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Prey BJ, Colburn ZT, Williams JM, Francis AD, Vu M, Lammers D, McClellan J, Bingham JR. The use of mobile thermal imaging and machine learning technology for the detection of early surgical site infections. Am J Surg 2024; 231:60-64. [PMID: 37173166 DOI: 10.1016/j.amjsurg.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/17/2023] [Accepted: 04/16/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Surgical Site Infections (SSI) yield subtle, early signs that are not readily identifiable. This study sought to develop a machine learning algorithm that could identify early SSIs based on thermal images. METHODS Images were taken of surgical incisions on 193 patients who underwent a variety of surgical procedures. Two neural network models were generated to detect SSIs, one using RGB images, and one incorporating thermal images. Accuracy and Jaccard Index were the primary metrics by which models were evaluated. RESULTS Only 5 patients in our cohort developed SSIs (2.8%). Models were instead generated to demarcate the wound site. The models had 89-92% accuracy in predicting pixel class. The Jaccard indices for the RGB and RGB + Thermal models were 66% and 64%, respectively. CONCLUSIONS Although the low infection rate precluded the ability of our models to identify surgical site infections, we were able to generate two models to successfully segment wounds. This proof-of-concept study demonstrates that computer vision has the potential to support future surgical applications.
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Affiliation(s)
- Beau J Prey
- Madigan Army Medical Center, Tacoma, WA, USA.
| | | | | | | | - Michael Vu
- Madigan Army Medical Center, Tacoma, WA, USA
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Lammers D, Hu P, Rokayak O, Baird EW, Betzold RD, Hashmi Z, Kerby JD, Jansen JO, Holcomb JB. Preferential whole blood transfusion during the early resuscitation period is associated with decreased mortality and transfusion requirements in traumatically injured patients. Trauma Surg Acute Care Open 2024; 9:e001358. [PMID: 38666013 PMCID: PMC11043766 DOI: 10.1136/tsaco-2023-001358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Introduction Whole blood (WB) transfusion represents a promising resuscitation strategy for trauma patients. However, a paucity of data surrounding the optimal incorporation of WB into resuscitation strategies persists. We hypothesized that traumatically injured patients who received a greater proportion of WB compared with blood product components during their resuscitative efforts would have improved early mortality outcomes and decreased transfusion requirements compared with those who received a greater proportion of blood product components. Methods Retrospective review from our Level 1 trauma center of trauma patients during their initial resuscitation (2019-2022) was performed. WB to packed red blood cell ratios (WB:RBC) were assigned to patients based on their respective blood product resuscitation at 1, 2, 3, and 24 hours from presentation. Multivariable regression models were constructed to assess the relationship of WB:RBC to 4 and 24-hour mortality, and 24-hour transfusion requirements. Results 390 patients were evaluated (79% male, median age of 33 years old, 48% penetrating injury rate, and a median Injury Severity Score of 27). Overall mortality at 4 hours was 9%, while 24-hour mortality was 12%. A significantly decreased 4-hour mortality was demonstrated in patients who displayed a WB:RBC≥1 at 1 hour (5.9% vs. 12.3%; OR 0.17, p=0.015), 2 hours (5.5% vs. 13%; OR 0.16, p=0.019), and 3 hours (5.5% vs. 13%, OR 0.18, p<0.01), while a decreased 24-hour mortality was displayed in those with a WB:RBC≥1 at 24 hours (7.9% vs. 14.6%, OR 0.21, p=0.01). Overall 24-hour transfusion requirements were significantly decreased within the WB:RBC≥1 cohort (12.1 units vs. 24.4 units, p<0.01). Conclusion Preferential WB transfusion compared with a balanced transfusion strategy during the early resuscitative period was associated with a lower 4 and 24-hour mortality, as well as decreased 24-hour transfusion requirements, in trauma patients. Future prospective studies are warranted to determine the optimal use of WB in trauma. Level of evidence Level III/therapeutic.
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Affiliation(s)
- Daniel Lammers
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Omar Rokayak
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily W Baird
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Zain Hashmi
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Jan O Jansen
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Siddiqi N, Lammers D, Hu P, Stonko D, DuBose J, Hurst S, Hashmi Z, Morrison J, Betzold R. Comparison of Contralateral vs Ipsilateral Vein Graft for Traumatic Vascular Injury Repair: A Cohort From PROOVIT. Am Surg 2024:31348241246167. [PMID: 38621410 DOI: 10.1177/00031348241246167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Traumatic injury leading to arterial damage has traditionally been repaired using autologous vein graft from the contralateral limb. This often requires a secondary surgical site and the potential of prolonged operative time for patients. We sought to assess the use of ipsilateral vs contralateral vein grafts in patients who experienced traumatic extremity vascular injury. A multicenter database was queried to identify arterial injuries requiring operative intervention with vein grafting. The primary outcome of interest was need for operative reintervention. Secondary outcomes included risk of thrombosis, infection, and intensive care unit length of stay. 358 patients (320 contralateral and 38 ipsilateral) were included in the analysis. The ipsilateral vein cohort did not display a statistically significant decrease in need for reoperation when compared to the contralateral group (11% vs 23%; OR 0.41, 95% CI -0.07-1.3; P = .14). Contralateral repair was associated with longer median intensive care unit (ICU) LOS (4.3 vs 3.1 days; P < .01).
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Affiliation(s)
- Noreen Siddiqi
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Daniel Lammers
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Parker Hu
- Department of Surgery, Chippenham Hospital, Richmond, VA, USA
| | - David Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph DuBose
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Stuart Hurst
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Zain Hashmi
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Jonathan Morrison
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Richard Betzold
- Department of Surgery, The University of Alabama at Birmingham Hospital, Birmingham, AL, USA
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Lammers D, Uhlich R, Rokayak O, Manley N, Betzold RD, Hu P. Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership. Trauma Surg Acute Care Open 2024; 9:e001332. [PMID: 38440096 PMCID: PMC10910416 DOI: 10.1136/tsaco-2023-001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Medical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian centers to maintain clinical readiness. It is unclear what impact this strategy may have on patient outcomes in these centers. We sought to compare emergent trauma laparotomy (ETL) outcomes between active-duty Air Force Special Operations Surgical Team (SOST) general surgeons and civilian faculty at an American College of Surgeons verified level 1 trauma center with a well-established military-civilian partnership. Methods Retrospective review of a prospectively maintained, single-center database of ETL from 2019 to 2022 was performed. ETL was defined as laparotomy from trauma bay within 90 min of patient arrival. The primary outcome was to assess for all-cause mortality differences at multiple time points. Results 514 ETL were performed during the study period. 22% (113 of 514) of patients were hypotensive (systolic blood pressure ≤90 mm Hg) on arrival. Six SOST surgeons performed 43 ETL compared with 471 ETL by civilian faculty. There were no differences in median ED length of stay (27 min vs 22 min; p=0.21), but operative duration was significantly longer for SOST surgeons (129 min vs 110 min; p=0.01). There were no differences in intraoperative (5% vs 2%; p=0.30), 6-hour (3% vs 5%; p=0.64), 24-hour (5% vs 5%; p=1.0), or in-hospital mortality rates (5% vs 8%; p=0.56) between SOST and civilian surgeons. SOST surgeons did not significantly impact the odds of 24-hour mortality on multivariable analysis (OR 0.78; 95% CI 0.10, 6.09). Conclusion Trauma-related mortality for patients undergoing ETL was not impacted by SOST surgeons when compared with their civilian counterparts. Military surgeons may benefit from the valuable clinical experience and mentorship of experienced civilian trauma surgeons at high volume trauma centers without creating a deficit in the quality of care provided. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
- Daniel Lammers
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Omar Rokayak
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nathan Manley
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard D Betzold
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Lammers D, Williams J, Conner J, Francis A, Prey B, Marenco C, Morte K, Horton J, Barlow M, Escobar M, Bingham J, Eckert M. Utilization of Machine Learning Approaches to Predict Mortality in Pediatric Warzone Casualties. Mil Med 2024; 189:345-351. [PMID: 35730578 DOI: 10.1093/milmed/usac171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/19/2022] [Accepted: 05/27/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Identification of pediatric trauma patients at the highest risk for death may promote optimization of care. This becomes increasingly important in austere settings with constrained medical capabilities. This study aimed to develop and validate predictive models using supervised machine learning (ML) techniques to identify pediatric warzone trauma patients at the highest risk for mortality. METHODS Supervised learning approaches using logistic regression (LR), support vector machine (SVM), neural network (NN), and random forest (RF) models were generated from the Department of Defense Trauma Registry, 2008-2016. Models were tested and compared to determine the optimal algorithm for mortality. RESULTS A total of 2,007 patients (79% male, median age range 7-12 years old, 62.5% sustaining penetrating injury) met the inclusion criteria. Severe injury (Injury Severity Score > 15) was noted in 32.4% of patients, while overall mortality was 7.13%. The RF and SVM models displayed recall values of .9507 and .9150, while LR and NN displayed values of .8912 and .8895, respectively. Random forest (RF) outperformed LR, SVM, and NN on receiver operating curve (ROC) analysis demonstrating an area under the ROC of .9752 versus .9252, .9383, and .8748, respectively. CONCLUSION Machine learning (ML) techniques may prove useful in identifying those at the highest risk for mortality within pediatric trauma patients from combat zones. Incorporation of advanced computational algorithms should be further explored to optimize and supplement the diagnostic and therapeutic decision-making process.
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Affiliation(s)
- Daniel Lammers
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - James Williams
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Jeff Conner
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Andrew Francis
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Beau Prey
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Christopher Marenco
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Kaitlin Morte
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - John Horton
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Meade Barlow
- Department of Pediatric Surgery, Mary Bridge Children's Hospital, Tacoma, WA 98405, USA
| | - Mauricio Escobar
- Department of Pediatric Surgery, Mary Bridge Children's Hospital, Tacoma, WA 98405, USA
| | - Jason Bingham
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Matthew Eckert
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
- Department of Surgery, University of North Carolina Medical Center, Chapel Hill, NC 27514, USA
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Lammers D, Scerbo M, Davidson A, Pommerening M, Tomasek J, Wade CE, Cardenas J, Jansen J, Miller CC, Holcomb JB. Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients. Trauma Surg Acute Care Open 2023; 8:e001140. [PMID: 37936904 PMCID: PMC10626753 DOI: 10.1136/tsaco-2023-001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
Background Trauma patients exhibit a multifactorial hypercoagulable state and have increased risk of venous thromboembolism (VTE). Despite early and aggressive chemoprophylaxis (CP) with various heparin compounds ("standard" CP; sCP), VTE rates remain high. In high-quality studies, aspirin has been shown to decrease VTE in postoperative elective surgical and orthopedic trauma patients. We hypothesized that inhibiting platelet function with aspirin as an adjunct to sCP would reduce the risk of VTE in trauma patients. Methods We performed a retrospective observational study of prospectively collected data from all adult patients admitted to an American College of Surgeons Level I Trauma center from January 2012 to June 2015 to evaluate the addition of aspirin (sCP+A) to sCP regimens for VTE mitigation. Cox proportional hazard models were used to assess the potential benefit of adjunctive aspirin for symptomatic VTE incidence. Results 10,532 patients, median age 44 (IQR 28 to 62), 68% male, 89% blunt mechanism of injury, with a median Injury Severity Score (ISS) of 12 (IQR 9 to 19), were included in the study. 8646 (82%) of patients received only sCP, whereas 1886 (18%) patients received sCP+A. The sCP+A cohort displayed a higher median ISS compared with sCP (13 vs 11; p<0.01). The overall median time of sCP initiation was hospital day 1 (IQR 0.8 to 2) and the median day for aspirin initiation was hospital day 3 (IQR 1 to 6) for the sCP+A cohort. 353 patients (3.4%) developed symptomatic VTE. Aspirin administration was independently associated with a decreased relative hazard of VTE (HR 0.57; 95% CI 0.36 to 0.88; p=0.01). There were no increased bleeding or wound complications associated with sCP+A (point estimate 1.23, 95% CI 0.68 to 2.2, p=0.50). Conclusion In this large trauma cohort, adjunctive aspirin was independently associated with a significant reduction in VTE and may represent a potential strategy to safely mitigate VTE risk in trauma patients. Further prospective studies evaluating the addition of aspirin to heparinoid-based VTE chemoprophylaxis regimens should be sought. Level of evidence Level III/therapeutic.
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Affiliation(s)
- Daniel Lammers
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michelle Scerbo
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Annamaria Davidson
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Matthew Pommerening
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jeffrey Tomasek
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Charles E Wade
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jessica Cardenas
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - Jan Jansen
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles C Miller
- Surgery/Center for Injury Research, The University of Texas Health Science Center McGovern School of Medicine, Houston, Texas, USA
| | - John B Holcomb
- Division of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Lammers D, Rokayak O, Uhlich R, Sensing T, Baird E, Richman J, Holcomb JB, Jansen J. Balanced resuscitation and earlier mortality end points: bayesian post hoc analysis of the PROPPR trial. Trauma Surg Acute Care Open 2023; 8:e001091. [PMID: 37575614 PMCID: PMC10414081 DOI: 10.1136/tsaco-2023-001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/23/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial failed to demonstrate a mortality difference for hemorrhaging patients receiving a balanced (1:1:1) vs a 1:1:2 resuscitation at 24 hours and 30 days. Recent guidelines recommend earlier mortality end points for hemorrhage-control trials, and the use of contemporary statistical methods. The aim of this post hoc analysis of the PROPPR trial was to evaluate the impact of a balanced resuscitation strategy at early resuscitation time points using a Bayesian analytical framework. Methods Bayesian hierarchical models were created to assess mortality differences at the 1, 3, 6, 12, 18, and 24 hours time points between study cohorts. Posterior probabilities and Bayes factors were calculated for each time point. Results A 1:1:1 resuscitation displayed a 96%, 99%, 94%, 92%, 96%, and 94% probability for mortality benefit at 1, 3, 6, 12, 18, and 24 hours, respectively, when compared with a 1:1:2 approach. Associated Bayes factors for each respective time period were 21.2, 142, 14.9, 11.4, 26.4, and 15.5, indicating 'strong' to 'decisive' supporting evidence in favor of balanced transfusions. Conclusion This analysis provides evidence in support that a 1:1:1 resuscitation has a high probability of mortality benefit when compared with a 1:1:2 strategy, especially at the newly defined more proximate time points during the resuscitative period. Researchers should consider using Bayesian approaches, along with more proximate end points when assessing hemorrhage-related mortality, for the analysis of future clinical trials. Level of evidence Level III/Therapeutic.
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Affiliation(s)
- Daniel Lammers
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Omar Rokayak
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Thomas Sensing
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Emily Baird
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Jan Jansen
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
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Lammers D, McClellan J. Modern Statistical Methods for the Surgeon Scientist: The Clash of Frequentist versus Bayesian Paradigms. Surg Clin North Am 2023; 103:259-269. [PMID: 36948717 DOI: 10.1016/j.suc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
The practice of evidence-based medicine is the result of a multitude of research and trials aimed toward improving health-care outcomes. An understanding of the associated data remains paramount toward optimizing patient outcomes. Medical statistics commonly revolve around frequentist concepts that are convoluted and nonintuitive for nonstatisticians. Within this article, we will discuss frequentist statistics, their limitations, as well as introduce Bayesian statistics as an alternative approach for data interpretation. By doing so, we intend to highlight the importance of correct statistical interpretations through clinically relevant examples while providing a deeper understanding of the underlying philosophies of frequentist and Bayesian statistics.
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Affiliation(s)
- Daniel Lammers
- Department of General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431, USA.
| | - John McClellan
- Department of General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431, USA
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Lammers D, Rokayak O, Uhlich R, Hu P, Baird E, Rakestraw S, Betzold R, McClellan J, Eckert M. Early Use of Extracorporeal Membrane Oxygenation for Traumatically Injured Patients: A National Trauma Database Analysis. Am Surg 2023:31348231161082. [PMID: 36876475 DOI: 10.1177/00031348231161082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) in acute trauma patients is a poorly characterized event. While ECMO most commonly has been deployed for advanced cardiopulmonary or respiratory failure following initial resuscitation, growing levels of evidence for out of hospital cardiac arrest support early ECMO cannulation as part of resuscitative efforts. We sought to perform a descriptive analysis evaluating traumatically injured patients, who were placed on ECMO, during their initial resuscitation period. METHODS We performed a retrospective analysis of the Trauma Quality Improvement Program Database from 2017 to 2019. All traumatically injured patients who received ECMO within the first 24 hours of their hospitalization were assessed. Descriptive statistics were used to define patient characteristics and injury patterns associated with the need for ECMO, while mortality represented the primary outcome evaluated. RESULTS A total of 696 trauma patients received ECMO during their hospitalization, of which 221 were placed on ECMO within the first 24 hours. Early ECMO patients were on average 32.5 years old, 86% male, and sustained a penetrating injury 9% of the time. The average ISS was 30.7, and the overall mortality rate was 41.2%. Prehospital cardiac arrest was noted in 18.2% of the patient population resulting in a 46.8% mortality. Of those who underwent resuscitative thoracotomy, a 53.3% mortality rate was present. CONCLUSION Early cannulation for ECMO in severely injured patients may provide an opportunity for rescue therapy following severe injury patterns. Further evaluation regarding the safety profile, cannulation strategies, and optimal injury patterns for these techniques should be evaluated.
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Affiliation(s)
- Daniel Lammers
- Center for Injury Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Omar Rokayak
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Rindi Uhlich
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Parker Hu
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Emily Baird
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Stephanie Rakestraw
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Richard Betzold
- Center for Injury Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - John McClellan
- Department of General Surgery, 19933Madigan Army Medical Center, Tacoma, WA, USA
| | - Matthew Eckert
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Chapel Hill, NC, USA
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Francis A, Williams J, Prey B, Lammers D, Vu M, Jones I, Gillette L, Reynolds G, McClellan J, Bingham J. Rapid cold sterilization of 3D printed surgical instruments for the austere environment. Am J Surg 2023; 225:909-914. [PMID: 37059641 DOI: 10.1016/j.amjsurg.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Medical operations are vulnerable to global supply chain fluctuations. The ability to locally produce and reliably sterilize medical equipment may mitigate this risk. This project developed a reliable high-level disinfection process for 3D printed surgical tools. METHODS Surgical instruments and consumables were designed and printed from various materials. Devices contaminated with known and unknown bacteria underwent one of three cleaning methods followed by high-level disinfection using submersion in a Cidex OPA Solution. Devices were then cultured on blood agar plates and incubated for 48 h. Positive and negative controls were performed. RESULTS The results of control experiments showed no growth on negative controls and significant growth on all positive control plates. Of the three cleaning methods tested, one showed no growth: cleaning with isopropyl alcohol and chlorhexidine followed by Cidex bath. DISCUSSION This project successfully developed a rapid high-level disinfection process for 3D printed surgical instruments made from two different types of 3D printing material.
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Williams J, Francis A, Prey B, Conner J, Lammers D, Choi PM, Vicente D, Bingham J, McClellan J. Impact of COVID on surgical case volume at military treatment facilities with surgical residencies. Am J Surg 2023; 225:897-902. [PMID: 36764898 DOI: 10.1016/j.amjsurg.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/21/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) ("direct care"; DC) & off-base civilian facilities ("purchased care"; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies. METHODS Retrospective review of 2017-2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets. RESULTS 5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 - Q1 2020 vs Q3 2020 - Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID. DISCUSSION Bariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.
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Affiliation(s)
| | | | - Beau Prey
- Madigan Army Medical Center, Tacoma, WA, USA
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Lammers D, Richman J, Holcomb JB, Jansen JO. Use of Bayesian Statistics to Reanalyze Data From the Pragmatic Randomized Optimal Platelet and Plasma Ratios Trial. JAMA Netw Open 2023; 6:e230421. [PMID: 36811858 PMCID: PMC9947730 DOI: 10.1001/jamanetworkopen.2023.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Frequentist statistical approaches are the most common strategies for clinical trial design; however, bayesian trial design may provide a more optimal study technique for trauma-related studies. OBJECTIVE To describe the outcomes of bayesian statistical approaches using data from the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study performed a post hoc bayesian analysis of the PROPPR Trial using multiple hierarchical models to assess the association of resuscitation strategy with mortality. The PROPPR Trial took place at 12 US level I trauma centers from August 2012 to December 2013. A total of 680 severely injured trauma patients who were anticipated to require large volume transfusions were included in the study. Data analysis for this quality improvement study was conducted from December 2021 and June 2022. INTERVENTIONS In the PROPPR Trial, patients were randomized to receive a balanced transfusion (equal portions of plasma, platelets, and red blood cells [1:1:1]) vs a red blood cell-heavy strategy (1:1:2) during their initial resuscitation. MAIN OUTCOMES AND MEASURES Primary outcomes from the PROPPR trial included 24-hour and 30-day all-cause mortality using frequentist statistical methods. Bayesian methods were used to define the posterior probabilities associated with the resuscitation strategies at each of the original primary end points. RESULTS Overall, 680 patients (546 [80.3%] male; median [IQR] age, 34 [24-51] years, 330 [48.5%] with penetrating injury; median [IQR] Injury Severity Score, 26 [17-41]; 591 [87.0%] with severe hemorrhage) were included in the original PROPPR Trial. Between the groups, no significant differences in mortality were originally detected at 24 hours (12.7% vs 17.0%; adjusted risk ratio [RR], 0.75 [95% CI, 0.52-1.08]; P = .12) or 30 days (22.4% vs 26.1%; adjusted RR, 0.86 [95% CI, 0.65-1.12]; P = .26). Using bayesian approaches, a 1:1:1 resuscitation was found to have a 93% (Bayes factor, 13.7; RR, 0.75 [95% credible interval, 0.45-1.11]) and 87% (Bayes factor, 6.56; RR, 0.82 [95% credible interval, 0.57-1.16]) probability of being superior to a 1:1:2 resuscitation with regards to 24-hour and 30-day mortality, respectively. CONCLUSIONS AND RELEVANCE In this quality improvement study, a post hoc bayesian analysis of the PROPPR Trial found evidence in support of mortality reduction with a balanced resuscitation strategy for patients in hemorrhagic shock. Bayesian statistical methods offer probability-based results capable of direct comparison between various interventions and should be considered for future studies assessing trauma-related outcomes.
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Affiliation(s)
- Daniel Lammers
- Department of Surgery, Madigan Army Medical Center and Center for Injury Science, University of Alabama at Birmingham
| | - Joshua Richman
- Center for Injury Science, University of Alabama at Birmingham
| | - John B. Holcomb
- Center for Injury Science, University of Alabama at Birmingham
| | - Jan O. Jansen
- Center for Injury Science, University of Alabama at Birmingham
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Holtestaul T, Jones I, Conner J, Lammers D, Weiss J, Bingham J, Martin MJ, Eckert M. Resuscitative endovascular balloon occlusion of the aorta management guided by a novel handheld pressure transducer. J Trauma Acute Care Surg 2022; 92:729-734. [PMID: 34789704 DOI: 10.1097/ta.0000000000003467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Management of noncompressible truncal hemorrhage using resuscitative endovascular balloon occlusion of the aorta (REBOA) requires arterial pressure monitoring that can be logistically challenging in austere or emergency settings. Novel pressure transducer devices such as the Centurion Compass device (CD) (Medline, Northfield, IL) offer an alternative to traditional monitoring systems. We sought to assess the feasibility of maintaining permissive hypotension during intermittent REBOA in a porcine model guided by CD monitoring. METHODS Eight Yorkshire swine underwent 20% hemorrhage with an uncontrolled iliofemoral vascular injury. Time-based intermittent zone 1 REBOA was performed with volume-based resuscitation to maintain permissive hypotension. Proximal mean arterial pressures (MAPs) from a carotid arterial line (AL) were obtained and compared with CD readings from the proximal REBOA port. The operator was blinded to AL MAP, and the REBOA was managed with exclusively the CD. RESULTS Mean survival time was 100 minutes (range, 41-120 minutes) from injury. Arterial line and CD measurements were closely correlated (r = 0.94, p < 0.001). Bland-Altman analysis for comparison of clinical measurements demonstrated a mean difference of 6 mm Hg (95% confidence interval, -22 to 34 mm Hg) for all MAPs, with a mean difference of 3 mm Hg (95% confidence interval, -6 to 12 mm Hg) in a clinically relevant MAP of <65 mm Hg subset. CONCLUSION The CD represents a miniaturized and portable arterial pressure monitor that provides an accurate alternative to logistically burdensome AL monitoring to guide REBOA use. The device is highly accurate even at hypotensive pressures and can be used to guide intermittent REBOA strategies.
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Affiliation(s)
- Torbjorg Holtestaul
- From the Department of Surgery (T.H., I.J., J.C., D.L., J.W., J.B.), Madigan Army Medical Center, Tacoma, Washington; Department of Surgery (M.J.M.), Scripps Mercy Hospital, San Diego, California; and Department of Surgery (M.E.), University of North Carolina Medical Center, Chapel Hill, North Carolina
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Conner J, Lammers D, Holtestaul T, Jones I, Kuckelman J, Letson H, Dobson G, Eckert M, Bingham J. Combatting ischemia reperfusion injury from resuscitative endovascular balloon occlusion of the aorta using adenosine, lidocaine and magnesium: A pilot study. J Trauma Acute Care Surg 2021; 91:995-1001. [PMID: 34446655 DOI: 10.1097/ta.0000000000003388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA), a minimally invasive alternative to resuscitative thoracotomy, has been associated with significant ischemia reperfusion injury (IRI). Resuscitation strategies using adenosine, lidocaine, and magnesium (ALM) have been shown to mitigate similar inflammatory responses in hemorrhagic and septic shock models. This study examined the effects of ALM on REBOA-associated IRI using a porcine model. METHODS Animals underwent a 20% controlled hemorrhage followed by 30 minutes of supraceliac balloon occlusion. They were assigned to one of four groups: control (n = 5), 4-hour ALM infusion starting at occlusion, 2-hour (n = 5) and 4-hour (n = 5) interventional ALM infusions starting at reperfusion. Adenosine, lidocaine, and magnesium cohorts received a posthemorrhage ALM bolus followed by their respective ALM infusion. Primary outcomes for the study assessed physiologic and hemodynamic parameters. RESULTS Adenosine, lidocaine, and magnesium infusion after reperfusion cohorts demonstrated a significant improvement in lactate, base deficit, and pH in the first hour following systemic reperfusion. At study endpoint, continuous ALM infusion initiated after reperfusion over 4 hours resulted in an overall improved lactate clearance when compared with the 2-hour and control cohorts. No differences in hemodynamic parameters were noted between ALM cohorts and controls. CONCLUSION Adenosine, lidocaine, and magnesium may prove beneficial in mitigating the inflammatory response seen from REBOA-associated IRI as evidenced by physiologic improvements early during resuscitation. Despite this, further refinement should be sought to optimize treatment strategies.
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Affiliation(s)
- Jeff Conner
- From the Madigan Army Medical Center (J.C., D.L., T.H., I.J., J.K., M.E., J.B.), Tacoma, Washington; Heart Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry (H.L., G.D.), James Cook University, Townsville, Queensland, Australia; and Department of Surgery (M.E.), University of North Carolina, Chapel Hill, North Carolina
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Morte K, Nelson D, Marenco C, Lammers D, DeBarros M, Bader J, Bingham J. Gender Differences in Medical Specialty Decision Making: The Importance of Mentorship. J Surg Res 2021; 267:678-686. [PMID: 34274906 DOI: 10.1016/j.jss.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/26/2021] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION While there have been many studies reviewing factors considered by medical students in deciding on a specialty, there is a relative paucity of data in how these factors differ between males and females. The aim of this study was to determine if there are differences in how male and female medical students' value various factors in choosing a career path in medicine. METHODS A survey of basic demographic information and a Likert-based questionnaire addressing various factors in specialty choice was sent to all military medical students in the class of 2019. RESULTS The survey response rate was 30%. Amongst the students that completed the survey, 72% were male and 28% were female. The majority of students were less than 27 years old (52%) and Caucasian (76%). Female medical students placed more importance in exposure to third year clerkships (P = 0.004) and gender diversity within the specialty (P = 0.03) than their male counterparts. There was no statistical difference in opinions of significant others or family members, desire to have a family, or having a well-balanced life between female, and male medical students. CONCLUSION Female medical students valued exposure to third year clerkships and gender diversity more than their male colleagues when choosing a future specialty. These findings suggest that a strategic focus should be placed on mentoring female medical students in order to promote a diverse medical workforce.
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Affiliation(s)
- Kaitlin Morte
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA
| | - Daniel Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX
| | | | - Daniel Lammers
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA
| | - Mia DeBarros
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA
| | - Julia Bader
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX
| | - Jason Bingham
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA.
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Lammers D, Conner J, Marenco C, Morte K, Martin M, Eckert M, Bingham J. Optimal Prospective Predictors of Mortality in Austere Environments. J Surg Res 2020; 255:297-303. [PMID: 32585467 DOI: 10.1016/j.jss.2020.05.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/18/2020] [Accepted: 05/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Prospective predictors of trauma-related outcomes have been validated to guide management in low-resource settings. The primary objective of this study was to determine the optimal prospective prediction method for mortality within combat and humanitarian trauma. MATERIALS AND METHODS Retrospective review of the Department of Defense Trauma Registry from 2008 to 2016 was performed for adult patients. Areas under receiver operating characteristic curves (AUROCs) were calculated to assess the predictability of shock index (SI), reverse SI × Glasgow Coma Scale (rSIG), SI × Glasgow Coma Scale (SIG), Revised Trauma Score, and Trauma and Injury Severity Score (TRISS) on mortality at point of injury, arrival in emergency department (ED), and the difference in vital signs between those time points. RESULTS A total of 22,218 patients were included. Overall, 97.1% were male, median age range 25-29 y, Injury Severity Score 9.4 ± 0.07, with predominantly penetrating injuries (58.1%), and mortality of 3.4%. ED vitals yielded higher predictability of mortality for all tests based on higher AUROCs. TRISS and rSIG demonstrated the highest AUROCs (0.955 and 0.923, respectively). The optimal cutoff value for rSIG was 14.1 (sensitivity 89% and specificity 87%). rSIG values <14.1 were significantly associated with mortality (P < 0.01; odds ratio = 5.901). CONCLUSIONS Initial ED vital signs represented a better predictor of early mortality compared with point of injury vital signs for all predictive tools assessed. TRISS and rSIG proved to be most predictive of mortality. However, of the prospective tools assessed, rSIG may be optimal scoring tool because of its ease of calculation and its increased ability to predict mortality.
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Affiliation(s)
- Daniel Lammers
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jeffrey Conner
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington.
| | - Chris Marenco
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Kaitlin Morte
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Matthew Martin
- Department of Trauma and Critical Care, Scripps Mercy Hospital, San Diego, California
| | - Matthew Eckert
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jason Bingham
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
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Morte K, Marenco C, Lammers D, Bingham J, Sohn V, Eckert M. Utilization of mobile application improves perioperative education and patient satisfaction in general surgery patients. Am J Surg 2020; 221:788-792. [PMID: 32381263 DOI: 10.1016/j.amjsurg.2020.03.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Clear and accurate communication is paramount in delivering high quality surgical care. Through the development of a mobile application, we provided patients with a source of education and instruction throughout the peri-operative period. METHODS Patients >18 years old with a smart-phone undergoing elective general surgery procedures were eligible. Patients received perioperative educational materials and text message reminders of time-sensitive events via the application. A System Usability Scale and survey was administered. RESULTS 100 patients were enrolled; 51% completed the survey. The average SUS score was 86, correlating with >90th percentile usability. 86% of patients felt that the application improved their surgical experience, 96% said the application provided essential reminders, and 90% felt that application clarified information. 84% of patients did not identify any inconsistency between the application and surgeon. CONCLUSION Utilizing patient's smart phones to aid in perioperative education is feasible and improves patient satisfaction. This application has a high usability score, indicating ease of use.
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Affiliation(s)
| | | | | | | | - Vance Sohn
- Madigan Army Medical Center, WA, United States
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Morte D, Lammers D, Bingham J, Kuckelman J, Eckert M, Martin M. Tranexamic acid administration following head trauma in a combat setting: Does tranexamic acid result in improved neurologic outcomes? J Trauma Acute Care Surg 2019; 87:125-129. [DOI: 10.1097/ta.0000000000002269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Kirana S, Stratmann B, Prante C, Prohaska W, Koerperich H, Lammers D, Gastens MH, Quast T, Negrean M, Stirban OA, Nandrean SG, Götting C, Minartz P, Kleesiek K, Tschoepe D. Autologous stem cell therapy in the treatment of limb ischaemia induced chronic tissue ulcers of diabetic foot patients. Int J Clin Pract 2012; 66:384-93. [PMID: 22284892 DOI: 10.1111/j.1742-1241.2011.02886.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIM Despite improvements in surgical revascularisation, limitations like anatomical factors or atherosclerosis limit the success of revascularisation in diabetic patients with critical limb ischaemia. Stem cells were shown to improve microcirculation in published studies. The aim of this study was to evaluate safety, feasibility and efficacy of transplantation of bone marrow derived cellular products regarding improvement in microcirculation and lowering of amputation rate. METHODS Bone marrow mononuclear cells (BMCs) in comparison with expanded bone marrow cells enriched in CD90+ cells ('tissue repair cells', TRCs) were used in the treatment of diabetic ulcers to induce revascularisation. Diabetic foot patients with critical limb ischaemia without option for surgical or interventional revascularisation were eligible. Parameters examined were ABI, TcPO(2) , reactive hyperaemia and angiographic imaging before and after therapy. RESULTS Of 30 patients included in this trial, 24 were randomised to receive either BMCs or TRCs. The high number of drop-outs in the control group (4 of 6) led to exclusion from evaluation. A total of 22 patients entered treatment; one patient in the TRC group and two in the BMC group did not show wound healing during follow up, one patient in each treatment group died before reaching the end of the study; one after having achieved wound healing (BMC group), the other one without having achieved wound healing (TRC group). Thus, 18 patients showed wound healing after 45 weeks. The total number of applicated cells was 3.8 times lower in the TRC group, but TRC patients received significantly higher amounts of CD90+ cells. Improvement in microvascularisation was detected in some, but not all patients by angiography, TcPO(2) improved significantly compared with baseline in both therapy groups. CONCLUSION The transplantation of BMCs as well as TRCs proved to be safe and feasible. Improvements of microcirculation and complete wound healing were observed in the transplant groups.
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Affiliation(s)
- S Kirana
- Diabetes Centre, Heart and Diabetes Centre NRW, Ruhr University Bochum, Germany
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Kirana S, Stratmann B, Lammers D, Quast T, Minartz P, Negrean M, Stirban A, Petrule S, Gastens MH, Götting C, Prohaska W, Prante C, Körperich H, Kleesiek K, Tschöpe D. Therapie mit expandierten autologen Knochenmark-Stammzellen bei Ischämie-bedingtem chronischen diabetischen Fußsyndom – Follow up Daten einer kontrollierten Studie. DIABETOL STOFFWECHS 2008. [DOI: 10.1055/s-2008-1076400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Prante C, Gastens M, Prohaska W, Stratmann B, Lammers D, Kirana S, Tschopev D, Kleesiek K. GMP-Compliant Manufacturing of Autologous Stem and Progenitor Cells For Tissue Repair. J Stem Cells Regen Med 2007; 2:9-10. [PMID: 24692875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- C Prante
- Institut fur Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - Mh Gastens
- Institut fur Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - W Prohaska
- Institut fur Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - B Stratmann
- Diabeteszentrum, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - D Lammers
- Diabeteszentrum, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - S Kirana
- Diabeteszentrum, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - D Tschopev
- Diabeteszentrum, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
| | - K Kleesiek
- Institut fur Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitatsklinik der Ruhr-Universitat Bochum , 32545 Bad Oeynhausen
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Kirana S, Stratmann B, Lammers D, Negrean M, Stirban A, Minartz P, Koerperich H, Gastens MH, Götting C, Prohaska W, Kleesiek K, Tschoepe D. Wound therapy with autologous bone marrow stem cells in diabetic patients with ischaemia-induced tissue ulcers affecting the lower limbs. Int J Clin Pract 2007; 61:690-2. [PMID: 17394441 DOI: 10.1111/j.1742-1241.2007.01303.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Previous studies suggest that autologous transplantation of bone marrow mononuclear cells is safe and effective in inducing therapeutic angiogenesis in patients with peripheral arterial occlusive disease (PAOD). Here we discuss a multidisciplinary approach to treating PAOD with a focus on the use of angiological diagnostic tools. We conclude that our autologous stem cell therapy is working in this patient and it is a potential new therapeutic option for diabetic patients with chronic foot ulcers induced by critical limb ischaemia.
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Kirana S, Stratmann B, Lammers D, Minartz P, Quast T, Negrean M, Stirban A, Petrule S, Gastens M, Goetting C, Prohaska W, Körperich H, Kleesiek K, Tschöpe D. Studie zur induzierten Wundheilung durch Applikation expandierter autologer Knochenmark-Stammzellen bei Diabetikern mit Ischämie-bedingten chronischen Gewebesulzera der unteren Gliedmaße. DIABETOL STOFFWECHS 2007. [DOI: 10.1055/s-2007-982188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
The number of reported cases of child abuse has increased dramatically over the past several years. Maltreatment of children can take several forms including neglect, sexual abuse, physical assault and psychological trauma. Five cases of child abuse presenting initially to the Otolaryngology Service are outlined: bilateral auricular hematomas, recurrent tympanic membrane lacerations, a pharyngeal laceration with retropharyngeal abscess and medical neglect of a patient with a parotid malignancy and one with laryngeal papillomatosis. Characteristic presentations and risk factors in family background are discussed toward the goal of early recognition and appropriate intervention.
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Affiliation(s)
- S C Manning
- Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas 75235-9035
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