfusions and those who did not (odds ratio 0.83, 95% confidence interval 0.45-1.55, p = 0.567). Additional complete case and sensitivity analyses yielded results similar to those of the main analysis. CONCLUSIONS In this single-center retrospective cohort study of ultrasound-guided central venous access in patients with very low PLT counts, no major bleeding was identified, and prophylactic PLT transfusions did not significantly decrease minor bleeding events.
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Affiliation(s)
- Virginia Zarama
- Department of Emergency Medicine, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | | | - Jaime A Quintero
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - Ramiro Manzano
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | | | | | - Laura M Ochoa
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | | | - Álvaro I Sánchez
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
- Division of Thoracic Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Gustavo A Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in in Critical Care Medicine (TransLab - CCM), Universidad Icesi, Cali, Colombia
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4
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Cook DJ, Swinton M, Krewulak KD, Fiest K, Dionne J, Debigare S, Guyatt G, Taneja S, Alhazzani W, Burns KEA, Marshall JC, Muscedere J, Gouskos A, Finfer S, Deane AM, Myburgh J, Rochwerg B, Ball I, Mele T, Niven D, English S, Verhovsek M, Vanstone M. What counts as patient-important upper gastrointestinal bleeding in the ICU? A mixed-methods study protocol of patient and family perspectives. BMJ Open 2023; 13:e070966. [PMID: 37208143 DOI: 10.1136/bmjopen-2022-070966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Clinically important upper gastrointestinal bleeding is conventionally defined as bleeding accompanied by haemodynamic changes, requiring red blood cell transfusions or other invasive interventions. However, it is unclear if this clinical definition reflects patient values and preferences. This protocol describes a study to elicit views from patients and families regarding features, tests, and treatments for upper gastrointestinal bleeding that are important to them. METHODS AND ANALYSIS This is a sequential mixed-methods qualitative-dominant multi-centre study with an instrument-building aim. We developed orientation tools and educational materials in partnership with patients and family members, including a slide deck and executive summary. We will invite intensive care unit (ICU) survivors and family members of former ICU patients to participate. Following a virtual interactive presentation, participants will share their perspectives in an interview or focus group. Qualitative data will be analysed using inductive qualitative content analysis, wherein codes will be derived directly from the data rather than using preconceived categories. Concurrent data collection and analysis will occur. Quantitative data will include self-reported demographic characteristics. This study will synthesise the values and perspectives of patients and family members to create a new trial outcome for a randomised trial of stress ulcer prophylaxis. This study is planned for May 2022 to August 2023. The pilot work was completed in Spring 2021. ETHICS AND DISSEMINATION This study has ethics approval from McMaster University and the University of Calgary. Findings will be disseminated via manuscript and through incorporation as a secondary trial outcome on stress ulcer prophylaxis. TRIAL REGISTRATION NUMBER NCT05506150.
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Affiliation(s)
- Deborah J Cook
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karla D Krewulak
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kirsten Fiest
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joanna Dionne
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sylvie Debigare
- Patient and Family Partnership Committee, Canadian Critical Care Trials Group, Montreal, Quebec, Canada
| | - Gordon Guyatt
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shipra Taneja
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John C Marshall
- Surgery and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Muscedere
- Critical Care Medicine, Kingston Health Sciences Center, Queens University, Kingston, Ontario, Canada
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee Representative, Toronto, Ontario, Canada
| | - Simon Finfer
- Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Adam M Deane
- Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - John Myburgh
- Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bram Rochwerg
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ian Ball
- Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Tina Mele
- Surgery and Critical Care Medicine, Western University, London, Ontario, Canada
| | - Daniel Niven
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Annetta MG, Bertoglio S, Biffi R, Brescia F, Giarretta I, Greca AL, Panocchia N, Passaro G, Perna F, Pinelli F, Pittiruti M, Prisco D, Sanna T, Scoppettuolo G. Management of antithrombotic treatment and bleeding disorders in patients requiring venous access devices: A systematic review and a GAVeCeLT consensus statement. J Vasc Access 2022; 23:660-671. [PMID: 35533088 DOI: 10.1177/11297298211072407] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.
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Affiliation(s)
| | | | - Roberto Biffi
- Surgical Unit, Istituto Europeo di Oncologia, Milano, Italy
| | - Fabrizio Brescia
- Anesthesia and Intensive Care, Centro di Riferimento Oncologico, Aviano, Italy
| | - Igor Giarretta
- Internal Medicine, University Hospital "A.Gemelli," Rome, Italy
| | - Antonio La Greca
- Vascular Access Team, University Hospital "A.Gemelli," Rome, Italy
| | - Nicola Panocchia
- Nephrology and Dialysis Unit, University Hospital "A.Gemelli," Rome, Italy
| | | | | | - Fulvio Pinelli
- Anesthesia and Intensive Care, Careggi University Hospital, Firenze, Italy
| | - Mauro Pittiruti
- Vascular Access Team, University Hospital "A.Gemelli," Rome, Italy
| | - Domenico Prisco
- Experimental and Clinical Medicine, Careggi University Hospital, Firenze, Italy
| | - Tommaso Sanna
- Cardiology, University Hospital 'A.Gemelli', Rome, Italy
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Contribution of Coagulopathy on the Risk of Bleeding After Central Venous Catheter Placement in Critically Ill Thrombocytopenic Patients. Crit Care Explor 2022; 4:e0621. [PMID: 35083436 PMCID: PMC8785929 DOI: 10.1097/cce.0000000000000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Supplemental Digital Content is available in the text. Critically ill patients often undergo central venous catheter placement during thrombocytopenia and/or coagulopathy. It is unclear whether severe coagulopathy increases the risk of postprocedural bleeding in critically ill patients with severe thrombocytopenia.
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Osman M, Abd El-Azeem H, Afifi O, Abdou MA, Elsayh K, Zahran A, Abdelaal A. Evaluation of platelet surface glycoproteins in inherited thrombocytopathy: relationship with bleeding severity. THE EGYPTIAN JOURNAL OF HAEMATOLOGY 2022. [DOI: 10.4103/ejh.ejh_54_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bunch CM, Thomas AV, Stillson JE, Gillespie L, Khan RZ, Zackariya N, Shariff F, Al-Fadhl M, Mjaess N, Miller PD, McCurdy MT, Fulkerson DH, Miller JB, Kwaan HC, Moore EE, Moore HB, Neal MD, Martin PL, Kricheff ML, Walsh MM. Preventing Thrombohemorrhagic Complications of Heparinized COVID-19 Patients Using Adjunctive Thromboelastography: A Retrospective Study. J Clin Med 2021; 10:jcm10143097. [PMID: 34300263 PMCID: PMC8303660 DOI: 10.3390/jcm10143097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/05/2021] [Accepted: 07/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The treatment of COVID-19 patients with heparin is not always effective in preventing thrombotic complications, but can also be associated with bleeding complications, suggesting a balanced approach to anticoagulation is needed. A prior pilot study supported that thromboelastography and conventional coagulation tests could predict hemorrhage in COVID-19 in patients treated with unfractionated heparin or enoxaparin, but did not evaluate the risk of thrombosis. METHODS This single-center, retrospective study included 79 severely ill COVID-19 patients anticoagulated with intermediate or therapeutic dose unfractionated heparin. Two stepwise logistic regression models were performed with bleeding or thrombosis as the dependent variable, and thromboelastography parameters and conventional coagulation tests as the independent variables. RESULTS Among all 79 patients, 12 (15.2%) had bleeding events, and 20 (25.3%) had thrombosis. Multivariate logistic regression analysis identified a prediction model for bleeding (adjusted R2 = 0.787, p < 0.001) comprised of increased reaction time (p = 0.016), decreased fibrinogen (p = 0.006), decreased D-dimer (p = 0.063), and increased activated partial thromboplastin time (p = 0.084). Multivariate analysis of thrombosis identified a weak prediction model (adjusted R2 = 0.348, p < 0.001) comprised of increased D-dimer (p < 0.001), decreased reaction time (p = 0.002), increased maximum amplitude (p < 0.001), and decreased alpha angle (p = 0.014). Adjunctive thromboelastography decreased the use of packed red cells (p = 0.031) and fresh frozen plasma (p < 0.001). CONCLUSIONS Significantly, this study demonstrates the need for a precision-based titration strategy of anticoagulation for hospitalized COVID-19 patients. Since severely ill COVID-19 patients may switch between thrombotic or hemorrhagic phenotypes or express both simultaneously, institutions may reduce these complications by developing their own titration strategy using daily conventional coagulation tests with adjunctive thromboelastography.
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Affiliation(s)
- Connor M. Bunch
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - Anthony V. Thomas
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - John E. Stillson
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN 46545, USA;
| | - Nuha Zackariya
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - Faadil Shariff
- Department of Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA;
| | - Mahmoud Al-Fadhl
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (M.A.-F.); (N.M.)
| | - Nicolas Mjaess
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (M.A.-F.); (N.M.)
| | - Peter D. Miller
- Department of Interventional Radiology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Michael T. McCurdy
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Daniel H. Fulkerson
- Department of Neurosurgery, Beacon Medical Group, South Bend, IN 46601, USA;
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA;
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Peter L. Martin
- Department of Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA;
| | - Mark L. Kricheff
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Mark M. Walsh
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (M.A.-F.); (N.M.)
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
- Correspondence:
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