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Kawano B, Grisel B, Wischmeyer P, Holsman M, Agarwal S, Fernandez-Moure J, Haines KL. Racial and ethnic demographics in malnutrition related deaths. Clin Nutr ESPEN 2024; 60:135-138. [PMID: 38479901 DOI: 10.1016/j.clnesp.2024.01.018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND AIMS Currently, 40 million Americans are food insecure. They are forced to skip meals and buy non-nutritious food, leading to health disparities for those of low socioeconomic status. This study aims to investigate relationships between malnutrition deaths and sociodemographic groups. METHODS This cross-sectional study from 2009 to 2018 used aggregate data from the CDC Wide-ranging Online Data for Epidemiologic Research (CDC Wonder). Patients with known race, gender, and Hispanic origin age ≥18 who died from malnutrition (E40-E46) were included. Place of death was grouped into home, inpatient medical facility, hospice facility, nursing facility/long-term care, other (including outpatient, ED, and DOA), and unknown. Crude rates of malnutrition deaths per 100,000 persons for race, gender, and Hispanic origin were calculated using US census estimates. Gross proportions of total deaths were calculated for each place of death. RESULTS Between 2009 and 2018, there were 46,517 malnutrition deaths in the US. Death rates for Black (1.8) and White Americans (2) were twice as high compared to Native Americans (1.1) and Asians or Pacific Islanders (0.7). Death rates among females (2.3) were higher than males (1.5). Death rates among non-Hispanics (2.1) were twice as high compared to Hispanics (0.7). Most people who died of malnutrition died in hospitals (37 %). CONCLUSION Malnutrition deaths occur at greater rates among White, Black, non-Hispanic Americans, and females. Despite reported disparities in food access, Black and White Americans have similar malnutrition mortality rates, raising concerns that malnutrition is under-diagnosed among Black patients. Given the existing nutrition literature, this finding requires further investigation.
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Affiliation(s)
- Bradley Kawano
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Braylee Grisel
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Paul Wischmeyer
- Division of Critical Care Surgery, Department of Anesthesia, Duke University Medical Center, Durham, NC, USA.
| | - Maximilian Holsman
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Joseph Fernandez-Moure
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Meizoso JP, Cotton BA, Lawless RA, Kodadek LM, Lynde JM, Russell N, Gaspich J, Maung A, Anderson C, Reynolds JM, Haines KL, Kasotakis G, Freeman JJ. Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2024:01586154-990000000-00680. [PMID: 38531812 DOI: 10.1097/ta.0000000000004327] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Whole blood resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of whole blood-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether whole blood should be considered in civilian trauma patients receiving blood transfusions. METHODS An EAST working group performed a systematic review and meta-analysis utilizing the GRADE methodology. One PICO question was developed to analyze the effect of whole blood resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and ICU length of stay. English language studies including adult civilian trauma patients comparing in-hospital whole blood to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro was used to assess quality of evidence and risk of bias. The study was registered on PROSPERO (#CRD42023451143). RESULTS A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., ED, 3-, or 6-hour), 24-hour, late (i.e., 28- or 30-day), and in-hospital. On meta-analysis, whole blood was not associated with decreased mortality. Whole blood was associated with decreased 4-hour RBC (mean difference -1.82, 95% CI -3.12 to -0.52), 4-hour plasma (mean difference -1.47, 95% CI -2.94 to 0), and 24-hour RBC transfusions (mean difference -1.22, 95% CI -2.24 to -0.19) compared to component therapy. There were no differences in infectious complications or ICU length of stay between groups. CONCLUSION We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE Level III, Guidelines.
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Affiliation(s)
| | | | | | - Lisa M Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Nicole Russell
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX
| | | | - Adrian Maung
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - John M Reynolds
- Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, FL
| | - Krista L Haines
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Collins RA, Herman T, Snyder RA, Haines KL, Stey A, Arora TK, Geevarghese SK, Phillips JD, Vicente D, Griggs CL, McElroy IE, Wall AE, Hughes TM, Sen S, Valinejad J, Alban A, Swan JS, Mercaldo N, Jalali MS, Chhatwal J, Gazelle GS, Rangel E, Yang CFJ, Donelan K, Gold JA, West CP, Cunningham C. Unspoken Truths: Mental Health Among Academic Surgeons. Ann Surg 2024; 279:429-436. [PMID: 37991182 DOI: 10.1097/sla.0000000000006159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.
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Affiliation(s)
- Reagan A Collins
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Tianna Herman
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Anne Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tania K Arora
- Department of Surgery, Augusta University at the Medical College of Georgia, Augusta, GA
| | | | | | - Diego Vicente
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Cornelia L Griggs
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, MA
| | - Imani E McElroy
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Srijan Sen
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Jaber Valinejad
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Andres Alban
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - J Shannon Swan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Nathaniel Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Mohammad S Jalali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Erika Rangel
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Karen Donelan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jessica A Gold
- Department of Psychiatry, Washington University in St Louis, St Louis, MO
| | - Colin P West
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Carrie Cunningham
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
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Eze A, Leraas H, Eze O, Chime C, Grisel B, Moore L, Cerullo M, Chang D, Agarwal S, Haines KL. Factors Associated with Discharge to Skilled Nursing Facility Following Gunshot Wounds. J Surg Res 2024; 294:1-8. [PMID: 37852139 DOI: 10.1016/j.jss.2023.08.059] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/02/2023] [Accepted: 08/31/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Firearm injury is a public health crisis. Most victims are minorities in underserved neighborhoods. Measuring firearm injury by mortality underestimates its impact, as most victims survive to discharge. This study was done to determine if race and insurance status are associated with discharge disposition for gunshot wound (GSW)-related trauma. METHODS Using the 2019 Trauma Quality Improvement Program database, we identified GSW patients with Abbreviated Injury Scale (AIS) = 1-3. Exclusion criteria included patients who died in hospital and routine home discharge. We compared discharge patterns of patients based on demographics (age, gender, race, ethnicity, payor, AIS, hospital designation, and length of stay [LOS]) and injury severity. Multivariable logistic regression models identified factors associated with discharge disposition. RESULTS Our sample included 2437 patients with GSWs. On univariable analysis, Black patients were more likely to discharge to home with home health (64.1% Black versus 34.7% White; P < 0.001). White patients were more likely to discharge to skilled nursing facility (SNF) (51.4% White versus 44.6% Black; P < 0.001). Controlling for age, race, Latin ethnicity, primary payor, LOS, AIS severity, and injury severity score factors independently associated with discharge to SNF included age (0.0462, P < 0.001), Medicaid (1.136, P < 0.0003), Medicare (1.452, P < 0.001), and LOS (0.03745, P < 0.001). CONCLUSIONS Postacute care following traumatic injuries is essential to recovery. Black GSW victims are more likely to be discharged to home health than White patients, who are more likely to be discharged to SNF. Targeted programs to reduce barriers to appropriate aftercare are necessary to eliminate this bias and improve the care of underserved populations.
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Affiliation(s)
- Anthony Eze
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Harold Leraas
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Oluebubechukwu Eze
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Chinecherem Chime
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Lauren Moore
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Marcelo Cerullo
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Doreen Chang
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina
| | - Krista L Haines
- Division of Trauma Critical Care and Acute Care Surgery, Duke University Department of Surgery, Durham, North Carolina.
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Cox CE, Ashana DC, Riley IL, Olsen MK, Casarett D, Haines KL, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Yang H, Pratt EH, Gu J, Dempsey K, Docherty SL, Johnson KS. Mobile Application-Based Communication Facilitation Platform for Family Members of Critically Ill Patients: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2349666. [PMID: 38175648 PMCID: PMC10767607 DOI: 10.1001/jamanetworkopen.2023.49666] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024] Open
Abstract
Importance Unmet and racially disparate palliative care needs are common in intensive care unit (ICU) settings. Objective To test the effect of a primary palliative care intervention vs usual care control both overall and by family member race. Design, Setting, and Participants This cluster randomized clinical trial was conducted at 6 adult medical and surgical ICUs in 2 academic and community hospitals in North Carolina between April 2019 and May 2022 with physician-level randomization and sequential clusters of 2 Black patient-family member dyads and 2 White patient-family member dyads enrolled under each physician. Eligible participants included consecutive patients receiving mechanical ventilation, their family members, and their attending ICU physicians. Data analysis was conducted from June 2022 to May 2023. Intervention A mobile application (ICUconnect) that displayed family-reported needs over time and provided ICU attending physicians with automated timeline-driven communication advice on how to address individual needs. Main Outcomes and Measures The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST; range 0-130, with higher scores reflecting greater need) score between study days 1 and 3. Secondary outcomes included family-reported quality of communication and symptoms of depression, anxiety, and posttraumatic stress disorder at 3 months. Results A total of 111 (51% of those approached) family members (mean [SD] age, 51 [15] years; 96 women [86%]; 15 men [14%]; 47 Black family members [42%]; 64 White family members [58%]) and 111 patients (mean [SD] age, 55 [16] years; 66 male patients [59%]; 45 Black patients [41%]; 65 White patients [59%]; 1 American Indian or Alaska Native patient [1%]) were enrolled under 37 physicians randomized to intervention (19 physicians and 55 patient-family member dyads) or control (18 physicians and 56 patient-family member dyads). Compared with control, there was greater improvement in NEST scores among intervention recipients between baseline and both day 3 (estimated mean difference, -6.6 points; 95% CI, -11.9 to -1.3 points; P = .01) and day 7 (estimated mean difference, -5.4 points; 95% CI, -10.7 to 0.0 points; P = .05). There were no treatment group differences at 3 months in psychological distress symptoms. White family members experienced a greater reduction in NEST scores compared with Black family members at day 3 (estimated mean difference, -12.5 points; 95% CI, -18.9 to -6.1 points; P < .001 vs estimated mean difference, -0.3 points; 95% CI, -9.3 to 8.8 points; P = .96) and day 7 (estimated mean difference, -9.5 points; 95% CI, -16.1 to -3.0 points; P = .005 vs estimated mean difference, -1.4 points; 95% CI, -10.7 to 7.8; P = .76). Conclusions and Relevance In this study of ICU patients and family members, a primary palliative care intervention using a mobile application reduced unmet palliative care needs compared with usual care without an effect on psychological distress symptoms at 3 months; there was a greater intervention effect among White family members compared with Black family members. These findings suggest that a mobile application-based intervention is a promising primary palliative care intervention for ICU clinicians that directly addresses the limited supply of palliative care specialists. Trial Registration ClinicalTrials.gov Identifier: NCT03506438.
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Affiliation(s)
- Christopher E. Cox
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha C. Ashana
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Krista L. Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Robert W. Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Hongqiu Yang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Katelyn Dempsey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Health Care System, Durham, North Carolina
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Gorenshtein L, Leraas H, Eze A, Lumpkin S, Chime C, Chang D, Wischmeyer P, Agarwal S, Fernandez J, Haines KL. The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury. J Surg Res 2024; 293:121-127. [PMID: 37738853 DOI: 10.1016/j.jss.2023.07.036] [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: 12/02/2022] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.
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Affiliation(s)
| | - Harold Leraas
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Anthony Eze
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Chinecherem Chime
- School of Medicine, Howard University College of Medicine, Washington, District of Columbia
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, North Carolina
| | - Paul Wischmeyer
- Department of Surgery, Duke University, Durham, North Carolina
| | - Suresh Agarwal
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina
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7
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Deutz NEP, Haines KL, Wischmeier PE, Engelen MPKJ. Amino acid kinetics in the critically ill. Curr Opin Clin Nutr Metab Care 2024; 27:61-69. [PMID: 37997794 PMCID: PMC10841855 DOI: 10.1097/mco.0000000000000995] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW Stable isotope methods have been used for many years to assess whole body protein and amino acid kinetics in critically ill patients. In recent years, new isotope approaches and tracer insights have been developed. The tracer pulse approach has some advantages above the established primed-continuous tracer infusion approach because of the high amount of metabolic information obtained, easy applicability, and low tracer costs. Effects of disease severity and sex on amino acid kinetics in ICU patients will also be addressed. RECENT FINDINGS Current knowledge was synthesized on specific perturbations in amino acid metabolism in critically ill patients, employing novel methodologies such as the pulse tracer approach and computational modeling. Variations were evaluated in amino acid production and linked to severity of critical illness, as measured by SOFA score, and sex. Production of the branched-chain amino acids (BCAAs), glutamine, tau-methylhistidine and hydroxyproline were elevated in critical illness, likely related to increased transamination of the individual BCAAs or increased breakdown of proteins. Citrulline production was reduced, indicative of impaired gut mucosa function. Sex and disease severity independently influenced amino acid kinetics in ICU patients. SUMMARY Novel tracer and computational approaches have been developed to simultaneously measure postabsorptive kinetics of multiple amino acids that can be used in critical illness. The collective findings lay the groundwork for targeted individualized nutritional strategies in ICU settings aimed at enhancing patient outcomes taking into account disease severity and sex.
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Affiliation(s)
- Nicolaas E P Deutz
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, Texas
| | - Krista L Haines
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Duke University Hospital, USA
| | - Paul E Wischmeier
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Duke University Hospital, USA
| | - Mariëlle P K J Engelen
- Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, Texas
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Thornton SW, Leraas HJ, Horne E, Cerullo M, Chang D, Greenwald E, Agarwal S, Haines KL, Tracy ET. A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study. J Surg Res 2023; 291:633-639. [PMID: 37542778 DOI: 10.1016/j.jss.2023.07.018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Most injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation. MATERIALS AND METHODS We queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size. RESULTS A total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism. CONCLUSIONS There is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.
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Affiliation(s)
- Steven W Thornton
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Harold J Leraas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Doreen Chang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Emily Greenwald
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elisabeth T Tracy
- Division Pediatric General Surgery, Department of Surgery, Duke University, Durham, North Carolina
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Leraas H, Moya-Mendez M, Donohue V, Kawano B, Olson L, Sekar A, Robles J, Wagner L, Greenup R, Haines KL, Tracy E. Using Crowdfunding Campaigns to Examine Financial Toxicity and Logistical Burdens Facing Families of Children With Wilms Tumor. J Surg Res 2023; 291:640-645. [PMID: 37542779 DOI: 10.1016/j.jss.2023.07.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 06/10/2023] [Accepted: 07/01/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Treatment for pediatric solid tumors is often intense and multidisciplinary and can create a substantial financial burden for families. Assessing these burdens, termed the financial toxicity of treatment, can be difficult. Using Wilms tumor as an example, we evaluated crowdfunding campaigns in an attempt to better understand the impact of economic and logistic challenges associated with pediatric solid tumor care and identify features associated with successful fundraising with this method. METHODS We used a webscraping algorithm to identify crowdfunding campaigns on GoFundMe.com for pediatric patients with Wilms tumor in the United States. We conducted a cross-sectional analysis to describe the patients and families seeking crowdfunding support for cancer care. After fundraizing information was extracted using the webscraping algorithm, each fundraiser was verified and examined by two independent reviewers to assess demographic, qualitative, disease, and treatment variables. Successful fundraisers, defined as those meeting stated financial goals, were compared to unsuccessful campaigns to identify variables associated with successful crowdfunding campaigns. RESULTS We identified 603 children with Wilms tumor and an associated crowdfunding campaign. The median age was 4 y. The majority lived in two-parent households (68.5%). Patients mentioned siblings in 35.5% of fundraisers. While motivations for crowdfunding varied, hardships endured by families included loss of employment (52.2%), need for childcare for other children (9.8%), direct costs of care [co-payments, insurance, pharmaceuticals, out-of-pocket care costs, etc.] (80.9%), indirect costs associated with seeking care [transportation, parking, lodging, lost opportunity cost, etc.] (56.2%), and need for relocation to pursue complex cancer care (6.8%). Disease characteristics in this cohort were limited to self-reports by families. However, fundraisers mentioned disease characteristics, including tumor stage (47.6%), size (11.4%), positive nodal status (9.6%), metastatic disease (3.6%), pathology (11.8%), upstaging (4.6%), and disease recurrence (8.6%). No individually examined demographic, support, disease, or hardship-related factors varied significantly between successful and unsuccessful crowdfunding campaigns (all P > 0.05). However, successful campaigns requested less money ($11,783.25 successful versus $22,442.2 unsuccessful, <0.001), received more money ($16,409.5 successful vs 7427.4 unsuccessful, P < 0.001), and solicited larger donor numbers (170.3 successful versus 86.3 unsuccessful, P < 0.001). CONCLUSIONS Families whose children undergo multimodal cancer care have significant expenses and burdens and can use crowdfunding to support their costs. Careful consideration of the financial and logistic strains associated with pediatric solid tumor treatment, including thorough analysis of crowdfunding sites, may support better understanding of nonclinical burdens, supporting therapeutic relationships and patient outcomes.
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Affiliation(s)
- Harold Leraas
- M.D., Duke University Department of Surgery, Durham, North Carolina.
| | | | | | - Brad Kawano
- Department of Surgery, University of California San Diego, San Diego, California
| | - Lindsay Olson
- Duke University School of Medicine, Durham, North Carolina
| | - Akshaya Sekar
- Campbell University School of Osteopathic Medicine, Harnett County, North Carolina
| | - Joanna Robles
- Duke University Department of Pediatrics, Durham, North Carolina
| | - Lars Wagner
- Duke University Department of Pediatrics, Durham, North Carolina
| | - Rachel Greenup
- M.D., Duke University Department of Surgery, Durham, North Carolina; Yale University Department of Surgery, New Haven, Connecticut
| | - Krista L Haines
- M.D., Duke University Department of Surgery, Durham, North Carolina
| | - Elisabeth Tracy
- M.D., Duke University Department of Surgery, Durham, North Carolina
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Haines KL, Ohnuma T, Grisel B, Krishnamoorthy V, Raghunathan K, Sulo S, Kerr KW, Besecker B, Cassady BA, Wischmeyer PE. Early enteral nutrition is associated with improved outcomes in critically ill mechanically ventilated medical and surgical patients. Clin Nutr ESPEN 2023; 57:311-317. [PMID: 37739674 DOI: 10.1016/j.clnesp.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS Data suggest that guidelines for enteral nutrition (EN) initiation are not closely followed in clinical practice. In addition, critically ill mechanically ventilated (MV) patients have varying metabolic needs, which often increase and persist over time, requiring personalized nutrition intervention. While both over- and under-nutrition can impact patient outcomes, recent data suggest that targeted early EN delivery may reduce mortality and improve clinical outcomes. This study examined if early EN improves clinical outcomes and decreases costs in critically ill patients on MV. METHODS Data from a nationwide administrative-financial database between 2018 and 2020 was utilized to identify eligible adult critical care patients. Patients who received EN within 3 days after intubation (early EN) were compared to patients who started EN after 3 days of intubation (late EN). Outcomes of interest included hospital mortality, discharge disposition, hospital and intensive care unit (ICU) length of stay (LOS), MV days, and total cost. After inverse-probability-of-treatment weighting, outcomes were modeled using a nominal logistic regression model for hospital mortality and discharge disposition, a linear regression model for cost, and Cox proportional-hazards model for MV days, hospital and ICU LOS. RESULTS A total of 27,887 adult patients with early MV were identified, of which 16,772 (60.1%) received early EN. Regression analyses showed that the early EN group had lower hospital mortality (OR = 0.88, 95% CI, 0.82 to 0.94), were more likely to be discharged home (OR = 1.47, 95% CI 1.38 to 1.56), had fewer MV days (HR = 1.23, 95% CI, 1.11 to 1.37), shorter hospital LOS (HR = 1.43, 95% CI, 1.33 to 1.54) and ICU LOS (HR = 1.36, 95% CI, 1.27 to 1.46), and lower cost (-$21,226; 95% CI, -$23,605 to -$18,848) compared to the late EN group. CONCLUSIONS Early EN within 3 days of MV initiation in real-world practice demonstrated improved clinical and economic outcomes. These data suggest that early EN is associated with decreased hospital mortality, increased discharge to home, and decreased hospital and ICU LOS, time on MV, and cost compared to delayed initiation of EN; highlighting the importance of early EN to optimize utcomes ando support the recovery of critically ill patients on MV.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA; The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA; Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Braylee Grisel
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA; Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Karthik Raghunathan
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA; Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Suela Sulo
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Kirk W Kerr
- Scientific and Medical Affairs, Abbott Nutrition, Columbus, OH, USA.
| | - Beth Besecker
- Scientific and Medical Affairs, Abbott Nutrition, Columbus, OH, USA.
| | - Bridget A Cassady
- Scientific and Medical Affairs, Abbott Nutrition, Columbus, OH, USA.
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA.
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Haines KL, Ohnuma T, Hornik CD, Grisel B, Leraas H, Trujillo CN, Krishnamoorthy V, Raghunathan K, Wischmeyer PE. Change to Mixed-Lipid Emulsion From Soybean Oil-Based Lipid Emulsion in Pediatric Patients. JAMA Netw Open 2023; 6:e2332389. [PMID: 37669048 PMCID: PMC10481238 DOI: 10.1001/jamanetworkopen.2023.32389] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/28/2023] [Indexed: 09/06/2023] Open
Abstract
Importance Critically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes. Objective To examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes. Design, Setting, and Participants Retrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023. Exposure In 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil-based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group). Main Outcomes and Measures Clinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin). Results A total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant. Conclusions and Relevance In this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy-LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.
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Affiliation(s)
- Krista L. Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Chi Dang Hornik
- Division of Pediatric Critical Care, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - Harold Leraas
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Charles N. Trujillo
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Paul E. Wischmeyer
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Abstract
BACKGROUND Studying firearm-related mortality is important to reduce preventable firearm death in the US. This study aims to determine the relationship between firearm laws and assault death with firearms. STUDY DESIGN This ecologic study used public data from the CDC Wide-Ranging Online Data for Epidemiologic Research on decedents age 18 years or older who died from assault with firearms between 2009 and 2018 in all 50 states and Washington, DC. The outcomes were the rate of mortality per 100,000 persons from assault death by firearm used. Exposures of interest included the presence of 7 state firearm laws extracted from the RAND State Firearm Law Database. Welch's t tests were performed to compare mean mortality rate in states with each firearm law to states without each law. RESULTS There were 114,945 deaths from assault with firearms from 2009 to 2018. States with "stand your ground" laws had a higher assault mortality rate from all firearms and from other/unspecified firearms than states without stand your ground laws (p = 0.026; p = 0.023). States with background checks for private sales of handguns and long guns had a lower assault mortality rate from handguns and rifles, shotguns, and large firearms, respectively, than states without either law (p = 0.019; p = 0.030). CONCLUSIONS Stand your ground laws are correlated with a higher rate of gun-related assault death, but background checks on private sales are correlated with a lower rate. Future studies should elucidate the specific pathways by which state laws reduce, or fail to reduce, firearm-related assault death.
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Affiliation(s)
- Bradley Kawano
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal, Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
| | - Suresh Agarwal
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal, Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
| | - Vijay Krishnamoorthy
- the Department of Anesthesiology (Krishnamoorthy, Raghunathan), Duke University Medical Center, Durham, NC
| | - Karthik Raghunathan
- the Department of Anesthesiology (Krishnamoorthy, Raghunathan), Duke University Medical Center, Durham, NC
| | - Joseph S Fernandez-Moure
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal, Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
| | - Krista L Haines
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal, Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
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Haines KL, Truong T, Trujillo CN, Freeman JJ, Cox CE, Fernandez-More J, Morris R, Antonescu I, Burlotos A, Grisel B, Agarwal S, Kuchibhatla M. Factors Associated With Triage Decisions in Older Adult Trauma Patients: Impact on Mortality and Morbidity. J Surg Res 2023; 288:157-165. [PMID: 36989831 DOI: 10.1016/j.jss.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 01/30/2023] [Accepted: 02/15/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION As medical advances have significantly increased the life expectancy among older adults, the number of older patients requiring trauma care has risen proportionately. Nevertheless, it is unclear among this growing population which sociodemographic and economic factors are associated with decisions to triage and transfer to level I/II centers. This study aims to assess for any association between patient sociodemographic characteristics, triage decisions, and outcomes during acute trauma care presentations. METHODS The National Trauma Data Bank was queried for patients aged 65 and older with an injury severity score > 15 between the years 2007 to 2017. Factors associated with subsequent levels of triage on presentation were assessed using multivariate logistic regression, and associations of levels of triage with outcomes of mortality, morbidity, and hospital length of stay are examined using logistic and linear regression models. RESULTS Triage of 210,310 older adult trauma patients showed significant findings. American Indian patients had higher odds of being transferred to level I/II centers, while Asian, Black, and Native Hawaiian patients had lower odds of being transferred to level I/II centers when compared to Caucasian patients (P < 0.001). Regarding insurance, self-pay (uninsured) patients were less likely to be transferred to a higher level of care; however, this was also demonstrated in private insurance holders (P < 0.001). Caucasian patients had significantly higher odds of mortality, with Black patients (odds ratio [OR] 0.80 [0.75, 0.85]) and American Indian patients (OR 0.87 [0.72, 1.04]) having significantly lower odds (P < 0.001). Compared to government insurance, private insurance holders (OR 0.82 [0.80, 0.85]) also had significantly lower odds of mortality, while higher odds among self-pay were observed (OR 1.75 [1.62, 1.90]), (P < 0.001). CONCLUSIONS Access to insurance is associated with triage decisions involving older adults sustaining trauma, with lower access increasing mortality risk. Factors such as race and gender were less likely to be associated with triage decisions. However, due to this study's retrospective design, further prospective analysis is necessary to fully assess the decisions that influence trauma triage decisions in this patient population.
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Mukherjee K, Schubl SD, Tominaga G, Cantrell S, Kim B, Haines KL, Kaups KL, Barraco R, Staudenmayer K, Knowlton LM, Shiroff AM, Bauman ZM, Brooks SE, Kaafarani H, Crandall M, Nirula R, Agarwal SK, Como JJ, Haut ER, Kasotakis G. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society. J Trauma Acute Care Surg 2023; 94:398-407. [PMID: 36730672 DOI: 10.1097/ta.0000000000003830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/04/2023]
Abstract
BACKGROUND Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level IV.
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Affiliation(s)
- Kaushik Mukherjee
- From the Division of Acute Care Surgery, Loma Linda University Medical Center (K.M.), Loma Linda; University of California Irvine Medical Center (S.D.S.), Irvine; Scripps Memorial La Jolla (G.T.), San Diego, California; Division of Trauma and Critical Care Surgery, Department of Surgery (S.C., K.L.H., S.K.A., G.K.), Duke University Medical Center, Durham, North Carolina; The Mayo Clinic (B.K.), Rochester, Minnesota; University of California San Francisco-Fresno (K.L.K.), Fresno, California; Lehigh Valley Health Network (R.B.), Allentown, Pennsylvania; Stanford University Medical Center (K.S., L.M.K.), Palo Alto, California; University of Pennsylvania Medical Center (A.M.S.), Philadelphia, Pennsylvania; University of Nebraska Medical Center (Z.M.B.), Omaha, Nevada; Texas Tech University Health Sciences Center (S.E.B.), Lubbock, Texas; Massachusetts General Hospital (H.K.), Boston, Massachusetts; University of Florida College of Medicine (M.C.), Jacksonville, Florida; University of Utah Medical Center (R.N.), Salt Lake City, Utah; MetroHealth Cleveland Medical Center (J.J.C.), Cleveland, Ohio; Johns Hopkins Medical Center (E.R.H.), Baltimore, Maryland
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Teichman AL, Bonne S, Rattan R, Dultz L, Qurashi FA, Goldenberg A, Polite N, Liveris A, Freeman JJ, Colosimo C, Chang E, Choron RL, Edwards C, Arabian S, Haines KL, Joseph D, Murphy PB, Schramm AT, Jung HS, Lawson E, Fox K, Mashbari HNA, Smith RN. Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2023; 8:e001041. [PMID: 36967863 PMCID: PMC10030790 DOI: 10.1136/tsaco-2022-001041] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundIntimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations.MethodsAn evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review.ResultsSeven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims.ConclusionOverall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions.PROSPERO registration numberCRD42020219517.
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Affiliation(s)
- Amanda L Teichman
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Stephanie Bonne
- Trauma and Surgical Critical Care, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Rishi Rattan
- Trauma Surgery and Critical Care, University of Miami School of Medicine, Miami, Florida, USA
| | - Linda Dultz
- Burns, Trauma, Acute and Critical Care Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Anna Goldenberg
- Trauma, Acute Care Surgery, and Surgical Critical Care, Cooper University Hospital Regional Trauma Center, Camden, New Jersey, USA
| | - Nathan Polite
- Trauma, Acute Care Surgery & Burns, University of South Alabama, Mobile, Alabama, USA
| | - Anna Liveris
- Trauma and Critical Care Services, Jacobi Medical Center, Bronx, New York, USA
| | - Jennifer J Freeman
- General Surgery, Trauma, and Surgical Critical Care, TCU School of Medicine, Fort Worth, Texas, USA
| | - Christina Colosimo
- Trauma, Surgical Critical Care, & Acute Care Surgery, University of Arizona Medical Center-University Campus, Tucson, Arizona, USA
| | - Erin Chang
- Acute Care Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Rachel L Choron
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Courtney Edwards
- Burns, Trauma, Acute and Critical Care Surgery, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Sandra Arabian
- Trauma and Emergency Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Krista L Haines
- Trauma, Critical Care, and Acute Care Surgery, Duke University Hospital, Durham, North Carolina, USA
| | - D'Andrea Joseph
- Surgery, NYU Langone Hospital-Long Island, Mineola, New York, USA
| | - Patrick B Murphy
- Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew T Schramm
- Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hee Soo Jung
- Acute Care Surgery and Regional General Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Emily Lawson
- Woodruff Health Sciences Center Library, Emory University Woodruff Health Sciences Center, Atlanta, Georgia, USA
| | - Kathleen Fox
- Woodruff Health Sciences Center Library, Emory University Woodruff Health Sciences Center, Atlanta, Georgia, USA
| | | | - Randi N Smith
- Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
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Murphy PB, Kasotakis G, Haut ER, Miller A, Harvey E, Hasenboehler E, Higgins T, Hoegler J, Mir H, Cantrell S, Obremskey WT, Wally M, Attum B, Seymour R, Patel N, Ricci W, Freeman JJ, Haines KL, Yorkgitis BK, Padilla-Jones BB. Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open 2023; 8:e001056. [PMID: 36844371 PMCID: PMC9945020 DOI: 10.1136/tsaco-2022-001056] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 11/07/2022] [Accepted: 01/09/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established. Methods Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations. Results A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use. Conclusions In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.
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Affiliation(s)
- Patrick B Murphy
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins Univ, Baltimore, Maryland, USA
| | - Anna Miller
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Edward Harvey
- Department of Surgery, McGill University, Montreal, Québec, Canada
| | - Eric Hasenboehler
- Holy Spirit Hospital Penn State Health, Camp Hill, Pennsylvania, USA
| | - Thomas Higgins
- Department of Orthopaedics, University of Utah Health, Salt Lake City, Utah, USA
| | - Joseph Hoegler
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hassan Mir
- Department of Orthopaedic Surgery, University of South Florida, Tampa, Florida, USA
| | - Sarah Cantrell
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - William T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Basem Attum
- Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nimitt Patel
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William Ricci
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer J Freeman
- Department of Surgery, TCU and UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Brandy B Padilla-Jones
- Department of General Surgery, Sunrise Hospital and Medical Center, Las Vegas, Nevada, USA
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Haines KL, Gorenshtein L, Lumpkin S, Grisel B, Gallagher S. Optimal Nutrition in the Older Adult: Beneficial Versus Ineffective Supplements. Curr Nutr Rep 2023:10.1007/s13668-023-00459-y. [PMID: 36689099 DOI: 10.1007/s13668-023-00459-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Proper nutrition in older adults is essential, as nutritional deficiencies are common in this population. This review aims to summarize the benefits and risks of nutritional supplementation in the older adult population including the efficacy of various supplements, their risks, and common drug interactions with frequently prescribed medications. RECENT FINDINGS In recent years, a growing percentage of older adults have been found to take multiple daily nutritional supplements. This population has complex nutritional needs due to the physiology of aging and the presence of comorbidities. However, many primary care providers are unaware of the benefits and drawbacks of nutritional supplementation in the elderly. This review summarizes the current literature to provide more clarity to providers on how to support this population's nutritional needs. Nutritional supplementation is essential for elderly populations who may not be able to obtain adequate nutrition from dietary sources. Supplements vary widely in efficacy and safety. As such, supplementation should be individualized and guided by a qualified healthcare provider to ensure patients receive effective, beneficial nutrition.
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Affiliation(s)
- Krista L Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | | | - Stephanie Lumpkin
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Scott Gallagher
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
BACKGROUND There were 23,854 suicides by firearms in 2017 in the US, accounting for 60% of all gun deaths. Studying firearm-related mortalities is vital for reducing preventable gun deaths. This study aims to determine the association between state-level presence of restrictive firearm laws and suicide rates with firearms. STUDY DESIGN This ecological study used data from the CDC Wide-Ranging Online Data for Epidemiologic Research on decedents older than 18 years who died from intentional self-harm with firearms between 2009 and 2018. Exposures of interest were state-level restrictive firearm laws: background checks on private sales, mandatory waiting periods, and prohibited possession for domestic violence restraining orders or mental health red flags. Outcomes were rates of suicide with firearms per 100,000 persons over the 10-year period within each state. Welch's t -tests compared mean mortality rates in exposed and unexposed states. RESULTS There were 208,621 deaths from intentional self-harm with firearms from 2009 to 2018. States with background checks, mandatory waiting periods, and prohibited possession were associated with lower suicide rates for all firearm types compared with states without these laws (p < 0.05). Only states with background checks and mandatory waiting periods were associated with lower suicide rates by handguns and large firearms (p < 0.05). CONCLUSION Background checks and mandatory waiting periods correlated with fewer suicides by all firearms and specific firearm types. This reduction could be due to firearm laws directly preventing people from accessing guns or existing concurrently with other suicide prevention measures. More research should be directed to understanding how firearm laws can help reduce suicide rates.
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Affiliation(s)
- Bradley Kawano
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
| | - Suresh Agarwal
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
| | - Vijay Krishnamoorthy
- Department of Anesthesiology (Krishnamoorthy, Raghunathan) Duke University Medical Center, Durham, NC
- the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC (Krishnamoorthy, Raghunathan, Haines)
| | - Karthik Raghunathan
- Department of Anesthesiology (Krishnamoorthy, Raghunathan) Duke University Medical Center, Durham, NC
- the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC (Krishnamoorthy, Raghunathan, Haines)
| | - Joseph S Fernandez-Moure
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
| | - Krista L Haines
- From the Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (Kawano, Agarwal Fernandez-Moure, Haines), Duke University Medical Center, Durham, NC
- the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC (Krishnamoorthy, Raghunathan, Haines)
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Haines KL, Nguyen BP, Antonescu I, Freeman J, Cox C, Krishnamoorthy V, Kawano B, Agarwal S. Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma. Am Surg 2023; 89:88-97. [PMID: 33877932 DOI: 10.1177/00031348211011115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Advanced directives (ADs) provide a framework from which families may understand patient's wishes. However, end-of-life planning may not be prioritized by everyone. This analysis aimed to determine what populations have ADs and how they affected trauma outcomes. METHODS Adult trauma patients recorded in the American College of Surgeons Trauma Quality Improvement Program (TQIP) from 2013-2015 were included. The primary outcome was presence of an AD. Secondary outcomes included mortality, length of stay (LOS), mechanical ventilation, ICU admission/LOS, withdrawal of life-sustaining measures, and discharge disposition. Multivariable logistic regression models were developed for outcomes. RESULTS 44 705 patients were included in the analyses. Advanced directives were present in 1.79% of patients. The average age for patients with ADs was 77.8 ± 10.7. African American (odds ratio (OR) .53, confidence intervals [CI] .36-.79) and Asian (OR .22, CI .05-.91) patients were less likely to have ADs. Conversely, Medicaid (OR 1.70, CI 1.06-2.73) and Medicare (OR 1.65, CI 1.25-2.17) patients were more likely to have ADs as compared to those with private insurance. The presence of ADs was associated with increased hospital mortality (OR 2.84, CI 2.19-3.70), increased transition to comfort measures (OR 2.87, CI 2.08-3.95), and shorter LOS (CO -.74, CI -1.26-.22). Patients with ADs had an increased odds of hospice care (OR 4.24, CI 3.18-5.64). CONCLUSION Advanced directives at admission are uncommon, particularly among African Americans and Asians. The presence of ADs was associated with increased mortality, use of mechanical ventilation, admission to the ICU, withdrawal of life-sustaining measures, and hospice. Future research should target expansion of ADs among minority populations to alleviate disparities in end-of-life treatment.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Benjamin P Nguyen
- Department of Surgery, 20868Kaweah Delta Health Care District, Medical Center, Visalia, CA, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Jennifer Freeman
- Department of Surgery, 3402TCU and UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Christopher Cox
- Division of Pulmonary Critical Care, Department of Medicine, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Brad Kawano
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
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20
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Nam JJ, McCravy MS, Haines KL, Thomas SB, Aden JK, Johnston LR, Mason PE, Gurney JM, Sams VG. Experience With Trauma-Induced ARDS: A Retrospective Study of US Wartime Casualties 2003-2015. J Spec Oper Med 2022; 22:111-116. [PMID: 36525023 DOI: 10.55460/mtvh-oncm] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The purpose of our study was to assess risks/ outcomes of acute respiratory distress syndrome (ARDS) in US combat casualties. We hypothesized that combat trauma patients with ARDS would have worse outcomes based on mechanism of injury (MOI) and labs/vital signs aberrancies. MATERIALS AND METHODS We reviewed data on military Servicemembers serving in Iraq and Afghanistan from 1 January 2003 to 31 December 2015 diagnosed with ARDS by ICD-9 code. We extracted patient demographics, injury specifics, and mortality from the Department of Defense Trauma Registry (DoDTR). RESULTS The most common MOI was an explosion, accounting for 67.6% of all injuries. Nonsurvivors were more likely to have explosion-related injuries, have higher injury severity score (ISS), higher international normalized ratio (INR), lower platelet count, greater base deficit, lower temperature, lower Glasgow Coma Scale (GCS) score, and lower pH. There was no significant difference in deaths across time. CONCLUSION By identifying characteristics of patients with higher mortality in trauma ARDS, we can develop treatment guidelines to improve outcomes. Given the high mortality associated with trauma ARDS and relative paucity of clinical data available, we need to improve battlefield data capture to better guide practice and ultimately improve care. The management of ARDS will be increasingly relevant in prolonged casualty care (PCC; formerly prolonged field care) on the modern battlefield.
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Freeman JJ, Asfaw SH, Vatsaas CJ, Yorkgitis BK, Haines KL, Burns JB, Kim D, Loomis EA, Kerwin AJ, McDonald A, Agarwal, S, Fox N, Haut ER, Crandall ML, Como JJ, Kasotakis G. Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2022; 7:e000886. [PMID: 36312819 PMCID: PMC9608538 DOI: 10.1136/tsaco-2022-000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 10/02/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. METHODS Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. RESULTS Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. DISCUSSION In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO REGISTRATION NUMBER CRD42018088759.
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Affiliation(s)
- Jennifer J Freeman
- Surgery, Texas Christian University Burnett School of Medicine, Fort Worth, Texas, USA
| | - Sofya H Asfaw
- General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cory J Vatsaas
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Krista L Haines
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - J Bracken Burns
- Surgery, East Tennessee State University, Johnson City, Tennessee, USA
| | - Dennis Kim
- Surgical Critical Care, Los Angeles County Harbor–UCLA Medical Center, Torrance, California, USA
| | | | - Andy J Kerwin
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Amy McDonald
- Surgery, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Suresh Agarwal,
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicole Fox
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | | | - Marie L Crandall
- Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - John J Como
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - George Kasotakis
- Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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22
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Haines KL, Ohnuma T, Trujillo C, Osamudiamen O, Krishnamoorthy V, Raghunathan K, Wischmeyer PE. Hospital change to mixed lipid emulsion from soybean oil-based lipid emulsion for parenteral nutrition in hospitalized and critically ill adults improves outcomes: a pre-post-comparative study. Crit Care 2022; 26:317. [PMID: 36258222 PMCID: PMC9578223 DOI: 10.1186/s13054-022-04194-8] [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: 07/18/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Early data suggest use of a mixed lipid emulsion (LE) with a soybean oil reduction strategy in parenteral nutrition (PN) may improve clinical outcomes. Duke University Hospital made a full switch to a Soybean oil/MCT/Olive/Fish Oil lipid (4-OLE) from pure soybean oil-based LE (Intralipid, Baxter Inc) in May 2017. Since 4-OLE has limited evidence related to its effects on clinical outcome parameters in US hospitals, evidence for clinical benefits of switching to 4-OLE is needed. Therefore, we examined the clinical utility of a hospital-wide switch to 4-OLE and its effect on patient outcomes. METHODS We conducted a single-center retrospective cohort study among adult patients (> 18 years) requiring PN from 2016 to 2019. Our primary exposure was treatment period (1-year pre-4-OLE switch versus 2-year post). We used multivariable regression models to examine our primary outcomes, the association of treatment period with hospital length of stay (LOS), and secondary outcomes liver function, infections, and ICU LOS. Analyses were stratified into critically ill and entire adult cohort. RESULTS We identified 1200 adults hospitalized patients. 28% of PN patients (n = 341) were treated pre-4-OLE switch and 72% post-4-OLE (n = 859). In the adult cohort, 4-OLE was associated with shorter hospital LOS (IRR 0.97, 95% CI 0.95-0.99, p = 0.039). The ICU cohort included 447 subjects, of which 25% (n = 110) were treated pre-4-OLE switch and 75% (n = 337) were post-switch. ICU patients receiving 4-OLE were associated with shorter hospital LOS (IRR 0.91, 95% CI 0.87-0.93, p < 0.0001), as well as a shorter ICU LOS (IRR 0.90, 95% CI 0.82-0.99, p = 0.036). 4-OLE ICU patients also had a significantly lower delta total bilirubin (- 1.6, 95% CI - 2.8 to - 0.2, p = 0.021) and reduced urinary tract infection (UTI) rates (OR 0.50, 95% CI 0.26-0.96, p = 0.038). There were no associations in AST, ALT, or total bilirubin in ICU and all adult patients. CONCLUSION 4-OLE was successfully implemented and reduced soybean oil LE exposure in a large academic hospital setting. The introduction of 4-OLE was associated with reduced LOS, UTI rates, and mitigated hepatic dysfunction in critically ill patients. Overall, these findings prove a switch to a soybean oil-LE sparing strategy using 4-OLE is feasible and safe and is associated with improved clinical outcomes in adult PN patients.
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Affiliation(s)
- Krista L. Haines
- grid.189509.c0000000100241216Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC USA ,grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA
| | - Tetsu Ohnuma
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA
| | - Charles Trujillo
- grid.189509.c0000000100241216Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC USA ,grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Obanor Osamudiamen
- grid.189509.c0000000100241216Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC USA ,grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Vijay Krishnamoorthy
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Karthik Raghunathan
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Paul E. Wischmeyer
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
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Fah M, Van Althuis LE, Ohnuma T, Winthrop HM, Haines KL, Williams DG, Krishnamoorthy V, Raghunathan K, Wischmeyer PE. Micronutrient deficiencies in critically ill patients receiving continuous renal replacement therapy. Clin Nutr ESPEN 2022; 50:247-254. [DOI: 10.1016/j.clnesp.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
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24
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Cross SH, Anderson DM, Cox CE, Agarwal S, Haines KL. Trends in Location of Death Among Older Adult Americans After Falls. Gerontol Geriatr Med 2022; 8:23337214221098897. [PMID: 35559359 PMCID: PMC9087234 DOI: 10.1177/23337214221098897] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction: Fall-related mortality is increasing among older adults, yet
trends and changes in the location of fall-attributed deaths are unknown; additionally,
potential disparities are understudied. Methods: To assess trends/factors
associated with place of death among older adult fall deaths in the US, a cross-sectional
analysis of deaths using mortality data from 2003–2017 was performed.
Results: Most deaths occurred in hospitals, however, the proportion
decreased from 66.4% (n = 9,095) to 50.7% (n = 15,817).
The proportion occurring in nursing facilities decreased from 15.9% (n =
2175) to 15.3% (n = 4,778), while deaths at home and in hospice
facilities increased. Male, Black, Native American, and married decedents had increased
odds of hospital death. Conclusion: As fall deaths increase among older
adults, end-of-life needs of this population deserve increased attention. Research should
explore needs and preferences of older adults who experience falls and their caregivers to
reduce disparities in place of death and to ensure high quality of care is received.
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Affiliation(s)
- Sarah H. Cross
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - David M. Anderson
- Duke-Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, NC, USA
| | - Christopher E. Cox
- Division of Pulmonary Critical Care, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Krista L. Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Kawano B, Agarwal S, Krishnamoorthy V, Raghunathan K, Haines KL. Trends in Assault Mortalities Among Asian Americans, 2009-2018. J Surg Res 2022; 275:336-340. [PMID: 35339002 DOI: 10.1016/j.jss.2022.01.015] [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: 09/19/2021] [Revised: 12/02/2021] [Accepted: 01/25/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION As of yet, few studies have described the prevalence or rates of assault mortalities involving Asian victims on a national level. This study aimed to describe yearly trends and regional differences in assault mortalities among Asians. METHODS This repeat cross-sectional study from 2009 to 2018 used data from the Mortality Multiple Cause-of-Death Public Use Record from the National Center for Health Statistics and the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Total and proportion of assault mortalities involving Asians or Pacific Islanders were calculated by year. Total and rates (per 100,000 Asians or Pacific Islanders) of assault mortalities among Asians or Pacific Islanders were stratified by state and county classification where deaths occurred. RESULTS In 2009, 344 assault mortalities among Asians or Pacific Islanders accounted for 2.07% of assault-related deaths. In 2018, 366 assault mortalities among Asians or Pacific Islanders accounted for 1.96% of assault-related deaths. Furthermore, there were more assault mortalities from 2009 to 2018 among Asians or Pacific Islanders in California (n = 1116) and large central metropolitan counties (n = 1707). However, the highest rates of assault mortalities were in Alaska and Mississippi (7.1 and 6.8 per 100,000, respectively) and noncore nonmetropolitan counties (2.9 per 100,000). CONCLUSIONS These findings emphasize the importance of studying and addressing violence toward Asians in rural regions and Southern states. Future studies should use these results as a baseline to analyze mortality data from 2019 to 2021, when available, to examine the coronavirus disease 2019 pandemic's impact on assault mortalities among Asian.
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Affiliation(s)
- Bradley Kawano
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Cox CE, Ashana DC, Haines KL, Casarett D, Olsen MK, Parish A, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Frear A, Pratt EH, Gu J, Riley IL, Otis-Green S, Johnson KS, Docherty SL. Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members. JAMA Netw Open 2022; 5:e2144093. [PMID: 35050358 PMCID: PMC8777568 DOI: 10.1001/jamanetworkopen.2021.44093] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Palliative care consultations in intensive care units (ICUs) are increasingly prompted by clinical characteristics associated with mortality or resource utilization. However, it is not known whether these triggers reflect actual palliative care needs. OBJECTIVE To compare unmet needs by clinical palliative care trigger status (present vs absent). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted in 6 adult medical and surgical ICUs in academic and community hospitals in North Carolina between January 2019 and September 2020. Participants were consecutive patients receiving mechanical ventilation and their family members. EXPOSURE Presence of any of 9 common clinical palliative care triggers. MAIN OUTCOMES AND MEASURES The primary outcome was the Needs at the End-of-Life Screening Tool (NEST) score (range, 0-130, with higher scores reflecting greater need), which was completed after 3 days of ICU care. Trigger status performance in identifying serious need (NEST score ≥30) was assessed using sensitivity, specificity, positive and negative likelihood ratios, and C statistics. RESULTS Surveys were completed by 257 of 360 family members of patients (71.4% of the potentially eligible patient-family member dyads approached) with a median age of 54.0 years (IQR, 44-62 years); 197 family members (76.7%) were female, and 83 (32.3%) were Black. The median age of patients was 58.0 years (IQR, 46-68 years); 126 patients (49.0%) were female, and 88 (33.5%) were Black. There was no difference in median NEST score between participants with a trigger present (45%) and those with a trigger absent (55%) (21.0; IQR, 12.0-37.0 vs 22.5; IQR, 12.0-39.0; P = .52). Trigger presence was associated with poor sensitivity (45%; 95% CI, 34%-55%), specificity (55%; 95% CI, 48%-63%), positive likelihood ratio (1.0; 95% CI, 0.7-1.3), negative likelihood ratio (1.0; 95% CI, 0.8-1.2), and C statistic (0.50; 95% CI, 0.44-0.57). CONCLUSIONS AND RELEVANCE In this cohort study, clinical palliative care trigger status was not associated with palliative care needs and no better than chance at identifying the most serious needs, which raises questions about an increasingly common clinical practice. Focusing care delivery on directly measured needs may represent a more person-centered alternative.
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Affiliation(s)
- Christopher E. Cox
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha Charan Ashana
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Krista L. Haines
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - David Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert W. Harrison
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Allie Frear
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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Williams DG, Aronson S, Murray S, Fuller M, Villalta E, Haines KL, Wischmeyer P. Validation of the Perioperative Nutrition Screen (PONS) for Prediction of Postoperative Outcomes. JPEN J Parenter Enteral Nutr 2021; 46:1307-1315. [PMID: 34850403 DOI: 10.1002/jpen.2310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preoperative nutrition risk is often underrecognized and undertreated. The Perioperative Nutrition Screen (PONS) was recently introduced as an efficient tool to rapidly screen for preoperative nutritional risk. The relationship between identification of "nutritional risk" via PONS and adverse outcomes postoperatively remains undescribed. METHODS Preoperative nutrition risk was assessed via PONS from 1/1/2019-9/30/2020. Key clinical outcomes were compared with individual and composite PONS components. RESULTS 3,151 patients with PONS evaluations were analyzed. Multivariate regression analysis adjusted for key co-variates demonstrated positive responses for specific PONS component questions was associated with adverse clinical outcomes as follows: 1) Unplanned weight loss (>10% in 6-months preoperatively) associated with a 22.4% increased length of stay (LOS) (95%CI: 13.3%-32.1%, p<0 .0001) and increased 30-day readmission rate (OR 2.44, 95%CI: 1.73-3.44, p<0.001); 2) History of < 50% of previous oral intake in past week associated with a 25% increased LOS (95%CI: 15.7%-35.2%, p<0.001); 3) Preoperative albumin <3.0g/l associated with a 29.9% increased LOS (p< 0.001) and increased 30-day readmission rate (OR 2.66 (95% CI: 1.63-4.35, p<0.001); 4) Low BMI (<18.5 kg/m2 ≤65 years old or <20 kg/m2 in ≥65 years old) was not associated with increased LOS by adjusted analysis although was predictive by univariate analysis. CONCLUSIONS The PONS and its individual components appear to predict risk of adverse postoperative outcomes, even independent of a validated malnutrition diagnosis. Further studies are needed to assess the impact of specific preoperative nutrition interventions on adverse outcomes predicted by PONS when delivered to patients identified via PONS screen. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Solomon Aronson
- Departments of Anesthesiology, Duke University School of Medicine.,Population Health, Duke University School of Medicine
| | - Sutton Murray
- Departments of Anesthesiology, Duke University School of Medicine
| | - Matt Fuller
- Departments of Anesthesiology, Duke University School of Medicine
| | | | | | - Paul Wischmeyer
- Departments of Anesthesiology, Duke University School of Medicine
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Antonescu I, Haines KL, Agarwal S. Role of Nutrition in the Elderly Surgical Patient – Review of the Literature and Current Recommendations. Curr Geri Rep 2021. [DOI: 10.1007/s13670-021-00367-5] [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: 10/19/2022]
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Niederer LE, Miller H, Haines KL, Molinger J, Whittle J, MacLeod DB, McClave SA, Wischmeyer PE. Prolonged progressive hypermetabolism during COVID-19 hospitalization undetected by common predictive energy equations. Clin Nutr ESPEN 2021; 45:341-350. [PMID: 34620338 PMCID: PMC8328525 DOI: 10.1016/j.clnesp.2021.07.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 06/30/2021] [Revised: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 01/03/2023]
Abstract
Background & aims Indirect calorimetry (IC) is the gold-standard for determining measured resting energy expenditure (mREE) in critical illness. When IC is not available, predicted resting energy expenditure (pREE) equations are commonly utilized, which often inaccurately predict metabolic demands leading to over- or under-feeding. This study aims to longitudinally assess mREE via IC in critically ill patients with SARS-CoV-2 (COVID-19) infection throughout the entirety of, often prolonged, intensive care unit (ICU) stays and compare mREE to commonly utilized pREE equations. Methods This single-center prospective cohort study of 38 mechanically ventilated COVID-19 patients from April 1, 2020 to February 1, 2021. The Q-NRG® Metabolic Monitor was used to obtain IC data. The Harris-Benedict (HB), Mifflin St-Jeor (MSJ), Penn State University (PSU), and weight-based equations from the American Society of Parenteral and Enteral Nutrition – Society of Critical Care Medicine (ASPEN-SCCM) Clinical Guidelines were utilized to assess the accuracy of common pREE equations and their ability to predict hypo/hypermetabolism in COVID-19 ICU patients. Results The IC measures collected revealed a relatively normometabolic or minimally hypermetabolic mREE at 21.3 kcal/kg/d or 110% of predicted by the HB equation over the first week of mechanical ventilation (MV). This progressed to significant and uniquely prolonged hypermetabolism over successive weeks to 28.1 kcal/kg/d or 143% of HB predicted by MV week 3, with hypermetabolism persisting to MV week 7. Obese individuals displayed a more truncated response with significantly lower mREE versus non-obese patients in MV week 1 (19.5 ± 1.0 kcal/kg/d vs 25.1 ± 1.8 kcal/kg/d, respectively; p < 0.01), with little change in weeks 2–3 (19.5 ± 1.5 kcal/kg/d vs 28.0 ± 2.0 kcal/kg/d; p < 0.01). Both ASPEN-SCCM upper range and PSU pREE equations provided close approximations of mREE yet, like all pREE equations, occasionally over- and under-predicted energy needs and typically did not predict late hypermetabolism. Conclusions Study results show a truly unique metabolic response in COVID-19 ICU patients, characterized by significant and prolonged, progressive hypermetabolism peaking at 3 weeks’ post-intubation, persisting for up to 7 weeks in ICU. This pattern was more clearly demonstrated in non-obese versus obese patients. This response is unique and distinct from any previously described model of ICU stress response in its prolonged hypermetabolic nature. This data reaffirms the need for routine, longitudinal IC measures to provide accurate energy targets in COVID-19 ICU patients. The PSU and ASPEN-SCCM equations appear to yield the most reasonable estimation to IC-derived mREE in COVID-19 ICU patients, yet still often over-/under-predict energy needs. These findings provide a practical guide for caloric prescription in COVID-19 ICU patients in the absence of IC.
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Affiliation(s)
- Laura E Niederer
- Duke Office of Clinical Research, Duke University School of Medicine, Durham, NC, USA; Duke Nutrition Services, Duke University Hospital, Durham, NC, USA
| | - Hilary Miller
- Duke Office of Clinical Research, Duke University School of Medicine, Durham, NC, USA; Duke Nutrition Services, Duke University Hospital, Durham, NC, USA
| | - Krista L Haines
- Department of Surgery, Division of Trauma Critical Care, and Acute Care Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jeroen Molinger
- Department of Anesthesiology, Duke University School of Medicine, Division of Critical Care, Durham, NC, USA
| | - John Whittle
- Centre for Perioperative Medicine, Division of Surgery & Interventional Science, University College London, London, UK
| | - David B MacLeod
- Department of Anesthesiology, Duke University School of Medicine, Division of Critical Care, Durham, NC, USA
| | - Stephen A McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Division of Critical Care, Durham, NC, USA.
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Haines KL, Kawano BA, Agarwal SK. Disparities in Asians' Hospice Utilization and Location of Death. Am Surg 2021; 88:2075-2076. [PMID: 34311558 DOI: 10.1177/00031348211034756] [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: 11/15/2022]
Affiliation(s)
- Krista L Haines
- Department of Surgery, School of Medicine, 3065Duke University, Durham, NC, USA
| | - Bradley A Kawano
- Department of Surgery, School of Medicine, 3065Duke University, Durham, NC, USA
| | - Suresh K Agarwal
- Department of Surgery, School of Medicine, 3065Duke University, Durham, NC, USA
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Morris RS, Karam BS, Murphy PB, Jenkins P, Milia DJ, Hemmila MR, Haines KL, Puzio TJ, de Moya MA, Tignanelli CJ. Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage. J Trauma Acute Care Surg 2021; 90:e138-e145. [PMID: 33605709 DOI: 10.1097/ta.0000000000003125] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.
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Affiliation(s)
- Rachel S Morris
- From the Department of Surgery (R.M., B.S.K., P.M., D.M., M.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (P.J.), Indiana University, Indianapolis, Indiana; Department of Surgery (M.H.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (K.H.), Duke University, Durham, North Carolina; Department of Surgery (T.P.), University of Texas Health Science Center, Houston, Texas; Department of Surgery (C.T.), and Institute for Health Informatics (C.T.), University of Minnesota, Minneapolis; and Department of Surgery (C.T.), North Memorial Health Hospital, Robbinsdale, Minnesota
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Haines KL, Fuller M, Antonescu I, Vaughan JG, Raghunathan K, Cox CE, Bartz RR, Ohnuma T, Agarwal S, Krishnamoorthy V. Underutilization of Acetaminophen in Older Adult Trauma Patients. Am Surg 2021; 88:2003-2010. [PMID: 34049451 DOI: 10.1177/00031348211023397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Older adults are more vulnerable to opioid-associated morbidity. The purpose of this study was to determine the frequency and timing of acetaminophen and opioid use in the postoperative period. METHODS Older adult trauma patients (≥65 years) with hip fractures requiring femur or hip fixation were reviewed (Premier Database 2008-2014). We examined rates of acetaminophen use on the day of surgery and prior to receipt of oral opioids. Mixed-effects linear regression models were used to examine the effects of an acetaminophen-first approach on opioid use the day prior to and on the day of discharge. RESULTS Of the 192 768 patients, 81.6% were Caucasian; 74.0% were female; and the mean age was 82.0 years [± 7.0]. Only 16.8% (32 291) of patients received acetaminophen prior to being prescribed opioids. 27.4% (52 779) received an acetaminophen-opioid combination, and 9.2% (17 730) received opioids without acetaminophen first. Acetaminophen first was associated with reduced opioid use on the day prior to and on the day of discharge (3.52 parenteral morphine equivalent doses (PMEs) less [95% CI: 3.33, 3.70]; P < .0001). A statistically but not clinically significant reduction in length of stay was observed in the acetaminophen-first group. CONCLUSION Nearly 37% of older adult patients did not receive acetaminophen as first-line analgesia after hip surgery. Multimodal analgesia, including non-opioid medications as first-line, should be encouraged.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Matthew Fuller
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Justin G Vaughan
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Christopher E Cox
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
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Williams DGA, Ohnuma T, Haines KL, Krishnamoorthy V, Raghunathan K, Sulo S, Cassady BA, Hegazi R, Wischmeyer PE. Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients. Br J Anaesth 2021; 126:730-737. [PMID: 33516455 DOI: 10.1016/j.bja.2020.12.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/05/2020] [Accepted: 12/12/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Malnutrition in older hip fracture patients is associated with increased complication rates and mortality. As postoperative nutrition delivery is essential to surgical recovery, postoperative nutritional supplements including oral nutritional supplements or tube feeding formulas can improve postoperative outcomes in malnourished hip/femur fracture patients. The association between early postoperative nutritional supplements utilisation and hospital length of stay was assessed in malnourished hip/femur fracture patients. METHODS This is a retrospective cohort study of malnourished hip/femur fracture patients undergoing surgery from 2008 to 2018. Patients were identified through International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes and nutritional supplement utilisation via hospital charge codes. The primary outcome was hospital length of stay. Secondary outcomes included infectious complications, hospital mortality, ICU admission, and costs. Propensity matching (1:1) and univariable analysis were performed. RESULTS Overall, 160 151 hip/femur fracture surgeries were identified with a coded-malnutrition prevalence of 8.7%. Early postoperative nutritional supplementation (by hospital day 1) occurred in 1.9% of all patients and only 4.9% of malnourished patients. Propensity score matching demonstrated early nutritional supplements were associated with significantly shorter length of stay (5.8 [6.6] days vs 7.6 [5.8] days; P<0.001) without increasing hospital costs. No association was observed between early nutritional supplementation and secondary outcomes. CONCLUSION Malnutrition is underdiagnosed in hip/femur fracture patients, and nutritional supplementation is underutilised. Early nutritional supplementation was associated with a significantly shorter hospital stay without an increase in costs. Nutritional supplementation in malnourished hip/femur fracture patients could serve as a key target for perioperative quality improvement.
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Affiliation(s)
- David G A Williams
- CAPER Unit, Department of Anesthesiology, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | - Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | | | | | - Paul E Wischmeyer
- CAPER Unit, Department of Anesthesiology, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Jones RC, Creutzfeldt CJ, Cox CE, Haines KL, Hough CL, Vavilala MS, Williamson T, Hernandez A, Raghunathan K, Bartz R, Fuller M, Krishnamoorthy V. Racial and Ethnic Differences in Health Care Utilization Following Severe Acute Brain Injury in the United States. J Intensive Care Med 2020; 36:1258-1263. [PMID: 32912070 DOI: 10.1177/0885066620945911] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine racial and ethnic differences in the utilization of 3 interventions (tracheostomy placement, gastrostomy tube placement, and hospice utilization) among patients with severe acute brain injury (SABI). DESIGN Retrospective cohort study. SETTING Data from the National Inpatient Sample, from 2002 to 2012. PATIENTS Adult patients with SABI defined as a primary diagnosis of stroke, traumatic brain injury, or post-cardiac arrest who received greater than 96 hours of mechanical ventilation. EXPOSURE Race/ethnicity, stratified into 5 categories (white, black, Hispanic, Asian, and other). MEASUREMENTS AND MAIN RESULTS Data from 86 246 patients were included in the cohort, with a mean (standard deviation) age of 60 (18) years. In multivariable analysis, compared to white patients, black patients had an 20% increased risk of tracheostomy utilization (relative risk [RR]: 1.20, 95% CI: 1.16-1.24, P < .001), Hispanic patients had a 10% increased risk (RR: 1.10, 95% CI: 1.06-1.14, P < .001), Asian patients had an 8% increased risk (RR: 1.08, 95% CI: 1.01-1.16, P = .02), and other race patients had an 10% increased risk (RR: 1.10, 95% CI: 1.04-1.16, P < .001). A similar relationship was observed for gastrostomy utilization. In multivariable analysis, compared to white patients, black patients had a 25% decreased risk of hospice discharge (RR: 0.75, 95% CI: 0.67-0.85, P < .001), Hispanic patients had a 20% decreased risk (RR: 0.80, 95% CI: 0.69-0.94, P < .01), and Asian patients had a 47% decreased risk (RR: 0.53, 95% CI: 0.39-0.73, P < .001). There was no observed relationship between race/ethnicity and in-hospital mortality. CONCLUSIONS Minority race was associated with increased utilization of tracheostomy and gastrostomy, as well as decreased hospice utilization among patients with SABI. Further research is needed to better understand the mechanisms underlying these race-based differences in critical care.
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Affiliation(s)
- Rayleen C Jones
- School of Nursing, Duke University, NC, USA.,Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA
| | | | | | - Krista L Haines
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Surgery, Duke University, NC, USA
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, WA, USA
| | | | | | - Karthik Raghunathan
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Raquel Bartz
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Matt Fuller
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
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Haines KL, Fuller M, Vaughan JG, Krishnamoorthy V, Raghunathan K, Kasotakis G, Agarwal S, Ohnuma T. The Impact of Nonsteroidal Anti-inflammatory Drugs on Older Adult Trauma Patients With Hip Fractures. J Surg Res 2020; 255:583-593. [PMID: 32650142 DOI: 10.1016/j.jss.2020.05.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/03/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID) use is frequently recommended for multimodal analgesia to reduce opioid use. We hypothesized that increased NSAID utilization will decrease opioid requirements without leading to significant complications in older adult trauma patients undergoing hip fracture repair. METHODS An observational cross-sectional cohort study of 190,057 adult trauma patients over a 6-y period (2008-2014) in the national Premier Healthcare Database was performed. Patients aged 65 or older undergoing femur repair and hip arthroplasty following fractures due to falls were analyzed. Primary outcome was opioid use, and secondary outcomes included transfusion requirements, length of stay (LOS), and organ system dysfunction. Continuous outcomes were analyzed using mixed-effect linear regression models to assess the effect of NSAIDs on the day of surgery. Fixed effects were included for patient and hospital characteristics, comorbidities, co-treatments, and surgery. Random intercepts for each hospital were included to control for clustering. Categorical outcomes were similarly analyzed using mixed-effect logistic regression models. RESULTS NSAIDs decreased opioids prescribed (12.01 versus 11.43 morphine milligram equivalents) (odds ratio [OR], -0.23; confidence interval [CI] = -0.41, -0.06) without overall increased bleeding (40.83% versus 43.18%; OR, 1.02; CI = 0.99, 1.05). NSAIDs were associated with reduced LOS (5.61 versus 5.96 d; CI = -0.24, -0.12), intensive care unit admissions (9.73% versus 10.59%; OR, 0.91; CI = 0.86, 0.96), and pulmonary complications (OR, 0.88; CI = 0.83, 0.93). Additionally, there was a 21% prescribing variability based solely on hospital. CONCLUSIONS NSAIDs were associated with decreased opioid requirements, hospital LOS, and intensive care unit admissions in older adult trauma patients without overall increase in bleeding. NSAIDs should be considered in multimodal pain regimens, moreover, given prescribing variability guidelines are needed. LEVEL OF EVIDENCE Level III, Prognostic.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina.
| | - Matthew Fuller
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Justin G Vaughan
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - George Kasotakis
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Ohnuma T, Raghunathan K, Moore S, Setoguchi S, Ellis AR, Fuller M, Whittle J, Pyati S, Bryan WE, Pepin MJ, Bartz RR, Haines KL, Krishnamoorthy V. Dose-Dependent Association of Gabapentinoids with Pulmonary Complications After Total Hip and Knee Arthroplasties. J Bone Joint Surg Am 2020; 102:221-229. [PMID: 31804238 DOI: 10.2106/jbjs.19.00889] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Gabapentinoids are commonly prescribed in perioperative multimodal analgesia protocols. Despite widespread use, the optimal dose to reduce opioid consumption while minimizing risks is unknown. We assessed dose-dependent effects of gabapentinoids on opioid consumption and postoperative pulmonary complications following total hip or knee arthroplasty (THA or TKA). We hypothesized that use of a gabapentinoid on the day of THA or TKA is associated with an increased risk of postoperative pulmonary complications in a dose-response fashion compared with the risk for patients who did not receive the drug. METHODS Using the Premier Database, we identified adults who underwent elective primary THA or TKA from 2009 to 2014. The exposure was receipt of a gabapentinoid (gabapentin or pregabalin) on the day of surgery. Gabapentin dose was categorized into 5 groups: none, 1 to 350, 351 to 700, 701 to 1,050, and >1,050 mg per day. Pregabalin dose was categorized into 4 groups: none, 1 to 110, 111 to 250, and >250 mg per day. The primary outcome was a composite of postoperative pulmonary complications, defined as respiratory failure, pneumonia, reintubation, pulmonary edema, noninvasive ventilation, or invasive mechanical ventilation. RESULTS Of 858,306 patients who underwent THA or TKA, 11.0% received gabapentin and 10.2% received pregabalin. The mean age (and standard deviation) of the patients was 65.6 ± 10.7 years, 39.6% were male, 78.2% were Caucasian, and 55.2% were covered by Medicare. In multilevel regression analysis, receipt of gabapentinoid at any dose on the day of surgery was associated with increased odds of postoperative pulmonary complications. Compared with no exposure to the drug being used by the particular group, all dose ranges of gabapentin and pregabalin were associated with greater odds of postoperative pulmonary complications (odds ratio, 95% confidence interval = 1.51, 1.40 to 1.63, for >1,050 mg of gabapentin and 1.81, 1.57 to 2.09, for >250 mg of pregabalin). We found no clinically meaningful associations between exposure to either gabapentin or pregabalin and perioperative opioid consumption or the length of the hospital stay. CONCLUSIONS Exposure to gabapentinoids at any dose on the day of THA or TKA was associated with increased odds of postoperative pulmonary complications in a dose-response fashion, with minimal effects on perioperative opioid consumption. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tetsu Ohnuma
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina.,CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina.,CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Sean Moore
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Soko Setoguchi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alan R Ellis
- Department of Social Work, North Carolina State University, Raleigh, North Carolina
| | - Matthew Fuller
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - John Whittle
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Srinivas Pyati
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina.,CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - William E Bryan
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina
| | - Marc J Pepin
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina
| | - Raquel R Bartz
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
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Chen H, Scarborough J, Zens T, Brummeyer B, Agarwal S, Haines KL. Race and Insurance Status as Predictors of Bicycle Trauma Outcome in Adults. J Surg Res 2019; 245:198-204. [PMID: 31421362 DOI: 10.1016/j.jss.2019.07.064] [Citation(s) in RCA: 8] [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: 01/09/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Race and insurance status have been shown to predict outcomes in pediatric bicycle traumas. It is unknown how these factors influence outcomes in adult bicycle traumas. This study aims to evaluate the association, if any, between race and insurance status with mortality in adults. METHODS This retrospective cohort study used the National Trauma Data Bank Research Data Set for the years 2013-2015. Multivariate logistic regression models were used to determine the independent association between patient race and insurance status on helmet use and on outcomes after hospitalization for bicycle-related injury. These models adjusted for demographic factors and comorbid variables. When examining the association between race and insurance status with outcomes after hospitalization, injury characteristics were also included. RESULTS A study population of 45,063 met the inclusion and exclusion criteria. Multivariate regression demonstrated that black adults and Hispanic adults were significantly less likely to be helmeted at the time of injury than white adults [adjusted odds ratio of helmet use for blacks 0.25 (95% CI 0.22-0.28) and for Hispanics 0.33 (95% CI 0.30-0.36) versus whites]. Helmet usage was also independently associated with insurance status, with Medicare-insured patients [AOR 0.51 (95% CI 0.47-0.56) versus private-insured patients], Medicaid-insured patients [AOR 0.18 (95% CI 0.17-0.20)], and uninsured patients [AOR 0.29 (95% CI 0.27-0.32)] being significantly less likely to be wearing a helmet at the time of injury compared with private-insured patients. Although patient race was not independently associated with hospital mortality among adult bicyclists, we found that uninsured patients had significantly higher odds of mortality [AOR 2.02 (AOR 1.31-3.12)] compared with private-insured patients. CONCLUSIONS Minorities and underinsured patients are significantly less likely to be helmeted at the time of bicycle-related trauma when compared with white patients and those with private insurance. Public health efforts to improve the utilization of helmets during bicycling should target these subpopulations.
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Affiliation(s)
- HuaFu Chen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John Scarborough
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Tiffany Zens
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brandon Brummeyer
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Haines KL, Nguyen BP, Vatsaas C, Alger A, Brooks K, Agarwal SK. Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury. J Surg Res 2018; 235:131-140. [PMID: 30691786 DOI: 10.1016/j.jss.2018.09.072] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/10/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI. METHODS This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS). RESULTS We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5. CONCLUSIONS Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.
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Affiliation(s)
- Krista L Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Benjamin P Nguyen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Cory Vatsaas
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amy Alger
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kelli Brooks
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh K Agarwal
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Haines KL, Rust CJ, Agarwal S. Effects of Obesity on Penetrating Trauma. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.174] [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: 10/28/2022]
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Haines KL, Zens T, Warner-Hillard C, DeSouza E, Jung HS, Agarwal S. Rib Fracture Location Should Be Evaluated When Predicting Morbidity and Mortality in Trauma Patients. Am Surg 2018; 84:1462-1465. [PMID: 30268176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Rib fractures represent up to 55 per cent of thoracic blunt traumatic injuries and lead to significant mortality and morbidity. The aim of this study is to determine whether not only number but also the location of rib fractures can be used to risk stratify patients. This is a retrospective study of all blunt trauma patients who presented with rib fractures from January 1, 2013 to April 1, 2015 and underwent chest CT. Rib fractures were categorized by location. Primary outcome was mortality, secondary outcomes were total hospital length of stay (LOS), intensive care unit LOS, and disposition. Multivariate regressions were performed to determine whether mortality and morbidity was dependent on the number of rib fractures as related to location. Nine hundred and twenty-nine patients were reviewed, 669 fit inclusion criteria, and 35 patients died. Mean Injury Severity Score (18 ± 10), total number of rib fractures (6 ± 5), and age (54 ± 19) significantly correlated with mortality. LOS correlated with the number of rib fractures (P < 0.001). Flail chest of indeterminate location significantly increased mortality (P = 0.002). Controlling for age, gender, and Injury Severity Score and for every lateral rib fracture, patients were 1.13 times (OR; P = 0.001) more likely to die. Posterior rib fractures only effected patient outcome if the patient has three or more posterior ribs broken and the patient was 45 years of age or older (P = 0.044); these patients were 12 times more likely to die. When evaluating blunt force trauma in patients with rib fractures, it is imperative to look at rib fracture location and not only the number of rib fractures sustained to predict outcomes.
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Haines KL, Zens T, Warner-Hillard C, DeSouza E, Jung HS, Agarwal S. Rib Fracture Location Should be Evaluated When Predicting Morbidity and Mortality in Trauma Patients. Am Surg 2018. [DOI: 10.1177/000313481808400950] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rib fractures represent up to 55 per cent of thoracic blunt traumatic injuries and lead to significant mortality and morbidity. The aim of this study is to determine whether not only number but also the location of rib fractures can be used to risk stratify patients. This is a retrospective study of all blunt trauma patients who presented with rib fractures from January 1, 2013 to April 1, 2015 and underwent chest CT. Rib fractures were categorized by location. Primary outcome was mortality, secondary outcomes were total hospital length of stay (LOS), intensive care unit LOS, and disposition. Multivariate regressions were performed to determine whether mortality and morbidity was dependent on the number of rib fractures as related to location. Nine hundred and twenty-nine patients were reviewed, 669 fit inclusion criteria, and 35 patients died. Mean Injury Severity Score (18 ± 10), total number of rib fractures (6 ± 5), and age (54 ± 19) significantly correlated with mortality. LOS correlated with the number of rib fractures (P < 0.001). Flail chest of indeterminate location significantly increased mortality (P = 0.002). Controlling for age, gender, and Injury Severity Score and for every lateral rib fracture, patients were 1.13 times (OR; P = 0.001) more likely to die. Posterior rib fractures only effected patient outcome if the patient has three or more posterior ribs broken and the patient was 45 years of age or older (P = 0.044); these patients were 12 times more likely to die. When evaluating blunt force trauma in patients with rib fractures, it is imperative to look at rib fracture location and not only the number of rib fractures sustained to predict outcomes.
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Affiliation(s)
- Krista L. Haines
- Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, North Carolina
| | - Tiffany Zens
- Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Charles Warner-Hillard
- Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, North Carolina
| | - Edwarda DeSouza
- Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hee Soo Jung
- Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Suresh Agarwal
- Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, North Carolina
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Haines KL, Agarwal S, Jung HS. Socioeconomics affecting quality outcomes in Asian trauma patients within the United States. J Surg Res 2018; 228:63-67. [PMID: 29907231 DOI: 10.1016/j.jss.2018.02.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 12/31/2017] [Revised: 02/17/2018] [Accepted: 02/27/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Asian-Americans and Pacific Islanders are often considered as a uniform group when examining race in health outcomes. However, the generally favorable economic outcomes in this group belie significant socioeconomic variance between its heterogeneous subgroups. This study evaluates the impact of socioeconomic status on the health outcomes of Asian trauma patients. METHODS From 2012 to 2015, 52,704 Asians who presented to trauma centers were registered with the National Trauma Data Bank with known disposition. Chi2 and multivariate logistic regression analysis for mortality were performed controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was performed. Subgroup analysis was done for polytrauma (Injury Severity Score >15, n = 14,787). RESULTS Asians represent 1.8% of the trauma population. Uninsured Asians were 1.9 times more likely to die than privately insured Asians (P < 0.001). Medicare patients were 1.8 times more likely to die (P < 0.001). Eighty-one Asians identified themselves as Hispanic, and there was no significant difference in their mortality or LOS for this group (P = 0.06, P = 0.18). Bleeding disorders, diabetes, cirrhosis, hypertension, respiratory disease, cancer, esophageal varices, angina, cerebrovascular accident, and dependent health care before trauma all individually affected mortality and were controlled for in this model (P < 0.05). LOS was 1.7 d longer in Medicaid patients (2.2 d with polytrauma) and 1.1 d longer in workman's compensation patients (2.1 d with polytrauma). Uninsured had a shorter LOS (P < 0.005). Asian males with polytrauma stayed 1.6 d longer than females (P < 0.001), and age did not affect LOS for this group. CONCLUSIONS Noteworthy socioeconomic disparities influence Asian trauma patients independent of their race. Mortality is affected by insurance status, despite controlling for injury severity and comorbidities.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care, Department of Surgery, Duke School of Medicine and Public Health, Duke University, Durham, North Carolina.
| | - Suresh Agarwal
- Division of Trauma and Critical Care, Department of Surgery, Duke School of Medicine and Public Health, Duke University, Durham, North Carolina
| | - Hee Soo Jung
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Haines KL, Jung HS, Zens T, Turner S, Warner-Hillard C, Agarwal S. Barriers to Hospice Care in Trauma Patients: The Disparities in End-of-Life Care. Am J Hosp Palliat Care 2018; 35:1081-1084. [PMID: 29361829 DOI: 10.1177/1049909117753377] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION End-of-life and palliative care are important aspects of trauma care and are not well defined. This analysis evaluates the racial and socioeconomic disparities in terms of utilization of hospice services for critically ill trauma patients. METHODS Trauma patients ≥15 years old from 2012 to 2015 were queried from the National Trauma Databank. Chi-square and multivariate logistic regression analyses for disposition to hospice were performed after controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was calculated for all patients discharged to hospice. RESULTS Chi-square analysis of 2 966 444 patient's transition to hospice found patients with cardiac disease, bleeding and psychiatric disorders, chemotherapy, cancer, diabetes, cirrhosis, respiratory disease, renal failure, cirrhosis, and cerebrovascular accident (CVA) affected transfer ( P < .0001). Logistic regression analysis after controlling for covariates showed uninsured patients were discharged to hospice significantly less than insured patients (odds ratio [OR]: 0.71; P < .0001). Asian, African American, and Hispanic patients all received less hospice care than Caucasian patients (OR: 0.65, 0.60, 0.73; P < .0001). Negative binomial regression analysis with margins for LOS showed Medicare patients were transferred to hospice 1.2 days sooner than insured patients while uninsured patients remained in the hospital 1.6 days longer ( P < .001). When compare to Caucasians, African Americans patients stayed 3.7 days longer in the hospital and Hispanics 2.4 days longer prior to transfer to hospice ( P < .0001). In all patients with polytrauma, African Americans stayed 4.9 days longer and Hispanics 2.3 days longer as compared to Caucasians ( P < .0001). CONCLUSIONS Race and ethnicity are independent predictors of a trauma patient's transition to hospice care and significantly affect LOS. Our data demonstrate prominent racial and socioeconomic disparities exist, with uninsured and minority patients being less likely to receive hospice services and having a delay in transition to hospice care when compared to their insured Caucasian counterparts.
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Affiliation(s)
- Krista L Haines
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hee Soo Jung
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tiffany Zens
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Scott Turner
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Charles Warner-Hillard
- 2 Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, NC, USA
| | - Suresh Agarwal
- 2 Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, NC, USA
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Affiliation(s)
- Krista L. Haines
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Suresh Agarwal
- University of Wisconsin School of Medicine and Public Health, Madison
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Gallagher SF, Haines KL, Osterlund LG, Mullen M, Downs JB. Postoperative hypoxemia: common, undetected, and unsuspected after bariatric surgery. J Surg Res 2009; 159:622-6. [PMID: 20006346 DOI: 10.1016/j.jss.2009.09.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 08/27/2009] [Accepted: 09/02/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients undergoing gastric bypass are at greater than ordinary risk for postoperative respiratory insufficiency, presumably related to obstructive sleep apnea (OSA) and patient-controlled analgesia (PCA). This study was proposed to quantify the magnitude of the problem. METHODS Fifteen patients undergoing gastric bypass had oxygen saturation (SpO(2)) recorded continuously, but not displayed, for 24h postoperatively; eight also had arterial blood analysis every 4h. All received narcotic PCA. SpO(2)<90% lasting more than 10 s was reviewed. Results are mean+/-SEM. RESULTS Mean age was 44+/-4 y, and mean BMI was 48+/-2kg/m(2); 77% had OSA. Every patient had more than one episode with SpO(2)<90% for longer than 30s undetected by routine monitoring; most had multiple episodes. Nadir SpO(2) averaged 75% +/- 8%. Mean longest duration of desaturation below 90% averaged 21+/-15min. Mean PaCO(2) was 37+/-3mm Hg; maximum PaCO(2) was 47mm Hg. CONCLUSIONS Severe and prolonged episodes of hypoxemia were a consistent finding, despite aggressive preoperative diagnosis and treatment of OSA, including use of CPAP postoperatively. Although some postoperative hypoventilation was expected, the degree and frequency of desaturation were surprising. No patient exhibited arterial PaCO(2) evidence of hypoventilation. No patient experienced cardiopulmonary arrest/instability, in spite of severe, repeated episodes of hypoxemia. In no instance was a significant hypoxemic episode suspected or detected. Continuous pulse oximetry monitoring, with an audible alarm set for a saturation less than 90% for 10 s, would have alerted providers to 100% of significant hypoxemic episodes. Our recommendation is routinely monitoring (with alarm capability enabled) every bariatric surgical patient, to prevent such occurrence.
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Affiliation(s)
- Scott F Gallagher
- Department of Surgery, USF Health, University of South Florida College of Medicine, Tampa, Florida 33606, USA.
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Haines KL, Downs JB, Cuculich C, Bowen B, Murr MM, Gallagher SF. QS262. Postoperative Hypoxemia: A Common, Undetected and Unsuspected Complication After Bariatric Surgery. J Surg Res 2008. [DOI: 10.1016/j.jss.2007.12.510] [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: 11/16/2022]
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Gallagher SF, Wahi M, Haines KL, Baksh K, Enriquez J, Lee TM, Murr MM, Fabri PJ. Trends in adrenalectomy rates, indications, and physician volume: A statewide analysis of 1816 adrenalectomies. Surgery 2007; 142:1011-21; discussion 1011-21. [PMID: 18063089 DOI: 10.1016/j.surg.2007.09.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 09/06/2007] [Accepted: 09/11/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Adrenalectomy rates seem to be increasing in Florida, possibly due to increased availability of laparoscopic adrenalectomy, identification of incidentalomas, and access to care for minorities. We hypothesized that the rate of adrenalectomies in Florida increased from 1998-2005 while characteristics of patients, diagnoses, operations, and operating physicians changed over this period. METHODS Prospectively-collected, mandatory-reported, hospital discharge data for all inpatient adrenalectomies undertaken in Florida from 1998-2005 were obtained along with Florida census and physician certification and education data. Characteristics of adrenalectomy patients, diagnoses, operations, and physicians were analyzed. RESULTS 1816 adrenalectomies were available for analysis. Yearly rates of adrenalectomy nearly doubled from 1.20 to 2.26 per 100,000 Florida residents (P = .0024). Overall, patient characteristics such as demographics, indications and comorbidities did not change, whereas hospital charges increased and length-of-stay (LOS) significantly decreased (P = .0031 and P < .0001, respectively). There was a non-significant trend toward a yearly increase in physician volume and an inverse relationship between physician volume categories and mean LOS (P < .0001). CONCLUSIONS The rate of adrenalectomies is increasing in Florida. This increase was not associated with distinct trends in patient characteristics, although a significant decrease in LOS was identified. As these trends continue and adrenalectomy is applied more liberally, indications for adrenalectomy may need to be re-evaluated.
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Affiliation(s)
- Scott F Gallagher
- Department of Surgery, USF Health, University of South Florida College of Medicine, Tampa, Florida 33606, USA.
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Haines KL, Nelson LG, Gonzalez R, Torrella T, Martin T, Kandil A, Dragotti R, Anderson WM, Gallagher SF, Murr MM. Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery 2006; 141:354-8. [PMID: 17349847 DOI: 10.1016/j.surg.2006.08.012] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Revised: 08/10/2006] [Accepted: 08/12/2006] [Indexed: 12/31/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to report objective improvement of obesity-related OSA and sleep quality after bariatric surgery. METHODS Prospective bariatric patients were referred for polysomnography if they scored >or=6 on the Epworth Sleepiness Scale. The severity of OSA was categorized by the respiratory disturbance index (RDI) as follows: absent, 0 to 5; mild, 6 to 20; moderate, 21 to 40; and severe, <40. Patients were referred for repeat polysomnography 6 to 12 months after bariatric surgery or when weight loss exceeded 75 lbs. Means were compared using paired t tests. Chi-square tests and linear regression models were used to assess associations between clinical parameters and RDI; P<.05 was considered statistically significant. RESULTS Of 349 patients referred for polysomnography, 289 patients had severe (33%), moderate (18%), and mild (32%) OSA; 17% had no OSA. At a median of 11 months (6 to 42 months) after bariatric surgery, mean body mass index (BMI) was 38 +/- 1 kg/m2 (P<.01 vs 56 +/- 1 kg/m2 preoperatively) and the mean RDI decreased to 15 +/- 2 (P<.01 vs 51 +/- 4 preoperatively) in 101 patients who underwent postoperative polysomnography. In addition, minimum oxygen saturation, sleep efficiency, and rapid eye movement latency improved, and the requirement for continuous positive airway pressure was reduced (P<or=.025). Male gender and increasing BMI correlated with increasing RDI (P<.01) by chi-square analysis. In a multivariate linear regression model adjusted for age and gender, preoperative BMI correlated with preoperative RDI (r=0.27; P<.01). CONCLUSIONS OSA is prevalent in at least 45% of bariatric surgery patients. Preoperative BMI correlates with the severity of OSA. Surgically induced weight loss significantly improves obesity-related OSA and parameters of sleep quality.
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Affiliation(s)
- Krista L Haines
- Department of Surgery, Interdisciplinary Obesity Group, University of South Florida, Health Sciences Center, Tampa, FL 33601, USA
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Murr MM, Martin T, Haines KL, Nelson LG, Gonzalez R, Gallagher SF. Statewide review of contemporary outcomes of bariatric surgery in Florida. Surg Obes Relat Dis 2005. [DOI: 10.1016/j.soard.2005.03.049] [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: 10/25/2022]
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Shalhub S, Parsee A, Gallagher SF, Haines KL, Willkomm C, Brantley SG, Pinkas H, Saff-Koche L, Murr MM. The importance of routine liver biopsy in diagnosing nonalcoholic steatohepatitis in bariatric patients. Obes Surg 2004; 14:54-9. [PMID: 14980034 DOI: 10.1381/096089204772787293] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Nonalcoholic Steatohepatitis (NASH) commonly occurs in obese patients and predisposes to cirrhosis. Prevalence of NASH in bariatric patients is unknown. Our aim was to determine the role of routine liver biopsy in managing bariatric patients. METHODS Prospective data on patients undergoing Roux-en-Y gastric bypass (RYGBP) was analyzed. One pathologist graded all liver biopsies as mild, moderate or severe steatohepatitis. NASH was defined as steatohepatitis without alcoholic or viral hepatitis. Consecutive liver biopsies were compared to those liver biopsies selected because of grossly fatty livers. RESULTS 242 patients underwent open and laparoscopic RYGBP from 1998-2001. Routine liver biopsies (68 consecutive patients) and selective liver biopsies (additional 86/174, 49%) were obtained. Findings of cirrhosis on frozen section changed the operation from a distal to a proximal RYGBP. The two groups were similar in age, gender, and BMI. The group with the routine liver biopsies showed a statistically significant larger preponderance of NASH (37% vs 32%). Both groups had a similar prevalence of cirrhosis. Neither BMI nor liver enzymes predicted the presence or severity of NASH. CONCLUSIONS Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH. Liver biopsy remains the gold-standard for diagnosing NASH. We recommend routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures.
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Affiliation(s)
- Sherene Shalhub
- Department of Surgery and Interdisciplinary Obesity Study Group, University of South Florida Health Sciences Center, Tampa, FL 33601, USA
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