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Lubkin DT, Mueck KM, Hatton GE, Brill JB, Sandoval M, Cardenas JC, Wade CE, Cotton BA. Does an early, balanced resuscitation strategy reduce the incidence of hypofibrinogenemia in hemorrhagic shock? Trauma Surg Acute Care Open 2024; 9:e001193. [PMID: 38596569 PMCID: PMC11002398 DOI: 10.1136/tsaco-2023-001193] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Objectives Some centers have recommended including concentrated fibrinogen replacement in massive transfusion protocols (MTPs). Given our center's policy of aggressive early balanced resuscitation (1:1:1), beginning prehospital, we hypothesized that our rates of hypofibrinogenemia may be lower than those previously reported. Methods In this retrospective cohort study, patients presenting to our trauma center November 2017 to April 2021 were reviewed. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography angle <60. Univariate and multivariable analyses assessed risk factors for HYPOFIB. Inverse probability of treatment weighting analyses assessed the relationship between cryoprecipitate administration and outcomes. Results Of 29 782 patients, 6618 level 1 activations, and 1948 patients receiving emergency release blood, <1%, 2%, and 7% were HYPOFIB. HYPOFIB patients were younger, had higher head Abbreviated Injury Scale value, and had worse coagulopathy and shock. HYPOFIB had lower survival (48% vs 82%, p<0.001), shorter time to death (median 28 (7, 50) vs 36 (14, 140) hours, p=0.012), and were more likely to die from head injury (72% vs 51%, p<0.001). Risk factors for HYPOFIB included increased age (OR (95% CI) 0.98 (0.96 to 0.99), p=0.03), head injury severity (OR 1.24 (1.06 to 1.46), p=0.009), lower arrival pH (OR 0.01 (0.001 to 0.20), p=0.002), and elevated prehospital red blood cell to platelet ratio (OR 1.20 (1.02 to 1.41), p=0.03). Among HYPOFIB patients, there was no difference in survival for those that received early cryoprecipitate (within 2 hours; 40 vs 47%; p=0.630). On inverse probability of treatment weighted analysis, early cryoprecipitate did not benefit the full cohort (OR 0.52 (0.43 to 0.65), p<0.001), nor the HYPOFIB subgroup (0.28 (0.20 to 0.39), p<0.001). Conclusions Low rates of hypofibrinogenemia were found in our center which treats hemorrhage with early, balanced resuscitation. Previously reported higher rates may be partially due to unbalanced resuscitation and/or delay in resuscitation initiation. Routine empiric inclusion of concentrated fibrinogen replacement in MTPs is not supported by the currently available data. Level of evidence Level III.
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Affiliation(s)
- David T Lubkin
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Krislynn M Mueck
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabrielle E Hatton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason B Brill
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jessica C Cardenas
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Brill JB, Mueck KM, Cotton ME, Tang B, Sandoval M, Kao LS, Cotton BA. Impact of COVID status and blood group on complications in patients in hemorrhagic shock. Trauma Surg Acute Care Open 2024; 9:e001250. [PMID: 38529316 PMCID: PMC10961517 DOI: 10.1136/tsaco-2023-001250] [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: 09/07/2023] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
Objective Among critically injured patients of various blood groups, we sought to compare survival and complication rates between COVID-19-positive and COVID-19-negative cohorts. Background SARS-CoV-2 infections have been shown to cause endothelial injury and dysfunctional coagulation. We hypothesized that, among patients with trauma in hemorrhagic shock, COVID-19-positive status would be associated with increased mortality and inpatient complications. As a secondary hypothesis, we suspected group O patients with COVID-19 would experience fewer complications than non-group O patients with COVID-19. Methods We evaluated all trauma patients admitted 4/2020-7/2020. Patients 16 years or older were included if they presented in hemorrhagic shock and received emergency release blood products. Patients were dichotomized by COVID-19 testing and then divided by blood groups. Results 3281 patients with trauma were evaluated, and 417 met criteria for analysis. Seven percent (29) of patients were COVID-19 positive; 388 were COVID-19 negative. COVID-19-positive patients experienced higher complication rates than the COVID-19-negative cohort, including acute kidney injury, pneumonia, sepsis, venous thromboembolism, and systemic inflammatory response syndrome. Univariate analysis by blood groups demonstrated that survival for COVID-19-positive group O patients was similar to that of COVID-19-negative patients (79 vs 78%). However, COVID-19-positive non-group O patients had a significantly lower survival (38%). Controlling for age, sex and Injury Severity Score, COVID-19-positive patients had a greater than 70% decreased odds of survival (OR 0.28, 95% CI 0.09 to 0.81; p=0.019). Conclusions COVID-19 status is associated with increased major complications and 70% decreased odds of survival in this group of patients with trauma. However, among patients with COVID-19, blood group O was associated with twofold increased survival over other blood groups. This survival rate was similar to that of patients without COVID-19.
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Affiliation(s)
- Jason Bradley Brill
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Krislynn M Mueck
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Madeline E Cotton
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Brian Tang
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
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Dodwad SJM, Mueck KM, Kregel HR, Guy-Frank CJ, Isbell KD, Klugh JM, Wade CE, Harvin JA, Kao LS, Wandling MW. Impact of Intra-Operative Shock and Resuscitation on Surgical Site Infections After Trauma Laparotomy. Surg Infect (Larchmt) 2024; 25:19-25. [PMID: 38170174 PMCID: PMC10825266 DOI: 10.1089/sur.2023.010] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
Background: Patients undergoing trauma laparotomy experience high rates of surgical site infection (SSI). Although intra-operative shock is a likely contributor to SSI risk, little is known about the relation between shock, intra-operative restoration of physiologic normalcy, and SSI development. Patients and Methods: A retrospective review of trauma patients who underwent emergent definitive laparotomy was performed. Using shock index and base excess at the beginning and end of laparotomy, patients were classified as normal, persistent shock, resuscitated, or new shock. Univariable and multivariable analyses were performed to identify predictors of organ/space SSI, superficial/deep SSI, and any SSI. Results: Of 1,191 included patients, 600 (50%) were categorized as no shock, 248 (21%) as resuscitated, 109 (9%) as new shock, and 236 (20%) as persistent shock, with incidence of any SSI as 51 (9%), 28 (11%), 26 (24%), and 32 (14%), respectively. These rates were similar in organ/space and superficial/deep SSIs. On multivariable analysis, resuscitated, new shock, and persistent shock were associated with increased odds of organ/space SSI (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3-3.5; p < 0.001) and any SSI (OR, 2.0; 95% CI, 1.4-3.2; p < 0.001), but no increased risk of superficial/deep SSI (OR, 1.4; 95% CI, 0.8-2.6; p = 0.331). Conclusions: Although the trajectory of physiologic status influenced SSI, the presence of shock at any time during trauma laparotomy, regardless of restoration of physiologic normalcy, was associated with increased odds of SSI. Further investigation is warranted to determine the relation between peri-operative shock and SSI in trauma patients.
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Affiliation(s)
- Shah-Jahan M. Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Krislynn M. Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Heather R. Kregel
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Chelsea J. Guy-Frank
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Kayla D. Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - James M. Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - John A. Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Michael W. Wandling
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
- Red Duke Trauma Institute, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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Dodwad SJM, Isbell KD, Mueck KM, Klugh JM, Meyer DE, Wade CE, Kao LS, Harvin JA. Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial. J Surg Res 2024; 293:57-63. [PMID: 37716101 PMCID: PMC10841256 DOI: 10.1016/j.jss.2023.06.042] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/21/2023] [Accepted: 06/13/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL). METHODS The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference. RESULTS Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively. CONCLUSIONS Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.
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Affiliation(s)
- Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas.
| | - Kayla D Isbell
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Krislynn M Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - James M Klugh
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - David E Meyer
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Charles E Wade
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
| | - John A Harvin
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas; Red Duke Trauma Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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Hatton GE, Brill JB, Tang B, Mueck KM, McCoy CC, Kao LS, Cotton BA. Patients with both traumatic brain injury and hemorrhagic shock benefit from resuscitation with whole blood. J Trauma Acute Care Surg 2023; 95:918-924. [PMID: 37506356 DOI: 10.1097/ta.0000000000004110] [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: 07/30/2023]
Abstract
BACKGROUND Hemorrhagic shock in the setting of traumatic brain injury (TBI) reduces cerebral blood flow and doubles mortality. The optimal resuscitation strategy for hemorrhage in the setting of TBI is unknown. We hypothesized that, among patients presenting with concomitant hemorrhagic shock and TBI, resuscitation including whole blood (WB) is associated with decreased overall and TBI-related mortality when compared with patients receiving component (COMP) therapy alone. METHODS An a priori subgroup of prospective, observational cohort study of injured patients receiving emergency-release blood products for hemorrhagic shock is reported. Adult trauma patients presenting November 2017 to September 2020 with TBI, defined as a Head Abbreviated Injury Scale of ≥3, were included. Whole blood group patients received any cold-store low-titer Group O WB units. The COMP group received fractionated blood components alone. Overall and TBI-related 30-day mortality, favorable discharge disposition (home or rehabilitation), and 24-hour blood product utilization were assessed. Univariate and inverse probabilities of treatment-weighted multivariable analyses were performed. RESULTS Of 564 eligible patients, 341 received WB. Patients who received WB had a higher injury severity score (median, 34 vs. 29), lower scene blood pressure (104 vs. 118), and higher arrival lactate (4.3 vs. 3.6, all p < 0.05). Univariate analysis noted similar overall mortality between WB and COMP; however, weighted multivariable analyses found WB was associated with decreased overall mortality and TBI-related mortality. There were no differences in discharge disposition between the WB group and COMP group. CONCLUSION In patients with concomitant hemorrhagic shock and TBI, WB transfusion was associated with decreased overall mortality and TBI-related mortality. Whole blood should be considered a first-line therapy for hemorrhage in the setting of TBI. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Gabrielle E Hatton
- From the Center for Translational Injury Research (G.E.H., J.B.B., B.T., K.M.M., C.C.M., L.S.K., B.A.C.), Department of Surgery (G.E.H., J.B.B., B.T., K.M.M., C.C.M., L.S.K., B.A.C.), and Center for Surgical Trials and Evidence-based Practice (G.E.H., K.M.M., L.S.K.), McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
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Thompson CM, Voldal EC, Davidson GH, Sanchez SE, Ayoung-Chee P, Victory J, Guiden M, Bizzell B, Glaser J, Hults C, Price TP, Siparsky N, Ohe K, Mandell KA, DeUgarte DA, Kaji AH, Uribe L, Kao LS, Mueck KM, Farjah F, Self WH, Clark S, Drake FT, Fischkoff K, Minko E, Cuschieri J, Faine B, Skeete DA, Dhanani N, Liang MK, Krishnadasan A, Talan DA, Fannon E, Kessler LG, Comstock BA, Heagerty PJ, Monsell SE, Lawrence SO, Flum DR, Lavallee DC. Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort. Ann Surg 2023; 277:886-893. [PMID: 35815898 PMCID: PMC10174100 DOI: 10.1097/sla.0000000000005458] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days. SUMMARY BACKGROUND DATA The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes. METHODS We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations. RESULTS The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret. CONCLUSIONS Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02800785.
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Affiliation(s)
- Callie M Thompson
- Vanderbilt University Medical Center, Nashville, TN
- University of Utah, Salt Lake City, UT
| | | | | | | | - Patricia Ayoung-Chee
- Tisch Hospital NYU Langone Medical Center, New York, NY
- Grady Health, Morehouse School of Medicine, Atlanta, GA
| | - Jesse Victory
- Bellevue Hospital Center NYU School of Medicine, New York, NY
| | | | | | - Jacob Glaser
- Providence Regional Medical Center Everett, Everett, WA
| | | | | | | | | | | | | | - Amy H Kaji
- Harbor-UCLA Medical Center, Torrance, CA
| | | | - Lillian S Kao
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Krislynn M Mueck
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Sunday Clark
- Boston University Medical Center, Boston, MA
- Weill Cornell Medicine, New York, NY
| | | | | | | | - Joseph Cuschieri
- Harborview Medical Center, Seattle, WA
- University of California, San Francisco, San Francisco, CA
| | - Brett Faine
- University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Naila Dhanani
- University of Texas Lyndon B. Johnson General Hospital, Houston, TX
| | - Mike K Liang
- University of Texas Lyndon B. Johnson General Hospital, Houston, TX
- University of Houston, HCA Healthcare Kingwood, Kingwood, TX
| | | | - David A Talan
- Olive View-UCLA Medical Center, Sylmar, CA
- Ronald Reagan UCLA Medical Center, Westwood, CA
| | | | | | | | | | | | | | | | - Danielle C Lavallee
- University of Washington, Seattle, WA
- BC Academic Science Health Network, Vancouver, BC, Canada
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Brill JB, Mueck KM, Tang B, Sandoval M, Cotton ME, Cameron McCoy C, Cotton BA. Is Low-Titer Group O Whole Blood Truly a Universal Blood Product? J Am Coll Surg 2023; 236:506-513. [PMID: 36730210 DOI: 10.1097/xcs.0000000000000489] [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: 02/03/2023]
Abstract
BACKGROUND Whole blood was historically transfused as a type-specific product. Given recent advocacy for low-titer group O whole blood (LTOWB) as a universal blood product, we examined outcomes after LTOWB transfusion stratified by recipient blood groups. STUDY DESIGN Adult trauma patients receiving prehospital or in-hospital transfusion of LTOWB (November 2017 to July 2020) at a single trauma center were prospectively evaluated. The patients were divided into blood type groups (O, A, B, and AB). Major complications and survival to 30 days were compared. Univariate analyses among blood groups were followed by purposeful regression modeling, reflecting 6 variables of significance: male sex, White race, injury severity, arrival lactate, arrival systolic blood pressure, and emergency department blood products. RESULTS Of 1,075 patients receiving any LTOWB, 539 (50.1%) were Group O, 340 (31.6%) were Group A, 150 (14.0%) were Group B, and 46 (4.3%) were Group AB. There were no statistically significant differences in demographics, injury severity, hemolysis panels, prehospital vitals, or resuscitation parameters (all p > 0.05). However, arrival systolic pressure was lower (91 vs 102, p = 0.034) and lactate was worse (5.5 vs 4.1, p = 0.048) in Group B patients compared to other groups. While survival and most major complications did not differ across recipient groups, acute kidney injury (AKI) initially appeared higher for Group B. Stepwise regression did not show a difference in AKI rates. This analysis was repeated in patients receiving only component products. Group B again showed no significantly increased risk of AKI (13%) compared to other groups (O 7%, A 7%, AB 5%; p = 0.091). CONCLUSIONS LTOWB appears to be a safe product for universal use across all blood groups. Group B recipients arrived with worse physiologic values associated with hemorrhagic shock whether receiving LTOWB or standard component products.
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Affiliation(s)
- Jason B Brill
- From the University of Texas Health Science Center at Houston, Houston, TX (Brill, Mueck, Tang, Sandoval, ME Cotton, BA Cotton)
| | - Krislynn M Mueck
- From the University of Texas Health Science Center at Houston, Houston, TX (Brill, Mueck, Tang, Sandoval, ME Cotton, BA Cotton)
| | - Brian Tang
- From the University of Texas Health Science Center at Houston, Houston, TX (Brill, Mueck, Tang, Sandoval, ME Cotton, BA Cotton)
| | - Mariela Sandoval
- From the University of Texas Health Science Center at Houston, Houston, TX (Brill, Mueck, Tang, Sandoval, ME Cotton, BA Cotton)
| | - Madeline E Cotton
- From the University of Texas Health Science Center at Houston, Houston, TX (Brill, Mueck, Tang, Sandoval, ME Cotton, BA Cotton)
| | - C Cameron McCoy
- the University of Kansas Medical Center, Kansas City, KS (McCoy)
| | - Bryan A Cotton
- From the University of Texas Health Science Center at Houston, Houston, TX (Brill, Mueck, Tang, Sandoval, ME Cotton, BA Cotton)
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Brill JB, Tang B, Hatton G, Mueck KM, McCoy CC, Kao LS, Cotton BA. Impact of Incorporating Whole Blood into Hemorrhagic Shock Resuscitation: Analysis of 1,377 Consecutive Trauma Patients Receiving Emergency-Release Uncrossmatched Blood Products. J Am Coll Surg 2022; 234:408-418. [PMID: 35290259 DOI: 10.1097/xcs.0000000000000086] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [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 Use of whole blood (WB) for trauma resuscitation has seen a resurgence. The purpose of this study was to investigate survival benefit of WB across a diverse population of bleeding trauma patients. STUDY DESIGN A prospective observational cohort study of injured patients receiving emergency-release blood products was performed. All adult trauma patients resuscitated between November 2017 and September 2020 were included. The WB group included patients receiving any group O WB units. The component (COMP) group received no WB units, instead relying on fractionated blood (red blood cells, plasma, and platelets). Univariate and multivariate analyses were performed. Given large observed differences in our regression model, post hoc adjustments with inverse probability of treatment were conducted and a propensity score created. Propensity scoring and Poisson regression supported these findings. RESULTS Of 1,377 patients receiving emergency release blood products, 840 received WB and 537 remained in the COMP arm. WB patients had higher Injury Severity Score (ISS; 27 vs 20), lower field blood pressure (103 vs 114), and higher arrival lactate (4.2 vs 3.5; all p < 0.05). Postarrival transfusions and complications were similar between groups, except for sepsis, which was lower in the WB arm (25 vs 30%, p = 0.041). Although univariate analysis noted similar survival between WB and COMP (75 vs 76%), logistic regression found WB was independently associated with a 4-fold increased survival (odds ratio [OR] 4.10, p < 0.001). WB patients also had a 60% reduction in overall transfusions (OR 0.38, 95% CI 0.21-0.70). This impact on survival remained regardless of location of transfusion, ISS, or presence of head injury. CONCLUSION In patients experiencing hemorrhagic shock, WB transfusion is associated with both improved survival and decreased overall blood utilization.
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Affiliation(s)
- Jason B Brill
- From The McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Brill, Tang, Hatton, Mueck, Kao, Cotton)
| | - Brian Tang
- From The McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Brill, Tang, Hatton, Mueck, Kao, Cotton)
| | - Gabrielle Hatton
- From The McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Brill, Tang, Hatton, Mueck, Kao, Cotton)
| | - Krislynn M Mueck
- From The McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Brill, Tang, Hatton, Mueck, Kao, Cotton)
| | - C Cameron McCoy
- The University of Kansas Medical Center, Kansas City, KS (McCoy)
| | - Lillian S Kao
- From The McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Brill, Tang, Hatton, Mueck, Kao, Cotton)
| | - Bryan A Cotton
- From The McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Brill, Tang, Hatton, Mueck, Kao, Cotton)
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9
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Isbell KD, Wei S, Dodwad SJM, Avritscher EB, Mueck KM, Bernardi K, Hatton GE, Liang MK, Ko TC, Kao LS. Impact of Early Cholecystectomy on the Cost of Treating Mild Gallstone Pancreatitis: Gallstone PANC Trial. J Am Coll Surg 2021; 233:517-525.e1. [PMID: 34325019 DOI: 10.1016/j.jamcollsurg.2021.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/04/2021] [Accepted: 06/22/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Gallstone Pancreatitis: Admission vs Normal Cholecystectomy (Gallstone PANC) Trial demonstrated that cholecystectomy within 24 hours of admission (early) compared with after clinical resolution (control) for mild gallstone pancreatitis, significantly reduced 30-day length-of-stay (LOS) without increasing major postoperative complications. We assessed whether early cholecystectomy decreased 90-day healthcare use and costs. STUDY DESIGN A secondary economic evaluation of the Gallstone PANC Trial was performed from the healthcare system perspective. Costs for index admissions and all gallstone pancreatitis-related care 90 days post-discharge were obtained from the hospital accounting system and inflated to 2020 USD. Negative binomial regression models and generalized linear models with log-link and gamma distribution, adjusting for randomization strata, were used. Bayesian analysis with neutral prior was used to estimate the probability of cost reduction with early cholecystectomy. RESULTS Of 98 randomized patients, 97 were included in the analyses. Baseline characteristics were similar in early (n = 49) and control (n = 48) groups. Early cholecystectomy resulted in a mean absolute difference in LOS of -0.96 days (95% CI, -1.91 to 0.00, p = 0.05). Ninety-day mean total costs were $14,974 (early) vs $16,190 (control) (cost ratio [CR], 0.92; 95% CI, 0.73-1.15, p = 0.47), with a mean absolute difference of $1,216 less (95% CI, -$4,782 to $2,349, p = 0.50) per patient in the early group. On Bayesian analysis, there was an 81% posterior probability that early cholecystectomy reduced 90-day total costs. CONCLUSION In this single-center trial, early cholecystectomy for mild gallstone pancreatitis reduced 90-day LOS and had an 81% probability of reducing 90-day healthcare system costs.
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Affiliation(s)
- Kayla D Isbell
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice
| | - Shuyan Wei
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice
| | - Shah-Jahan M Dodwad
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice
| | - Elenir Bc Avritscher
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Krislynn M Mueck
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice
| | - Karla Bernardi
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice
| | - Gabrielle E Hatton
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice
| | - Mike K Liang
- University of Houston, HCA Healthcare Kingwood, Kingwood, TX
| | | | - Lillian S Kao
- Department of Surgery; Center for Surgical Trials and Evidence-based Practice; Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX.
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10
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Mueck KM, Kao LS. Applying the Swiss Cheese Model to Incisional Hernia Management: Opportunities to Reduce Excess Mortality from Acute Incarceration. J Am Coll Surg 2020; 231:545-546. [DOI: 10.1016/j.jamcollsurg.2020.08.754] [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] [Received: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
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11
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Wei S, Avritscher EB, Mueck KM, Bernardi K, Hatton GE, Liang MK, Ko TC, Kao LS. Impact of Early Cholecystectomy on the Costs of Treating Mild Gallstone Pancreatitis (Gallstone PANC Trial). J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.224] [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: 11/28/2022]
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12
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Mueck KM, Wei S, Pedroza C, Bernardi K, Jackson ML, Liang MK, Ko TC, Tyson JE, Kao LS. Gallstone Pancreatitis: Admission Versus Normal Cholecystectomy-a Randomized Trial (Gallstone PANC Trial). Ann Surg 2019; 270:519-527. [PMID: 31415304 PMCID: PMC6949044 DOI: 10.1097/sla.0000000000003424] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Early cholecystectomy shortly after admission for mild gallstone pancreatitis has been proposed based on observational data. We hypothesized that cholecystectomy within 24 hours of admission versus after clinical resolution of gallstone pancreatitis that is predicted to be mild results in decreased length-of-stay (LOS) without an increase in complications. METHODS Adults with predicted mild gallstone pancreatitis were randomized to cholecystectomy with cholangiogram within 24 hours of presentation (early group) versus after clinical resolution (control) based on abdominal exam and normalized laboratory values. Primary outcome was 30-day LOS including readmissions. Secondary outcomes were time to surgery, endoscopic retrograde cholangiopancreatography (ERCP) rates, and postoperative complications. Frequentist and Bayesian intention-to-treat analyses were performed. RESULTS Baseline characteristics were similar in the early (n = 49) and control (n = 48) groups. Early group had fewer ERCPs (15% vs 29%, P = 0.038), faster time to surgery (16 h vs 43 h, P < 0.005), and shorter 30-day LOS (50 h vs 77 h, RR 0.68 95% CI 0.65 - 0.71, P < 0.005). Complication rates were 6% in early group versus 2% in controls (P = 0.613), which included recurrence/progression of pancreatitis (2 early, 1 control) and a cystic duct stump leak (early). On Bayesian analysis, early cholecystectomy has a 99% probability of reducing 30-day LOS, 93% probability of decreasing ERCP use, and 72% probability of increasing complications. CONCLUSION In patients with predicted mild gallstone pancreatitis, cholecystectomy within 24 hours of admission reduced rate of ERCPs, time to surgery, and 30-day length-of-stay. Minor complications may be increased with early cholecystectomy. Identification of patients with predicted mild gallstone pancreatitis in whom early cholecystectomy is safe warrants further investigation.
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Affiliation(s)
- Krislynn M Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Shuyan Wei
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Karla Bernardi
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Margaret L Jackson
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Mike K Liang
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Tien C Ko
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Jon E Tyson
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
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13
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Cherla DV, Viso CP, Holihan JL, Bernardi K, Moses ML, Mueck KM, Olavarria OA, Flores-Gonzalez JR, Balentine CJ, Ko TC, Adams SD, Pedroza C, Kao LS, Liang MK. The Effect of Financial Conflict of Interest, Disclosure Status, and Relevance on Medical Research from the United States. J Gen Intern Med 2019; 34:429-434. [PMID: 30604124 PMCID: PMC6420588 DOI: 10.1007/s11606-018-4784-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/31/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Financial interactions between industry and healthcare providers are reportable. Substantial discrepancies have been detected between industry and self-report of these conflicts of interest (COIs). OBJECTIVE Our aim was to determine if authors who fail to disclose reportable COI are more likely to publish findings that are favorable to industry than authors with no COI. DESIGN In this blinded, observational study of medical and surgical primary research articles in PubMed, 590 articles were reviewed. MAIN MEASURES Reportable financial relationships between authors and industry were evaluated. COIs were considered to have relevance if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, defined as an impression favorable to the product(s) discussed by an article and determined by 3 independent, blinded clinicians for each article. Primary analysis compared Incomplete Self-Disclosure to No COI. Two-level multivariable mixed-effects ordered logistic regression was used to assess factors associated with favorability. KEY RESULTS A 69% discordance rate existed between industry and self-report in COI disclosure. When authors failed to disclose COI, their conclusions were more likely to favor industry partners than authors without COI (favorable ratings 73% versus 62%, RR 1.18, p = < 0.001). On univariate (any COI 74% versus no COI 62%, RR 1.11, p = < 0.001) and multivariable analyses, any COI was associated with favorability. CONCLUSIONS All financial COIs (disclosed or undisclosed, relevant or not relevant, research or non-research) influence whether studies report findings favorable to industry sponsors.
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Affiliation(s)
- Deepa V Cherla
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cristina P Viso
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Karla Bernardi
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Department of Surgery, General Surgery Clinical Research Fellow, Houston, TX, USA.
| | - Maya L Moses
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Krislynn M Mueck
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Oscar A Olavarria
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan R Flores-Gonzalez
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Courtney J Balentine
- Department of Surgery & Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tien C Ko
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Claudia Pedroza
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mike K Liang
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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14
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Cherla DV, Viso CP, Olavarria OA, Bernardi K, Holihan JL, Mueck KM, Flores-Gonzalez J, Liang MK, Adams SD. The Impact of Financial Conflict of Interest on Surgical Research: An Observational Study of Published Manuscripts. World J Surg 2018; 42:2757-2762. [PMID: 29426969 DOI: 10.1007/s00268-018-4532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Substantial discrepancies exist between industry-reported and self-reported conflicts of interest (COI). Although authors with relevant, self-reported financial COI are more likely to write studies favorable to industry sponsors, it is unknown whether undisclosed COI have the same effect. We hypothesized that surgeons who fail to disclose COI are more likely to publish findings that are favorable to industry than surgeons with no COI. METHODS PubMed was searched for articles in multiple surgical specialties. Financial COI reported by surgeons and industry were compared. COI were considered to be relevant if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, which was defined as an impression favorable to the product(s) discussed by an article and was determined by 3 independent, blinded clinicians for each article. Primary analysis compared incomplete self-disclosure to no COI. Ordered logistic multivariable regression modeling was used to assess factors associated with favorability. RESULTS Overall, 337 articles were reviewed. There was a high rate of discordance in the reporting of COI (70.3%). When surgeons failed to disclose COI, their conclusions were significantly more likely to favor industry than surgeons without COI (RR 1.2, 95% CI 1.1-1.4, p < 0.001). On multivariable analysis, any COI (regardless of relevance, disclosure, or monetary amount) were significantly associated with favorability. CONCLUSIONS Any financial COI (disclosed or undisclosed, relevant or not relevant) significantly influence whether studies report findings favorable to industry. More attention must be paid to improving research design, maximizing transparency in medical research, and insisting that surgeons disclose all COI, regardless of perceived relevance.
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Affiliation(s)
- Deepa V Cherla
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cristina P Viso
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Oscar A Olavarria
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Karla Bernardi
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA.
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Julie L Holihan
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan Flores-Gonzalez
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Mike K Liang
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sasha D Adams
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
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15
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Mueck KM, Wei S, Liang MK, Ko TC, Tyson JE, Kao LS. Protocol for a randomized trial of the effect of timing of cholecystectomy during initial admission for predicted mild gallstone pancreatitis at a safety-net hospital. Trauma Surg Acute Care Open 2018; 3:e000152. [PMID: 29766134 PMCID: PMC5887782 DOI: 10.1136/tsaco-2017-000152] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/31/2017] [Indexed: 01/06/2023] Open
Abstract
Background There is evidence-based consensus for laparoscopic cholecystectomy during index admission for predicted mild gallstone pancreatitis, defined by the absence of organ failure and of local or systemic complications. However, the optimal timing for surgery within that admission is controversial. Early cholecystectomy may shorten hospital length of stay (LOS) and increase patient satisfaction. Alternatively, it may increase operative difficulty and complications resulting in readmissions. Methods This trial is a single-center randomized trial of patients with predicted mild gallstone pancreatitis comparing laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) at index admission within 24 hours of presentation versus after clinical resolution on clinical and patient-reported outcomes (PROs). The primary endpoint is 30-day LOS (hours) after initial presentation, which includes the index admission and readmissions. Secondary outcomes are conversion to open, complications, time from admission to cholecystectomy, initial hospital LOS, number of procedures within 30 days, 30-day readmissions, and PROs (change in Gastrointestinal Quality-of-Life Index). Discussion The primary goal of this research is to obtain the least biased estimate of effect of timing of cholecystectomy for mild gallstone pancreatitis on clinical and PROs; the results of this trial will be used to inform patient care locally as well as to design future multicenter effectiveness and implementation trials. This trial will provide data regarding PROs including health-related quality of life that can be used in cost-utility and cost-effectiveness analyses. Trial registration number NCT02806297, ClinicalTrials.gov.
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Affiliation(s)
- Krislynn M Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Departments of Surgery and Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Shuyan Wei
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Departments of Surgery and Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Mike K Liang
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Departments of Surgery and Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Tien C Ko
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Jon E Tyson
- Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Departments of Surgery and Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice (CSTEP), McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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16
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Lee JC, Williams GW, Kozar RA, Kao LS, Mueck KM, Emerald AD, Villegas NC, Moore LJ. Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit. JPEN J Parenter Enteral Nutr 2017; 42:529-537. [PMID: 29187048 DOI: 10.1177/0148607117699561] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 01/08/2017] [Accepted: 02/21/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch-up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies. METHODS All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014-May 2015 (intervention) and May 2012-June 2013 (baseline). RESULTS The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28-ay ventilator-free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31-0.89; P = .017) after adjusting sex and Injury Severity Score. CONCLUSIONS Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.
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Affiliation(s)
- Jenny C Lee
- Department of Clinical Nutrition, Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| | - George W Williams
- Department of Anesthesiology, Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Rosemary A Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lillian S Kao
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Krislynn M Mueck
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Andrew D Emerald
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
| | - Natacha C Villegas
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Laura J Moore
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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17
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Mueck KM, Leal IM, Wan CC, Goldberg BF, Saunders TE, Millas SG, Liang MK, Ko TC, Kao LS. Shared decision-making during surgical consultation for gallstones at a safety-net hospital. Surgery 2017; 163:680-686. [PMID: 29223328 DOI: 10.1016/j.surg.2017.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 09/04/2017] [Accepted: 10/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Understanding patient perspectives regarding shared decision-making is crucial to providing informed, patient-centered care. Little is known about perceptions of vulnerable patients regarding shared decision-making during surgical consultation. The purpose of this study was to evaluate whether a validated tool reflects perceptions of shared decision-making accurately among patients seeking surgical consultation for gallstones at a safety-net hospital. METHODS A mixed methods study was conducted in a sample of adult patients with gallstones evaluated at a safety-net surgery clinic between May to July 2016. Semi-structured interviews were conducted after their initial surgical consultation and analyzed for emerging themes. Patients were administered the Shared Decision-Making Questionnaire and Autonomy Preference Scale. Univariate analyses were performed to identify factors associated with shared decision-making and to compare the results of the surveys to those of the interviews. RESULTS The majority of patients (N = 30) were female (90%), Hispanic (80%), Spanish-speaking (70%), and middle-aged (45.7 ± 16 years). The proportion of patients who perceived shared decision-making was greater in the Shared Decision-Making Questionnaire versus the interviews (83% vs 27%, P < .01). Age, sex, race/ethnicity, primary language, diagnosis, Autonomy Preference Scale score, and decision for operation was not associated with shared decision-making. Contributory factors to this discordance include patient unfamiliarity with shared decision-making, deference to surgeon authority, lack of discussion about different treatments, and confusion between aligned versus shared decisions. CONCLUSION Available questionnaires may overestimate shared decision-making in vulnerable patients suggesting the need for alternative or modifications to existing methods. Furthermore, such metrics should be assessed for correlation with patient-reported outcomes, such as satisfaction with decisions and health status.
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Affiliation(s)
- Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Health Science Center, Houston, TX.
| | - Isabel M Leal
- Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Charlie C Wan
- Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Braden F Goldberg
- Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Tamara E Saunders
- Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Stefanos G Millas
- Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Mike K Liang
- Department of Surgery, University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Health Science Center, Houston, TX
| | - Tien C Ko
- Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Lillian S Kao
- Department of Surgery, University of Texas Health Science Center, Houston, TX; Center for Surgical Trials and Evidence-based Practice (CSTEP), University of Texas Health Science Center, Houston, TX
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Mueck KM, Cherla DV, Taylor A, Ko TC, Liang MK, Kao LS. Randomized Controlled Trials Evaluating Patient-Reported Outcomes after Cholecystectomy: A Systematic Review. J Am Coll Surg 2017; 226:183-193.e5. [PMID: 29154921 DOI: 10.1016/j.jamcollsurg.2017.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/20/2017] [Accepted: 10/25/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Krislynn M Mueck
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-based Practice (C-STEP), Departments of Surgery and Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX.
| | - Deepa V Cherla
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-based Practice (C-STEP), Departments of Surgery and Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Amy Taylor
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Tien C Ko
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Mike K Liang
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-based Practice (C-STEP), Departments of Surgery and Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-based Practice (C-STEP), Departments of Surgery and Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
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Mueck KM, Putnam LR, Anderson KT, Lally KP, Tsao K, Kao LS. Does compliance with antibiotic prophylaxis in pediatric simple appendicitis matter? J Surg Res 2017; 216:1-8. [DOI: 10.1016/j.jss.2017.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/31/2017] [Accepted: 04/11/2017] [Indexed: 12/17/2022]
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Cherla DV, Moses ML, Mueck KM, Hannon C, Ko TC, Kao LS, Liang MK. External Validation of the HERNIAscore: An Observational Study. J Am Coll Surg 2017; 225:428-434. [PMID: 28554782 DOI: 10.1016/j.jamcollsurg.2017.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/03/2017] [Accepted: 05/13/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND The HERNIAscore is a ventral incisional hernia (VIH) risk assessment tool that uses only preoperative variables and predictable intraoperative variables. The aim of this study was to validate and modify, if needed, the HERNIAscore in an external dataset. STUDY DESIGN This was a retrospective observational study of all patients undergoing resection for gastrointestinal malignancy from 2011 through 2015 at a safety-net hospital. The primary end point was clinical postoperative VIH. Patients were stratified into low-risk, medium-risk, and high-risk groups based on HERNIAscore. A revised HERNIAscore was calculated with the addition of earlier abdominal operation as a categorical variable. Cox regression of incisional hernia with stratification by risk class was performed. Incidence rates of clinical VIH formation within each risk class were also calculated. RESULTS Two hundred and forty-seven patents were enrolled. On Cox regression, in addition to the 3 variables of the HERNIAscore (BMI, COPD, and incision length), earlier abdominal operation was also predictive of VIH. The revised HERNIAscore demonstrated improved predictive accuracy for clinical VIH. Although the original HERNIAscore effectively stratified the risk of an incisional radiographic VIH developing, the revised HERNIAscore provided a statistically significant stratification for both clinical and radiographic VIHs in this patient cohort. CONCLUSIONS We have externally validated and improved the HERNIAscore. The revised HERNIAscore uses BMI, incision length, COPD, and earlier abdominal operation to predict risk of postoperative incisional hernia. Future research should assess methods to prevent incisional hernias in moderate-to-high risk patients.
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Affiliation(s)
- Deepa V Cherla
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, Houston, TX.
| | - Maya L Moses
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, Houston, TX
| | - Craig Hannon
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Tien C Ko
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Lillian S Kao
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, Houston, TX
| | - Mike K Liang
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, Houston, TX
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Abstract
BACKGROUND Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes. METHODS Review of the pertinent English-language literature. RESULTS High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications. CONCLUSIONS Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.
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Affiliation(s)
- Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center at Houston , Houston, Texas
| | - Lillian S Kao
- Department of Surgery, University of Texas Health Science Center at Houston , Houston, Texas
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Affiliation(s)
- Krislynn M. Mueck
- Department of Surgery, The University of Texas Health Science Center at Houston2Center for Surgical Trials and Evidence-Based Practice, The University of Texas Health Science Center at Houston
| | - Luke R. Putnam
- Department of Surgery, The University of Texas Health Science Center at Houston2Center for Surgical Trials and Evidence-Based Practice, The University of Texas Health Science Center at Houston
| | - Lillian S. Kao
- Department of Surgery, The University of Texas Health Science Center at Houston2Center for Surgical Trials and Evidence-Based Practice, The University of Texas Health Science Center at Houston
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