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Ardeshna S, Esposito E, Spalding C, Dunn J, Nahmias J, Grigorian A, Harmon L, Gergen A, Young A, Pascual J, Murry J, Ong A, Appelbaum R, Bugaev N, Tatar A, Zreik K, Scalea TM, Stein D, Lauerman M. Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury. Am Surg 2023; 89:5183-5190. [PMID: 36417771 DOI: 10.1177/00031348221138083] [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] [Indexed: 12/22/2023]
Abstract
BACKGROUND Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.
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Affiliation(s)
| | | | | | - Julie Dunn
- University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Anna Gergen
- University of Colorado Denver, Denver, CO, USA
| | - Andrew Young
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jose Pascual
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Rachel Appelbaum
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Deborah Stein
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Yang S, Esposito E, Spalding C, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Lieser MJ, Scalea TM, Stein DM, Lauerman M. Grade 1 Internal Carotid Artery Blunt Cerebrovascular Injury Persistence Risks Stroke With Current Management: An EAST Multicenter Study. Am Surg 2023; 89:2618-2627. [PMID: 35652129 DOI: 10.1177/00031348221082277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics. METHODS A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only. RESULTS From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury. DISCUSSION While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.
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Affiliation(s)
- Sarah Yang
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | - Linda Zier
- University of Colorado, Loveland, CO, USA
| | | | - Paul Kim
- Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Andrew J Young
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margaret Lauerman
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
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Appelbaum RD, Esposito E, Spaulding MC, Simpson JP, Dunn J, Zier LB, Burruss S, Kim PP, Jacobson LE, Williams JM, Nahmias J, Grigorian A, Harmon L, Gergen AK, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Bugaev N, Tatar A, Zreik K, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study. Injury 2022; 53:3702-3708. [PMID: 36085175 DOI: 10.1016/j.injury.2022.08.043] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. METHODS This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. RESULTS 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p < 0.001) as was the median AIS head score (2.0 vs 1.0, p < 0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. CONCLUSIONS Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.
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Affiliation(s)
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Margaret H Lauerman
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
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Lauerman M, Esposito E, Spalding C, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Lieser MJ, Scalea TM, Stein DM. Endovascular Intervention in Internal Carotid Artery Blunt Cerebrovascular Injury: An EAST Multicenter Study. Am Surg 2022; 88:1962-1969. [PMID: 35437020 DOI: 10.1177/00031348221078958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown. METHODS A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use. RESULTS From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI. DISCUSSION Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.
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Affiliation(s)
- Margaret Lauerman
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Joshua Simpson
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Linda Zier
- University of Colorado, Loveland, CO, USA
| | | | - Paul Kim
- 4608Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Andrew J Young
- 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Rovinder S Sandhu
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachel Appelbaum
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nikolay Bugaev
- 1867Tufts University School of Medicine, Boston, MA, USA
| | - Antony Tatar
- 1867Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
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Esposito EC, Kufera JA, Wolff TW, Spalding MC, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Hustad L, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:347-354. [PMID: 34739003 DOI: 10.1097/ta.0000000000003455] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level IV.
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Affiliation(s)
- Emily C Esposito
- From the University of Maryland School of Medicine (E.E., J.A.K., T.M.S., M.H.L.), Baltimore, Maryland; Ohio State University Wexner Medical Center (T.W.W., M.C.S., A.J.Y.), Columbus, Ohio; Greenville Health System (J.S.), Greenville, South Carolina; University of Colorado (J.A.D., L.Z., La.H., An.G.), Boulder, Colorado; Loma Linda University (S.B., P.K.)., Loma Linda, California; Ascension Health (L.E.J., J.W.), St. Louis, Missouri; University of California (J.N., Ar.G.), Oakland, California; University of Miami (M.C., R.R.), Miami, Florida; Perelman School of Medicine at the University of Pennsylvania (J.L.P.), Philadelphia, Pennsylvania; UT Health Tyler (J.M.), Tyler, Texas; Towerhealth (A.W.O., A.M.), West Reading, Pennsylvania; Lehigh Valley Health Network (R.S.S., R.A.), Allentown, Pennsylvania; Tufts University School of Medicine (N.B., A.T.), Boston, Massachusetts; Sanford Health (K.Z., Le.H.), Sioux Falls, South Dakota; Research Medical Center (M.J.L.), Kansas City, Missouri; University of California San Francisco (D.M.S.), San Francisco, California
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Cucher D, Harmon L, Myer B, Ngyuen A, Rankin T, Cook A, Hu C, Tesoriero R, Scalea T, Stein D. Critical traumatic brain injury is associated with worse coagulopathy. J Trauma Acute Care Surg 2021; 91:331-335. [PMID: 34397954 DOI: 10.1097/ta.0000000000003253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated. METHODS Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated. RESULTS In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30). CONCLUSION Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis. LEVEL OF EVIDENCE Prognostic/epidemiological, level IV; prognostic/epidemiological, level III.
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Affiliation(s)
- Daniel Cucher
- From the Division of Trauma (D.C., A.C., C.H.), Chandler Regional Medical Center, Chandler, Arizona; Section of Trauma Acute Care Surgery, Surgical Critical Care, and Burn Surgery (L.H.), Anschutz Medical Center, University of Colorado, Aurora, Colorado; Division of Critical Care & Acute Care Surgery (B.M.), University of Minnesota Health, Saint Paul, Minnesota; Division of Trauma Surgery & Surgical Critical Care (A.N.), Riverside University Health System Medical Center, Riverside, California; Department of Surgery (T.R.), Vanderbilt University Medical Center, Nashville, Tennessee; Program in Trauma ( R.T., T.S., D.S.), R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
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Jayaraman SS, Kulkarni SS, Eaton B, Sides J, Gergen AK, Harmon L, Weinberger JM, Bruns BR, Neal MD, Turcotte J, Feather C, Klune JR. Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study. Surgery 2021; 170:1554-1560. [PMID: 34175115 DOI: 10.1016/j.surg.2021.05.022] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/05/2021] [Accepted: 05/15/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks. METHODS We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not. RESULTS Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000). CONCLUSION Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.
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Affiliation(s)
| | | | - Barbara Eaton
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Jake Sides
- Department of Surgery, Christiana Care Health System, Wilmington, DE
| | - Anna K Gergen
- Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Laura Harmon
- Department of Surgery, University of Colorado Hospital, Aurora, CO. https://twitter.com/lauraharmonmd
| | | | - Brandon R Bruns
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD. https://twitter.com/BrandonRBruns1
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, PA. https://twitter.com/macky_neal
| | - Justin Turcotte
- Department of Surgery, Anne Arundel Medical Center, Annapolis, MD
| | - Cristina Feather
- Department of Surgery, Anne Arundel Medical Center, Annapolis, MD
| | - John R Klune
- Department of Surgery, Anne Arundel Medical Center, Annapolis, MD.
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Demyan L, Siskind S, Harmon L, Ramirez CL, Bank MA, Dela Cruz RA, Giangola MD, Patel VM, Scalea TM, Stein DM, Botwinick I. Do It to Them, Not to Me: Doctors' and Nurses' Personal Preferences Versus Recommendations for End-of-Life Care. J Surg Res 2021; 264:76-80. [PMID: 33794388 DOI: 10.1016/j.jss.2021.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The emotional toll and financial cost of end-of-life care can be high. Existing literature suggests that medical providers often choose to forego many aggressive interventions and life-prolonging therapies for themselves. To further investigate this phenomenon, we compared how providers make medical decisions for themselves versus for relatives and unrelated patients. METHODS Between 2016 and 2019, anonymous surveys were emailed to physicians (attendings, fellows, and residents), nurse practitioners, physician assistances, and nurses at two multifacility tertiary medical centers. Participants were asked to decide how likely they would offer a tracheostomy and feeding gastrostomy to a hypothetical patient with a devastating neurological injury and an uncertain prognosis. Participants were then asked to reconsider their decision if the patient was their own family member or if they themselves were the patient. The Kruskal-Wallis H, Mann-Whitney U, and Tukey tests were used to compare quantitative data. Statistical significance was set at P < 0.05. RESULTS Seven hundred seventy-three surveys were completed with a 10% response rate at both institutions. Regardless of professional identity, age, or gender, providers were significantly more likely to recommend a tracheostomy and feeding gastrostomy to an unrelated patient than for themselves. Professional identity and age of the respondent did influence recommendations made to a family member. CONCLUSIONS We demonstrate that medical practitioners make different end-of-life care decisions for themselves compared with others. It is worth investigating further why there is such a discrepancy between what medical providers choose for themselves compared with what they recommend for others.
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Affiliation(s)
- Lyudmyla Demyan
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
| | - Sara Siskind
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; The Feinstein Institutes for Medical Research, Manhasset, New York
| | - Laura Harmon
- Deparment of Surgery, Surgical Critical Care, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Matthew A Bank
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Acute Care Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Ronald A Dela Cruz
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Acute Care Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Matthew D Giangola
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Acute Care Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Vihas M Patel
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Acute Care Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah M Stein
- Department of Surgery, Zuckerberg San Francisco General Hospital and the University of California, San Francisco
| | - Isadora Botwinick
- Division of Trauma, Emergency Surgery, Surgical Critical Care, Department of Surgery, Stony Brook Medicine, Stony Brook, New York
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Eaton BC, Vesselinov R, Ahmeti M, Stansbury JJ, Regner J, Sadler C, Nevarez S, Lissauer M, Stout L, Harmon L, Glassett B, Hampton DA, Castro HJ, Cunningham K, Mulkey S, O'Meara L, Dia JJ, Bruns BR. Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey. Am Surg 2020; 87:971-978. [PMID: 33295188 DOI: 10.1177/0003134820956929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. METHODS Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. RESULTS Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. CONCLUSION This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.
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Affiliation(s)
- Barbara C Eaton
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, Department of Anesthesiology, 12264University of Maryland, Baltimore, MD, USA
| | - Mentor Ahmeti
- 23506Sanford Medical Center Fargo, ND, USA.,School of Medicine and Health Sciences, 12281University of North Dakota, ND, USA
| | | | | | - Craig Sadler
- 6040Eastern Virginia Medical School, VA, USA.,Norfolk General Hospital, VA, USA
| | | | | | | | | | | | - David A Hampton
- Department of Surgery, Section of Trauma and Acute Care Surgery, University of Chicago Medicine and Biological Sciences, IL, USA
| | - Helen J Castro
- Department of Surgery, Section of Trauma and Acute Care Surgery, University of Chicago Medicine and Biological Sciences, IL, USA
| | | | | | - Lindsay O'Meara
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
| | - Jose J Dia
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
| | - Brandon R Bruns
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, MD, USA
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Boccalandro F, Shreyder K, Harmon L, Dhindsa M, Fahim T, Sheikh S. Five-year follow-up of patients with radio-contrast-induced acute renal injury. Can intravenous sodium-bicarbonate improve long-term outcomes? Cardiovasc Revasc Med 2020; 31:61-68. [PMID: 33250404 DOI: 10.1016/j.carrev.2020.11.017] [Citation(s) in RCA: 2] [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: 10/04/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND/PURPOSE Radiocontrast-induced acute kidney injury (RAKI) is a frequent complication during angiography and is associated with adverse prognosis. Most of the studies evaluating the long-term outcome of patients with RAKI are based on institutional registries. This is the first prospective study to evaluate the 5-year outcomes of patients with RAKI, and assess the effect of sodium bicarbonate (SB) in the long-term outcomes of patients with chronic kidney disease (CKD) undergoing non-emergent coronary angiography. MATERIALS/METHODS 382 CKD stage III-IV patients undergoing elective non-emergent coronary angiography were randomized to SB (n = 192) or normal saline (NS) solution (n = 190). Incidence of RAKI, in-hospital, 1- and 5-year mortality and renal replacement therapy (RRT), and 5-year major adverse renal and cardiovascular events (MARCE) were compared between groups. Outcomes of patient with and without RAKI were compared after five-years of prospective follow-up. Multivariate predictors of RAKI and death at 5-years were determined. RESULTS The use of SB did not improve the incidence of RAKI, in-hospital outcomes, survival, and freedom from RRT or MARCE after 5-years of follow-up. Patients that developed RAKI had a significantly higher mortality at 1-year [8.9% Vs. 1.2%] and 5-years (36% Vs. 11%) (P < 0.01). CONCLUSIONS Hydration with SB showed no benefit compared to NS in preventing RAKI. The use of SB was not superior to NS after 5-years of follow-up regarding MARCE, survival or freedom of RRT. Five-year mortality among patients who developed RAKI remains high, and further research is needed to find the best preventive strategy for this high-risk group of patients. SUMMARY Radiocontrast-induced acute-kidney-injury (RAKI) is associated with poor long-term outcomes in observational and short-term studies. Hydration with sodium bicarbonate (SB) had been evaluated in the prevention of RAKI; but its long-term effect has not been evaluated. We randomized 382 high high-risk patients undergoing coronary angiography to SB or normal saline following them for five years. SB showed no benefit in preventing RAKI, decreasing major adverse renal and cardiovascular events, improving survival or freedom from dialysis after 5-years. This is the first study to follow patients with RAKI for a period of 5-years, showing a significantly higher mortality in this group of patients.
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Affiliation(s)
- Fernando Boccalandro
- ProCare/Odessa Heart Institute & Permian Research Foundation, Odessa, TX, United States of America; Texas Tech University Health Sciences Center, Department of Internal Medicine, Odessa, TX, United States of America.
| | - Katherine Shreyder
- Lahey Hospital and Medical Center, Department of Cardiovascular Medicine, Tufts University School of Medicine, Burlington, MA, United States of America
| | - Laura Harmon
- University of Colorado School of Medicine, Department of Surgery, Denver, CO, United States of America
| | - Mandeep Dhindsa
- Community Medical Center, Stockton, CA, United States of America
| | - Tallat Fahim
- Kaiser Permanente - Bellevue Medical Center. Tacoma, WA, United States of America
| | - Samia Sheikh
- Fresenius Medical Center, Inidanapolis, IN, United States of America
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D'Agostino R, Kursinskis A, Parikh P, Letarte P, Harmon L, Semon G. Management of Penetrating Traumatic Brain Injury: Operative versus Non-Operative Intervention. J Surg Res 2020; 257:101-106. [PMID: 32818778 DOI: 10.1016/j.jss.2020.07.046] [Citation(s) in RCA: 4] [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] [Received: 02/28/2020] [Revised: 07/06/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Penetrating traumatic brain injury (pTBI) is the most lethal form of TBI, with mortality rates as high as 90%. This high mortality rate leads many providers to feel that the treatment of pTBI is futile. Contrary to this point of view, several studies have shown that victims of pTBI who present with a Glasgow Coma Scale (GCS) ≥6 have a reasonable chance of a meaningful outcome. This study sought to investigate outcomes of pTBI patients based on GCS score who underwent neurosurgical intervention (craniotomy or craniectomy) and compare them with patients who did not undergo surgical intervention. MATERIALS AND METHODS The study represents a secondary analysis of the data that were collected from 2006 to 2016 from 17 institutions as part of a multi-center study, investigating clinical outcomes for adult patients sustaining pTBI and surviving >72 h. Patients were divided into those with GCS 3-5 and those with GCS ≥6. Within these groups, patients were stratified by whether they received surgical intervention, compared with standard non-surgical care. Patient level data (age and gender), clinical data (Injury Severity Score and Abbreviated Injury Score), GCS on admission, post-op infection rates, and outcomes data (mortality, length of stay [LOS], intensive care unit LOS) were collected. Both groups were compared using independent sample t-test or chi-squared test. RESULTS Seven hundred twenty patients with pTBI were identified over 11 y, out of which 336 (46.7%) underwent surgery. The mean Injury Severity Score and Abbreviated Injury Score on admission were higher in the surgical intervention group than their non-surgical counterpart in patients with a GCS ≥6 (P < 0.0001). Patients with GCS of 3-5 with surgical intervention demonstrated a higher survival rate than non-surgical patients (P < 0.0001). In the GCS ≥6 group, surgical intervention did not impact near-term mortality. Intensive care unit LOS was significantly longer in the surgical intervention group in patients with GCS ≥ 6 (P < 0.0001) and GCS of 3-5 (P < 0.0001), as was total hospital LOS (P < 0.0001). Patients with a GCS 3-5 and ≥6 who underwent surgical intervention were more likely to develop a central nervous system infection (P = 0.016; P = 0.017). CONCLUSIONS Surgical intervention in pTBI patients with GCS 3-5 results in improved mortality but comes at a cost of increased resource utilization in the form of longer LOS and higher infection rate. On the other hand, in patients with GCS ≥6, surgery does not provide significant benefits in patient survival. Future prospective studies providing insight as to the impact of surgery on the resource utilization and quality of survival would be beneficial in determining the need for surgical intervention in this population.
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Affiliation(s)
| | | | - Priti Parikh
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Peter Letarte
- Department of Neurosurgery, Premier Health, Dayton, Ohio
| | - Laura Harmon
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
| | - Gregory Semon
- Department of Surgery, Wright State University, Dayton, Ohio.
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Harmon L, Bilow R, Shanmuganathan K, Lauerman M, Todd SR, Cardenas J, Haugen CE, Albrecht R, Pittman S, Cohen M, Kaups K, Dirks R, Burlew CC, Fox CJ, Con J, Inaba K, Harrison PB, Berg GM, Waller CJ, Kallies KJ, Kozar RA. Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study. Am J Surg 2019; 218:579-583. [PMID: 31284948 DOI: 10.1016/j.amjsurg.2019.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 03/01/2019] [Revised: 06/17/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. METHODS Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. RESULTS Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. CONCLUSION This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.
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Affiliation(s)
- Laura Harmon
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Ronald Bilow
- Department of Radiology, UTHealth McGovern Medical School, Houston, TX, USA.
| | - Kathirkama Shanmuganathan
- Shock Trauma and Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Margret Lauerman
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA.
| | - S Rob Todd
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Cardenas
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | | | | | | | - Mitchell Cohen
- University of Colorado, Denver Health Medical Center, Denver CO, USA.
| | | | | | | | - Charles J Fox
- University of Colorado, Denver Health Medical Center, Denver CO, USA.
| | - Jorge Con
- Department of Surgery, New York Medical College-Westchester, Valhalla, NY, USA.
| | - Kenji Inaba
- University of Southern California, Los Angeles County, Los Angeles, CA, USA.
| | | | - Gina M Berg
- Wesley Medical Center Trauma Services, Wichita, KS, USA.
| | | | | | - Rosemary Ann Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA.
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Harmon L, Sukri L, Kufera JA, Nguyen A, Grunnagle M, Ramirez CL, Botwinick I, Cucher D, Feather CB, Scalea TM, Stein DM. Is Opioid Prescribing Driving Trauma Recidivism or is Trauma Driving Opioid Use? Am Surg 2019. [DOI: 10.1177/000313481908500618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission ( P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.
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Affiliation(s)
- Laura Harmon
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Colorado Denver, Anschutz, Denver, Colorado
| | - Leah Sukri
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Joseph A. Kufera
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Andrew Nguyen
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Meilin Grunnagle
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | | | - Isadora Botwinick
- Northwell Health, Long Island Jewish Hospital, Long Island, New York; and
| | | | - Cristina B. Feather
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M. Scalea
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M. Stein
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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14
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Harmon L, Sukri L, Kufera JA, Nguyen A, Grunnagle M, Ramirez CL, Botwinick I, Cucher D, Feather CB, Scalea TM, Stein DM. Is Opioid Prescribing Driving Trauma Recidivism or Is Trauma Driving Opioid Use? Am Surg 2019; 85:567-571. [PMID: 31267895] [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: 06/09/2023]
Abstract
In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission (P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.
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15
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Martin ET, Haider S, Palleschi M, Eagle S, Crisostomo DV, Haddox P, Harmon L, Mazur R, Moshos J, Marchaim D, Kaye KS. Bathing hospitalized dependent patients with prepackaged disposable washcloths instead of traditional bath basins: A case-crossover study. Am J Infect Control 2017; 45:990-994. [PMID: 28502637 DOI: 10.1016/j.ajic.2017.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Basins used for patient bathing have been shown to be contaminated with multidrug-resistant organisms (MDROs) and have prompted the evaluation of alternatives to soap and water bathing methods. METHODS We conducted a prospective, randomized, open-label interventional crossover study to assess the impact of replacing traditional bath basins with prepackaged washcloths on the incidence of hospital-associated infections (HAIs), MDROs, and secondarily, rates of skin deterioration. Unit-wide use of disposable washcloths over an 8-month period was compared with an 8-month period of standard care using basins. RESULTS A total of 2,637 patients were included from 2 medical-surgical units at a single tertiary medical center, contributing 16,034 patient days. During the study period, there were a total of 33 unit-acquired infections, the rates of which were not statistically different between study phases (incidence rate ratio, 1.05; 95% confidence interval [CI], 0.50-2.23; P = .88). However, occurrence of skin integrity deterioration was significantly less in the intervention group (odds ratio, 0.44; 95% CI, 0.22-0.88; P = .02). CONCLUSIONS Although we were unable to demonstrate a significant reduction in HAI or MDRO acquisition, we found a decrease in skin deterioration with the use of disposable washcloths and confirmed earlier findings of MDRO contamination of wash basins.
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Omer Y, Kuflic M, Kozarinsky M, Branse J, Harmon L, Keren C. DOMESTIC: a minicomputer based information storage and retrieval system. J Inf Sci 2016. [DOI: 10.1177/016555158100300202] [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: 11/16/2022]
Abstract
DOMESTIC (Development of Minicomputers in an Envi ronment of Scientific and Technological Information Cen ters) is a joint Israeli-German project for the application of minicomputers in information storage and retrieval. The DOMESTIC software package includes functions for online creation and updating of inhouse databases; assimila tion of external databases; setting up, running and reformu lating online database searches; viewing search results; printing the output in selected formats; and various tasks associated with the acquisition, cataloging and circulation phases of information-center activities. At present (June 1980) the DOMESTIC database management system and the information-retrieval functions have been programmed and development is underway on the functions for online input, database maintenance, the print generator and library management.
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Affiliation(s)
- Y. Omer
- National Center of Scientific and Technological Information, P.O. Box 20215, Tel-Aviv, Israel
| | - M. Kuflic
- National Center of Scientific and Technological Information, P.O. Box 20215, Tel-Aviv, Israel
| | - M. Kozarinsky
- National Center of Scientific and Technological Information, P.O. Box 20215, Tel-Aviv, Israel
| | - J. Branse
- National Center of Scientific and Technological Information, P.O. Box 20215, Tel-Aviv, Israel
| | - L. Harmon
- National Center of Scientific and Technological Information, P.O. Box 20215, Tel-Aviv, Israel
| | - C. Keren
- National Center of Scientific and Technological Information, P.O. Box 20215, Tel-Aviv, Israel
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Affiliation(s)
- Laura Harmon
- Department of Surgery Baylor Scott and White Memorial Hospital Temple, Texas
| | - Stephen Abernathy
- Department of Surgery Baylor Scott and White Memorial Hospital Temple, Texas
| | - Justin Regner
- Department of Surgery Baylor Scott and White Memorial Hospital Temple, Texas
| | - Travis Isbell
- Department of Surgery Baylor Scott and White Memorial Hospital Temple, Texas
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Harmon L, Abernathy S, Regner J, Isbell T. An Uncommon Presentation of Gastric Outlet Obstruction: Bouveret's Syndrome. Am Surg 2016; 82:E49-E51. [PMID: 26874125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Laura Harmon
- Department of Surgery, Baylor Scott and White Memorial Hospital, Temple, Texas, USA
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19
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Abstract
The American Recovery and Reinvestment Act mandates "meaningful use" of an electronic health record (EHR) to receive current financial incentives and to avoid future financial penalties. Surgeons' ongoing adoption of an EHR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records. We conducted a survey to query surgeons at our institution regarding their perception of the EHR 3 months after institutional implementation. A total of 59 surveys were obtained from 24 senior staff and 35 residents. Results showed that surgeons believed the EHR was more effective as a billing tool than as a form of clinical documentation and believed the billing was more complete and accurate with the EHR. Surgeons also expressed concern that the EHR would negatively impact patient satisfaction, but in spite of this, they indicated that their personal quality of life was not negatively impacted.
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Affiliation(s)
- Richard Frazee
- Department of Surgery, Baylor Scott & White Health, Temple, Texas
| | - Laura Harmon
- Department of Surgery, Baylor Scott & White Health, Temple, Texas
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20
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Harmon L, Chilton RJ, Spellman C. Reducing Cardiovascular Events and End-Organ Damage in Patients with Hypertension: New Considerations. Postgrad Med 2015; 123:7-17. [DOI: 10.3810/pgm.2011.03.2258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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21
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Harmon L, Boccalandro F. Comparison of carotid artery dimensions and lesion length measured by B-mode ultrasonography and quantitative angiography in patients with severe stenosis undergoing percutaneous revascularization. J Clin Ultrasound 2014; 42:270-276. [PMID: 24449254 DOI: 10.1002/jcu.22132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 10/20/2013] [Accepted: 12/16/2013] [Indexed: 06/03/2023]
Abstract
BACKGROUND To evaluate the correlation and agreement of the carotid artery landmarks necessary for carotid artery stenting obtained by B-mode ultrasonography (BMU), and by quantitative angiography (QCA) in patients with severe carotid artery stenosis. METHODS In 75 patients undergoing carotid artery stenting, the distal common (CCA), proximal internal (ICA) carotid artery diameter, and lesion length were measured preoperatively by BMU, and intraoperatively by QCA. RESULTS In 96% of the subjects, BMU imaging was adequate for interpretation. BMU and QCA Pearson correlation and Lin concordance coefficients were 0.75 (p < 0.001) and 0.959 (95% CI: 0.930 - 0.996), respectively, for CCA diameter, 0.88 (p < 0.001) and 0.954 (95% CI: 0.928-0.983), respectively, for ICA diameter, and 0.62 (p < 0.001) and 0.734 (95% CI: 0.719-0.760), respectively, for lesion length, with a 0.765 bias correction factor and a wider data scatter by Bland Altman plots showing shorter lesion length by BMU than by QCA. CONCLUSIONS In patients with carotid artery stenosis, BMU can provide reliable distal CCA and proximal ICA diameters in comparison with QCA, whereas lesion length measured by BMU has an acceptable correlation, but a poor agreement with QCA.
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Affiliation(s)
- Laura Harmon
- Scott and White Memorial Hospital and Clinic, Department of Surgery, Temple, TX
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22
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Harmon L, Viney S, Frazee R, Van Husen R. Management of an Incidentally Discovered Hypoglossal Paraganglioma. Am Surg 2013. [DOI: 10.1177/000313481307900307] [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)
- Laura Harmon
- Department of Surgery Texas Tech University Health Sciences Center–Permian Basin Odessa, Texas
- Scott and White Memorial Hospital Temple, Texas
| | - Shelton Viney
- Department of Surgery Texas Tech University Health Sciences Center–Permian Basin Odessa, Texas
- Midland Surgical Associates Midland, Texas
| | | | - Russell Van Husen
- Department of Surgery Texas Tech University Health Sciences Center–Permian Basin Odessa, Texas
- Midland Surgical Associates Midland, Texas
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Harmon L, Viney S, Frazee R, Van Husen R. Management of an incidentally discovered hypoglossal paraganglioma. Am Surg 2013; 79:E114-E115. [PMID: 23461934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Laura Harmon
- Department of Surgery, Texas Tech University Health Sciences, Center-Permian Basin, Odessa, Texas, USA.
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Harmon L, Boccalandro F. Cardiogenic shock secondary to severe acute ischemic mitral regurgitation managed with an impella 2.5 percutaneous left ventricular assist device. Catheter Cardiovasc Interv 2011; 79:1129-34. [DOI: 10.1002/ccd.23271] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 06/01/2011] [Indexed: 11/10/2022]
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Abstract
Diabetic peripheral polyneuropathy is characterized by axonal degeneration and regeneration as well as by Schwann cell and microvascular changes. These changes have been described at both the light (LM) and the electron microscopic (EM) levels; however, EM has not been applied to large clinical trials. Our goal was to adapt the rigorous techniques used for quantifying human biopsies with LM image analysis to accommodate ultrastructural analyses. We applied digital image capture and analysis to the ultrastructural examination of axons in sural nerve biopsies from diabetic patients enrolled in a multicenter clinical trial. The selection of sural nerve biopsies was based on the quality of specimen fixation, absence of physical distortion, and nerve fascicle size (> or =100,000; < or =425,000 microm2). Thin sections were collected on formvar-coated slot grids, stabilized with carbon and scanned on a Phillips CM100 transmission electron microscope. Digital images were captured with a Kodak Megaplus 1.6 camera. A montage was constructed using software derived from aerial mapping applications, and this virtual image was viewed by EM readers. Computer-assisted analyses included identification and labeling of individual axons and axons within regenerating clusters. The average density of regenerating myelinated axon clusters per mm2 was 65.8 +/- 5.1, range of 0-412 (n = 193). These techniques increase the number of samples that may be analyzed by EM and extend the use of this technique to clinical trials using tissue biopsies as a primary endpoint.
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Affiliation(s)
- K A Sullivan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan 48109-0580, USA.
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26
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Abstract
This study examined whether patient symptoms and relatives' affective behavior, when expressed during directly observed family interactions, are associated with the short-term course of bipolar disorder. Twenty-seven bipolar patients and their relatives participated in two 10-minute family interactions when patients were discharged after a manic episode. Results indicated that patients who showed high levels of odd and grandiose thinking during the interactions were more likely to relapse during a 9-month followup period than patients who did not show these symptoms during the family discussions. Relapse was also associated with high rates of harshly critical and directly supportive statements by relatives. Patients' odd thinking and relatives' harsh criticism were significantly more likely to be correlated when patients relapsed (r = .53) than when they did not relapse (r = .12). Results suggest that bipolar patients who show increased signs of residual symptomatology during family transactions during the post-hospital period are at increased relapse risk. The data also suggest that relatives of relapsing patients cope with these symptoms by increasing both positive and negative affective behaviors. Moreover, a bidirectional, interactional relationship between patients' symptoms and relatives' coping style seems to capture best the role of the family in predicting relapse in bipolar disorder.
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Affiliation(s)
- I S Rosenfarb
- Department of Psychology and Family Studies, United States International University, 10455 Pomerado Road, San Diego, CA 92131, USA.
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27
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Barton JC, Shih WW, Sawada-Hirai R, Acton RT, Harmon L, Rivers C, Rothenberg BE. Genetic and clinical description of hemochromatosis probands and heterozygotes: evidence that multiple genes linked to the major histocompatibility complex are responsible for hemochromatosis. Blood Cells Mol Dis 1997; 23:135-45; discussion 145a-b. [PMID: 9215758 DOI: 10.1006/bcmd.1997.0129] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We evaluated Alabama hemochromatosis probands (n = 74) and normal control subjects (n = 142) for expression of the hemochromatosis-associated mutations nt 845G-->A (845A; Cys282Tyr) and nt 187C-->G (His63Asp) in a gene linked to the major histocompatibility complex (MHC). We also tabulated parameters of iron metabolism and iron overload in probands and in obligate heterozygote family members of homozygous Cys282Tyr probands. Among probands, 59.4% were Cys282Tyr homozygotes and 20.3% were heterozygotes; 20.3% did not express this mutation. In normal control subjects, 14.7% were heterozygous for the Cys282Tyr mutation; one normal control subject was homozygous for the Cys282Tyr mutation. None (0 of 44) of our Cys282Tyr-homozygous hemochromatosis probands had the His63Asp mutation. Of the Cys282Tyr-heterozygous and -negative probands, the His63Asp mutation occurred in 26.7% (4/15) and 53.3% (8/15), respectively. In normal control subjects, 23.2% were heterozygous for the His63Asp mutation; 2.8% were homozygous. Induction phlebotomy requirements and other manifestations of iron overload were significantly greater in Cys282Tyr homozygotes than among other probands. Cys282Tyr-heterozygous probands had significantly higher values of serum iron parameters than did obligate Cys282Tyr heterozygotes whose values were, on the average, normal. Co-expression of HLA-A3, HLA-B7, and D6S105(8) was significantly more frequent in all subgroups of probands stratified by Cys282Tyr expression than in normal control subjects. These results demonstrate that the severity of iron overload in hemochromatosis is affected significantly by genetic factors. Further, our findings support the hypothesis that one or more MHC-linked genes other than that corresponding to the Cys282Tyr and His63Asp mutations contributes to increased iron absorption and iron overload in hemochromatosis probands.
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Affiliation(s)
- J C Barton
- Southern Iron Disorders Center and Brookwood Medical Center, Birmingham, Alabama 35209, USA.
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28
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Abstract
We postulated that the severity of iron overload in homozygous hemochromatosis probands is related to the expression of HLA-A3 or D6S105 allele 8. Therefore, we used these markers to characterize Alabama hemochromatosis probands and normal control subjects. We then quantified the blood removed by phlebotomy to exhaust body iron stores and maintain normal serum ferritin concentrations in our hemochromatosis probands. Induction and maintenance phlebotomy requirements were significantly greater in presumed HLA-A3 homozygotes or in D6S105 allele 8 homozygotes than in homozygous probands lacking these markers. Intermediate values were observed in probands who were HLA-A3 or allele 8 heterozygotes, respectively. We also analyzed data from males and females separately. Among subjects of the same sex, the induction and maintenance phlebotomy requirements in subjects presumed to be HLA-A3 homozygotes or in allele 8 homozygotes were greater than those of other groups. Our results support the hypothesis that the severity of iron overload in hemochromatosis is determined predominantly by genetic factors, and provide evidence that two or more mutations for hemochromatosis exist. However, the design of our study does not permit a distinction to be made between allelic and locus heterogeneity for the hemochromatosis gene(s).
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Affiliation(s)
- J C Barton
- Department of Medicine, Brookwood Medical Center, Birmingham, Alabama 35209, USA
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29
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Abstract
While this work is in its very early stages, the 3D laser scanner shows significant promise as a surgical localization device with advantages over other sensing methods. Accurate 3D surface extraction and matching, a central problem in computer vision, is the key to frameless stereotaxic neurosurgery using this technique.
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Affiliation(s)
- J Taren
- Department of Neurosurgery, University of Michigan, Ann Arbor, USA
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30
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Abstract
More relationships exist today between HIV-positive and HIV-negative partners. This article explores the underlying dynamics that might account for this phenomenon. Codependency theories may explain these relationships for some couples. For other couples, it is suggested that positive-negative homosexual relationships may be influenced by both unhealthy and healthy gay developmental experiences as well as by a sense of compassion. The article addresses both HIV-positive people choosing HIV-negative partners and vice versa. Treatment issues for the various theories are discussed and recommendations are made.
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Affiliation(s)
- L Harmon
- Lambda Counseling Center, Miami, Florida, USA
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