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Butts CA, Byerly S, Nahmias J, Gelbard R, Ziesmann M, Bruns B, Davidson GH, Di Saverio S, Esposito TJ, Fischkoff K, Joseph B, Kaafarani H, Mentula P, Podda M, Sakran JV, Salminen P, Sammalkorpi H, Sawyer RG, Skeete D, Tesoriero R, Yeh DD. A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology. J Trauma Acute Care Surg 2024; 96:487-492. [PMID: 37751156 DOI: 10.1097/ta.0000000000004144] [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] [Indexed: 09/27/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level V.
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Affiliation(s)
- Christopher A Butts
- From the Division of Trauma, Acute Care Surgery & Surgical Critical Care (C.A.B.), Department of Surgery, Reading Hospital-Tower Health, West Reading, Pennsylvania; Department of Surgery, University of Tennessee Health Science Center (S.B.), Memphis, Tennessee; UC Irvine Healthcare, Orange (J.N.), California; Department of Surgery, University of Alabama at Birmingham (R.G.), Birmingham, Alabama; University of Manitoba, Winnipeg (M.Z.), Manitoba, Canada; Department of Surgery, University of Texas Southwestern, Dallas (B.B.), Texas; Department of Surgery, University of Washington, Seattle (G.H.D.), Washington; AST5 ASR Marche, Hospital Madonna del Soccorso (S.D.S.), San Benedetto del Tronto, Italy; Department of Medicine, University of Illinois School of Medicine (T.J.E.), Peoria, Illinois; Department of Surgery, Columbia University Irving Medical Center (K.F.), New York, New York; Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tuscon, Arizona; Trauma, Emergency Surgery, and Surgical Critical Care (H.K.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Gastroenterological Surgery (P.M., H.S.), Helsinki University Hospital, Helsinki, Finland; Department of General and Emergency Surgery (M.P.), Cagliari University Hospital, Cagliari, Italy; Division of Acute Care Surgery, Department of Surgery (J.V.S.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery (P.S.), University of Turku, Turku, Finland; Department of Surgery, Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine (R.G.S.), Kalamazoo, Michigan; Roy J. and Lucille A. Carver College of Medicine (D.S.), University of Iowa, Iowa City, Iowa; Division of General Surgery, Trauma and Surgical Critical Care, Acute Care Surgery (R.T.), Zuckerberg San Francisco General Hospital, San Francisco, California; and Ernest E Moore Shock Trauma Center at Denver Health (D.D.Y.), University of Colorado, Denver, Colorado
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Abouzeid M, Alam HB, Arif H, Ballman K, Bennion R, Bernardi K, Burris D, Carter D, Chee P, Chen F, Chung B, Clark S, Cooper R, Cuschieri J, Deeney K, Dhanani N, Diflo T, Drake FT, Fairfield C, Farjah F, Ferrigno L, Fischkoff K, Fleischman R, Foster C, Gerry T, Gibbons M, Guiden M, Haas N, Hayes LA, Hayward A, Hennessey L, Hernandez M, Horvath KF, Howell EC, Hsu C, Johnson J, Johnsson B, Kim D, Kim D, Ko TC, Lavallee DC, Lew D, Mack J, MacKenzie D, Maggi J, Marquez S, Martinez R, McGrane K, Melis M, Miller K, Mireles D, Moran GJ, Morgan D, Morris A, Moser KM, Mount L, O'Connor K, Odom SR, Olavarria O, Olbrich N, Osborn S, Owens O, Park P, Parr Z, Parsons CS, Pathmarajah K, Patki D, Patton JH, Peacock RK, Pierce K, Pullar K, Putnam B, Rushing A, Sabbatini A, Saltzman D, Salzberg M, Schaetzel S, Schmidt PJ, Shah P, Shapiro NI, Sinha P, Skeete D, Skopin E, Sohn V, Spence LH, Steinberg S, Tichter A, Tschirhart J, Tudor B, Uribe L, VanDusen H, Wallick J, Weiss M, Wells S, Wiebusch A, Williams EJ, Winchell RJ, Wisler J, Wolfe B, Wolff E, Yealy DM, Yu J, Zhang IY, Voldal EC, Davidson GH, Liao JM, Thompson CM, Self WH, Kao LS, Cherry-Bukowiec J, Raghavendran K, Kaji AH, DeUgarte DA, Gonzalez E, Mandell KA, Ohe K, Siparsky N, Price TP, Evans DC, Victory J, Chiang W, Jones A, Kutcher ME, Ciomperlik H, Liang MK, Evans HL, Faine BA, Neufeld M, Sanchez SE, Krishnadasan A, Comstock BA, Heagerty PJ, Lawrence SO, Monsell SE, Fannon EEC, Kessler LG, Talan DA, Flum DR. Association of Patient Belief About Success of Antibiotics for Appendicitis and Outcomes: A Secondary Analysis of the CODA Randomized Clinical Trial. JAMA Surg 2022; 157:1080-1087. [PMID: 36197656 PMCID: PMC9535504 DOI: 10.1001/jamasurg.2022.4765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance A patient's belief in the likely success of a treatment may influence outcomes, but this has been understudied in surgical trials. Objective To examine the association between patients' baseline beliefs about the likelihood of treatment success with outcomes of antibiotics for appendicitis in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial. Design, Setting, and Participants This was a secondary analysis of the CODA randomized clinical trial. Participants from 25 US medical centers were enrolled between May 3, 2016, and February 5, 2020. Included in the analysis were participants with appendicitis who were randomly assigned to receive antibiotics in the CODA trial. After informed consent but before randomization, participants who were assigned to receive antibiotics responded to a baseline survey including a question about how successful they believed antibiotics could be in treating their appendicitis. Interventions Participants were categorized based on baseline survey responses into 1 of 3 belief groups: unsuccessful/unsure, intermediate, and completely successful. Main Outcomes and Measures Three outcomes were assigned at 30 days: (1) appendectomy, (2) high decisional regret or dissatisfaction with treatment, and (3) persistent signs and symptoms (abdominal pain, tenderness, fever, or chills). Outcomes were compared across groups using adjusted risk differences (aRDs), with propensity score adjustment for sociodemographic and clinical factors. Results Of the 776 study participants who were assigned antibiotic treatment in CODA, a total of 425 (mean [SD] age, 38.5 [13.6] years; 277 male [65%]) completed the baseline belief survey before knowing their treatment assignment. Baseline beliefs were as follows: 22% of participants (92 of 415) had an unsuccessful/unsure response, 51% (212 of 415) had an intermediate response, and 27% (111 of 415) had a completely successful response. Compared with the unsuccessful/unsure group, those who believed antibiotics could be completely successful had a 13-percentage point lower risk of appendectomy (aRD, -13.49; 95% CI, -24.57 to -2.40). The aRD between those with intermediate vs unsuccessful/unsure beliefs was -5.68 (95% CI, -16.57 to 5.20). Compared with the unsuccessful/unsure group, those with intermediate beliefs had a lower risk of persistent signs and symptoms (aRD, -15.72; 95% CI, -29.71 to -1.72), with directionally similar results for the completely successful group (aRD, -15.14; 95% CI, -30.56 to 0.28). Conclusions and Relevance Positive patient beliefs about the likely success of antibiotics for appendicitis were associated with a lower risk of appendectomy and with resolution of signs and symptoms by 30 days. Pathways relating beliefs to outcomes and the potential modifiability of beliefs to improve outcomes merit further investigation. Trial Registration ClinicalTrials.gov Identifier: NCT02800785.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cindy Hsu
- Writing Group for the CODA Collaborative
| | | | | | - Dennis Kim
- Writing Group for the CODA Collaborative
| | - Daniel Kim
- Writing Group for the CODA Collaborative
| | - Tien C. Ko
- Writing Group for the CODA Collaborative
| | | | - Debbie Lew
- Writing Group for the CODA Collaborative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Olga Owens
- Writing Group for the CODA Collaborative
| | | | - Zoe Parr
- Writing Group for the CODA Collaborative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Vance Sohn
- Writing Group for the CODA Collaborative
| | | | | | | | | | | | | | | | | | | | - Sean Wells
- Writing Group for the CODA Collaborative
| | | | | | | | - Jon Wisler
- Writing Group for the CODA Collaborative
| | | | | | | | | | - Irene Y. Zhang
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Emily C. Voldal
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Giana H. Davidson
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Joshua M. Liao
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Callie M. Thompson
- Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Surgery, University of Utah, Salt Lake City
| | - Wesley H. Self
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lillian S. Kao
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | | | | | - Amy H. Kaji
- Harbor–UCLA Medical Center, West Carson, California
| | | | - Eva Gonzalez
- Harbor–UCLA Medical Center, West Carson, California
| | | | - Kristen Ohe
- The Swedish Medical Center, Seattle, Washington
| | | | | | - David C. Evans
- The Ohio State University Wexner Medical Center, Columbus
| | - Jesse Victory
- Bellevue Hospital Center, NYU School of Medicine, New York, New York
| | - William Chiang
- Tisch Hospital, NYU Langone Medical Center, New York, New York
| | - Alan Jones
- The University of Mississippi Medical Center, Jackson
| | | | | | - Mike K. Liang
- Lyndon B. Johnson General Hospital, University of Texas, Houston
- HCA Healthcare, University of Houston, Kingwood, Kingwood, Texas
| | - Heather L. Evans
- Harborview Medical Center, UW Medicine, Seattle, Washington
- The Medical University of South Carolina, Charleston
| | | | | | | | | | - Bryan A. Comstock
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Patrick J. Heagerty
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Sarah O. Lawrence
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Sarah E. Monsell
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Erin E. C. Fannon
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Larry G. Kessler
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - David A. Talan
- Olive View–UCLA Medical Center, Los Angeles, California
- Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - David R. Flum
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
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Galet C, Lawrence K, Skipton Romanowski KS, Skeete D, Mashruwala N. 5 Admission Frailty Is Associated with Acute Respiratory Failure and Mortality in Burn Patients > 50. J Burn Care Res 2022. [PMCID: PMC8946053 DOI: 10.1093/jbcr/irac012.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Introduction
Pre-injury frailty has been shown to predict mortality of older burn patients. Herein, we assessed the utility of the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS) to predict burn-specific outcomes. We hypothesize that frail patients are at greater risk for complications such as graft loss, acute respiratory failure, and acute kidney injury and will require increased healthcare support at discharge.
Methods
This is a retrospective cohort study. Patients 50 years and older admitted to our Institution for burn injuries between July 2009 and June 2019 were included. Patients with inhalation injury only, no data on total burn surface area, or for whom medical history was incomplete were excluded. Demographics; comorbidities; pre-injury functional status; admission, injury, and hospitalization information; complications (graft loss, acute respiratory failure, and acute kidney disease (AKI)); mortality, and discharge disposition were collected. Patients were scored on the CSHA-CFS based on pre-admission health and functional status. The frail and non-frail groups were compared. Multivariate analyses were performed to assess the association between admission frailty and outcomes. P < 0.05 was considered significant.
Results
We included 851 patients, 697 were not frail and 154 were frail. Frail patients were significantly older (66.1 ± 10.8 vs. 63.5 ± 10.9, p = 0.002), more likely Caucasian (98.1% vs. 91%, p = 0.027) and to have suffered flame burn injuries (68.8% vs. 59.8%, p < 0.001). Frail patients had a lower %TBSA (4.4 ± 8.1% vs. 10.1 ± 13.1, p < 0.001) but were more likely to stay longer in hospital relative to %TBSA (3.6 ± 6.7 vs. 1.9 ± 3.1, p < 0.001). Frail patients were less likely to have had skin graft procedures (27.3% vs. 57.4, p < 0.001). On multivariate analysis, controlling for age, sex, race, mechanism of injury, %TBSA, 2nd degree and 3rd degree burn surface, inhalation injury, frailty was associated with acute respiratory failure (OR = 2.599 [1.460-4.628], p = 0.001). Frailty was also associated with mortality (OR = 6.915 [2.455-19.980]; p < 0.001) when controlling for the same variables as well as acute respiratory failure and AKI. Frailty was also associated with discharge to home with healthcare services (OR = 2.678 [1.491-4.809], p = 0.001), to SNF, rehabilitation, or long-term acute care facilities (OR = 3.572 [1.933-6.602], p < 0.001), and to hospice (OR = 5.759 [1.519-21.827], p = 0.010) when compared to home without healthcare services.
Conclusions
Frailty is associated with increased risk of acute respiratory failure, mortality, and requiring increased healthcare support post-discharge. Our data suggest frailty as a tool to predict morbidity and mortality as well as for goals of care discussions for the burn patient.
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Affiliation(s)
- Colette Galet
- University of Iowa, Iowa City, Iowa; Naval Medical Center San Diego, Iowa City, Iowa; UC Davis, Sacramento, California; University of Iowa, Iowa City, Iowa; Carle Foundation Hospital, Urbana, Illinois
| | - Kevin Lawrence
- University of Iowa, Iowa City, Iowa; Naval Medical Center San Diego, Iowa City, Iowa; UC Davis, Sacramento, California; University of Iowa, Iowa City, Iowa; Carle Foundation Hospital, Urbana, Illinois
| | - Kathleen S Skipton Romanowski
- University of Iowa, Iowa City, Iowa; Naval Medical Center San Diego, Iowa City, Iowa; UC Davis, Sacramento, California; University of Iowa, Iowa City, Iowa; Carle Foundation Hospital, Urbana, Illinois
| | - Dionne Skeete
- University of Iowa, Iowa City, Iowa; Naval Medical Center San Diego, Iowa City, Iowa; UC Davis, Sacramento, California; University of Iowa, Iowa City, Iowa; Carle Foundation Hospital, Urbana, Illinois
| | - Neil Mashruwala
- University of Iowa, Iowa City, Iowa; Naval Medical Center San Diego, Iowa City, Iowa; UC Davis, Sacramento, California; University of Iowa, Iowa City, Iowa; Carle Foundation Hospital, Urbana, Illinois
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Engelbart J, Zhou P, Johnson J, Lilienthal M, Zhou Y, Ten-Eyck P, Galet C, Skeete D. Geriatric clinical screening tool for cervical spine injury after ground-level falls. Emerg Med J 2021; 39:301-307. [PMID: 34108196 DOI: 10.1136/emermed-2020-210693] [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: 09/19/2020] [Accepted: 05/28/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI. METHODS The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set. RESULTS Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%). CONCLUSION Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.
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Affiliation(s)
- Jacklyn Engelbart
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Peige Zhou
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Jenna Johnson
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Michele Lilienthal
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Yunshu Zhou
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Patrick Ten-Eyck
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Colette Galet
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Dionne Skeete
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Loftus RW, Dexter F, Goodheart MJ, McDonald M, Keech J, Noiseux N, Pugely A, Sharp W, Sharafuddin M, Lawrence WT, Fisher M, McGonagill P, Shanklin J, Skeete D, Tracy C, Erickson B, Granchi T, Evans L, Schmidt E, Godding J, Brenneke R, Persons D, Herber A, Yeager M, Hadder B, Brown JR. The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201934. [PMID: 32219407 PMCID: PMC11071519 DOI: 10.1001/jamanetworkopen.2020.1934] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Importance Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration ClinicalTrials.gov Identifier: NCT03638947.
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Affiliation(s)
| | | | | | | | - John Keech
- Department of Anesthesia, University of Iowa, Iowa City
| | | | - Andrew Pugely
- Department of Anesthesia, University of Iowa, Iowa City
| | - William Sharp
- Department of Anesthesia, University of Iowa, Iowa City
| | | | | | - Mark Fisher
- Department of Anesthesia, University of Iowa, Iowa City
| | | | - Jennifer Shanklin
- Department of Anesthesia, University of Iowa, Iowa City
- now with Allina Health Surgical Specialists, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Dionne Skeete
- Department of Anesthesia, University of Iowa, Iowa City
| | - Chad Tracy
- Department of Anesthesia, University of Iowa, Iowa City
| | | | | | - Lance Evans
- Department of Anesthesia, University of Iowa, Iowa City
| | - Eli Schmidt
- Department of Anesthesia, University of Iowa, Iowa City
| | | | | | | | - Alexia Herber
- Department of Anesthesia, University of Iowa, Iowa City
| | - Mark Yeager
- Department of Anesthesia, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Brent Hadder
- Department of Anesthesia, University of Iowa, Iowa City
| | - Jeremiah R Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Nagpal P, Policeni BA, Kwofie M, Bathla G, Derdeyn CP, Skeete D. Reply. AJNR Am J Neuroradiol 2018; 39:E104. [PMID: 30093481 DOI: 10.3174/ajnr.a5758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- P Nagpal
- Department of Radiology University of Iowa Hospitals and Clinics Iowa City, Iowa
| | - B A Policeni
- Department of Radiology University of Iowa Hospitals and Clinics Iowa City, Iowa
| | - M Kwofie
- Department of Radiology University of Iowa Hospitals and Clinics Iowa City, Iowa
| | - G Bathla
- Department of Radiology University of Iowa Hospitals and Clinics Iowa City, Iowa
| | - C P Derdeyn
- Department of Radiology University of Iowa Hospitals and Clinics Iowa City, Iowa
| | - D Skeete
- Trauma Services, Department of Surgery University of Iowa Hospitals and Clinics Iowa City, Iowa
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Nagpal P, Policeni BA, Bathla G, Khandelwal A, Derdeyn C, Skeete D. Blunt Cerebrovascular Injuries: Advances in Screening, Imaging, and Management Trends. AJNR Am J Neuroradiol 2017; 39:ajnr.A5412. [PMID: 29025722 PMCID: PMC7655313 DOI: 10.3174/ajnr.a5412] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Blunt cerebrovascular injury is a relatively uncommon but sometimes life-threatening injury, particularly in patients presenting with ischemic symptoms in that vascular territory. The decision to pursue vascular imaging (generally CT angiography) is based on clinical and imaging findings. Several grading scales or screening criteria have been developed to guide the decision to pursue vascular imaging, as well as to recommend different treatment options for various injuries. The data supporting many of these guidelines and options are limited however. The purpose of this article is to review and compare these scales and criteria and the data supporting clinical efficacy and to make recommendations for future research in this area.
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Affiliation(s)
- P Nagpal
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - B A Policeni
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - G Bathla
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - A Khandelwal
- Department of Radiology (A.K.), Mayo Clinic, Rochester, Minnesota
| | - C Derdeyn
- From the Department of Radiology (P.N., B.A.P., G.B., C.D.)
| | - D Skeete
- Trauma Services (D.S.), Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Ahmed A, Harland KK, Hoffman B, Liao J, Choi K, Skeete D, Denning G. Not Just an Urban Phenomenon: Uninsured Rural Trauma Patients at Increased Risk for Mortality. West J Emerg Med 2015; 16:632-41. [PMID: 26587084 PMCID: PMC4644028 DOI: 10.5811/westjem.2015.7.27351] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/04/2022] Open
Abstract
Introduction National studies of largely urban populations showed increased risk of traumatic death among uninsured patients, as compared to those insured. No similar studies have been done for major trauma centers serving rural states. Methods We performed retrospective analyses using trauma registry records from adult, non-burn patients admitted to a single American College of Surgeons-certified Level 1 trauma center in a rural state (2003–2010, n=13,680) and National Trauma Data Bank (NTDB) registry records (2002–2008, n=380,182). Risk of traumatic death was estimated using multivariable logistic regression analysis. Results We found that 9% of trauma center patients and 27% of NTDB patients were uninsured. Overall mortality was similar for both (~4.5%). After controlling for covariates, uninsured trauma center patients were almost five times more likely to die and uninsured NTDB patients were 75% more likely to die than commercially insured patients. The risk of death among Medicaid patients was not significantly different from the commercially insured for either dataset. Conclusion Our results suggest that even with an inclusive statewide trauma system and an emergency department that does not triage by payer status, uninsured patients presenting to the trauma center were at increased risk of traumatic death relative to patients with commercial insurance.
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Affiliation(s)
- Azeemuddin Ahmed
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
| | - Karisa K Harland
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
| | - Bryce Hoffman
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
| | - Junlin Liao
- University of Iowa, Department of Surgery, Iowa City, Iowa
| | - Kent Choi
- University of Iowa, Department of Surgery, Iowa City, Iowa
| | - Dionne Skeete
- University of Iowa, Department of Surgery, Iowa City, Iowa
| | - Gerene Denning
- University of Iowa, Department of Emergency Medicine, Iowa City, Iowa
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Mohr NM, Harland KK, Skeete D, Pearson K, Choi K. Duration of prehospital intubation is not a risk factor for development of early ventilator-associated pneumonia. J Crit Care 2014; 29:539-44. [PMID: 24793661 DOI: 10.1016/j.jcrc.2014.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 10/24/2013] [Revised: 03/26/2014] [Accepted: 03/28/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality among critically ill patients with trauma. Few VAP prevention strategies have been studied in the prehospital environment. The objectives of this study are to measure the association between duration of prehospital intubation and intubation location with subsequent incidence of early (within 5 days) VAP. MATERIALS AND METHODS Single-center retrospective cohort study of all intubated adult (age≥18 years) patients with trauma presenting to a 711-bed Midwestern Level I trauma center between January 2005 and December 2011 (n=860). RESULTS Thirty-five patients (6.4%) were diagnosed as having early VAP during the study period. Using multivariable logistic regression to adjust for age, injury severity score, and year (corresponding to VAP bundle implementation), the duration of intubation prior to hospital admission was not associated with subsequent diagnosis of VAP (adjusted odds ratio, 0.90 per hour; 95% confidence interval, 0.70-1.15). Location of intubation was similarly not associated with VAP. CONCLUSIONS Duration of prehospital intubation and intubation location were not different in patients with trauma who developed early VAP. Further prospective analyses should be conducted to better elucidate the effect of prehospital management on the development of traditionally in-hospital complications.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Anesthesia, Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, IA.
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Injury Prevention Research Center, University of Iowa College of Public Health, Iowa City, IA
| | - Dionne Skeete
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kent Pearson
- Department of Anesthesia, Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kent Choi
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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10
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Sun R, Skeete D, Wetjen K, Lilienthal M, Liao J, Madsen M, Lancaster G, Shilyansky J, Choi K. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res 2013; 183:341-6. [PMID: 23357274 DOI: 10.1016/j.jss.2012.12.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 12/14/2012] [Accepted: 12/21/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND To minimize radiation exposure in children and reduce resource use, we implemented an age-specific algorithm to evaluate cervical spine injuries at a Level 1 trauma center. The effects of protocol implementation on computed tomography (CT) use in children (≤ 10 y) were determined. METHODS With institutional review board approval, we conducted a retrospective review using the institutional trauma registry. All pediatric patients (≤ 10 y) (n = 324) between January 2007 and present were reviewed. We excluded cases in which no imaging or outside imaging was performed. Patients were evaluated by physical exam alone, with the aid of plain radiograms or with cervical spine CT. All patients who required head CT also had CT of cervical spine to C3. We analyzed demographic, injury, and outcome data using STATA to perform chi-square and t-test, and to determine P value. P < 0.05 was defined as significant. We used the WinDose program to calculate the radiation-effective dose used in cervical spine CT. RESULTS There were 123 and 124 patients in the pre-protocol and post-protocol groups, respectively. Demographics, GCS, and injury analysis, specifically head-neck and face Injury Severity Scores showed no significant difference between groups. There was a 60% (P < 0.001) decrease in the use of full CTs after protocol implementation. We estimated that the protocol reduced the exposed area by 50% and decreased the radiation dose to the thyroid by > 80%. We extrapolated the combined effect results in a threefold reduction in radiation exposure. CONCLUSIONS Implementation of a cervical spine protocol led to a significant reduction in radiation exposure among children.
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Affiliation(s)
- Raphael Sun
- Department of Surgery, Division of Acute Care Surgery and Pediatric Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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Ahmed A, Hoffman B, Harland K, Skeete D, Choi K, Liao J. 257 Not Just an Urban Phenomenon: Uninsured Trauma Patients in Rural Setting at Risk for Increased Mortality. Ann Emerg Med 2012. [DOI: 10.1016/j.annemergmed.2012.06.235] [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: 10/27/2022]
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Fang S, Skeete D, Cullen JJ. Preoperative risk factors for postoperative Staphylococcus aureus nosocomial infections. Surg Technol Int 2004; 13:35-8. [PMID: 15744674] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Of the 40 million patients who undergo surgery each year in the United States, 20% may develop a postoperative nosocomial infection. Staphylococcus aureus (S. aureus) is the most common organism involved, and carriage of S. aureus in the anterior nares has been identified as a risk factor for these infections. Topical mupirocin applied to the anterior nares has been successful in eliminating S. aureus and decreasing nosocomial infections due to S. aureus. Concurrent use of preoperative chlorhexidine showers may further reduce the incidence of S. aureus surgical site infections (SSIs). In addition to treating the patient, active surveillance programs to eliminate nasal colonization in hospital surgical personnel have controlled outbreaks of S. aureus SSIs. Recently, a large study identified risk factors linked to S. aureus nasal colonization, which included obesity, male gender, and a history of a cerebrovascular accident. Protective factors included older age, current smoking, and alcohol use. Thus, by modulating these variables, investigators may create interventions aimed at reducing S. aureus nasal carriage and ultimately, postoperative nosocomial infections.
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Affiliation(s)
- Sandy Fang
- Department of Surgery, University of Iowa College of Medicine and Veterans Affairs Medical Center, Iowa City, Iowa, USA
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