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Zhang AL, How R, Efron DT, Nigam R, Harfouche MN. To Drain or Not: Drainage Procedures Remain a Central Tenet of Management of Infected Collections in Acute Pancreatitis. Am Surg 2024:31348241241721. [PMID: 38655580 DOI: 10.1177/00031348241241721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Recent literature advocates for delayed or avoidance of catheter drainage of infected peri-pancreatic collections (IPCs) in acute pancreatitis (AP). This may not be realistic for patients at academic centers, many of whom are critically ill. We retrospectively reviewed 72 patients admitted to our institution from 2016-2021 with AP and IPCs. 34.7% had a Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥3, and 56.9% had a Balthazar score of E. 65.3% were admitted to the ICU, 51.4% experienced respiratory failure, and 47.2% had acute renal failure. In-hospital mortality was 9.7%. Catheter-based drainage alone was the most frequent intervention. Only 8 individuals did not undergo any drainage. Individuals with severe AP complicated by IPCs are critically ill. Avoidance or delay of source control could lead to significant morbidity. Until further research is done on this population, drainage should remain a central tenet of management of IPCs.
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Affiliation(s)
- Ashling L Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Remealle How
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David T Efron
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Melike N Harfouche
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Harfouche MN, Kundi R, Scalea TM. Response to the letter to the editor for our article entitled "A Pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?". J Trauma Acute Care Surg 2024:01586154-990000000-00702. [PMID: 38622768 DOI: 10.1097/ta.0000000000004360] [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: 04/17/2024]
Affiliation(s)
- Melike N Harfouche
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System
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Harfouche MN, Kundi R, Scalea TM. Response to the letter to the editor for our article entitled "A Pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?". J Trauma Acute Care Surg 2024:01586154-990000000-00697. [PMID: 38595222 DOI: 10.1097/ta.0000000000004359] [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: 04/11/2024]
Affiliation(s)
- Melike N Harfouche
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System
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Rao AS, Scalea TM, Feliciano DV, Harfouche MN. More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury. Am Surg 2024:31348241244629. [PMID: 38590003 DOI: 10.1177/00031348241244629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). METHODS Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. RESULTS Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). CONCLUSIONS In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.
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Radding S, Harfouche MN, Dhillon NK, Ko A, Hawley KL, Kundi R, Maddox JS, Radowsky JS, DuBose JJ, Feliciano DV, Kozar RA, Scalea TM. A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms? J Trauma Acute Care Surg 2024; 96:313-318. [PMID: 37599423 DOI: 10.1097/ta.0000000000004117] [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: 08/22/2023]
Abstract
BACKGROUND Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. METHODS We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. RESULTS Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. CONCLUSION There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sydney Radding
- From the Department of Surgery (S.R.), Virginia Commonwealth University, Richmond, VA; R Adams Cowley Shock Trauma Center (M.N.H., N.K.D., K.L.H., R.K., J.S.M., J.S.R., D.V.F., R.A.K., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (A.K.), Stanford University, Stanford, California; and Department of Surgery (J.J.DB.), University of Texas at Austin, Austin, Texas
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Dhillon NK, Harfouche MN, Hawley KL, DuBose JJ, Kozar RA, Scalea TM. Embolization of Pseudoaneurysms is Associated With Improved Outcomes in Blunt Splenic Trauma. J Surg Res 2024; 293:656-662. [PMID: 37839096 DOI: 10.1016/j.jss.2023.08.054] [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: 02/28/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The necessity of angioembolization for all splenic pseudoaneurysms (PSAs) is unknown after blunt trauma. We compared the outcomes of patients with PSAs managed with splenic artery embolization (EMBO) versus no embolization (NO-EMBO). METHODS We retrospectively reviewed all patients with blunt splenic trauma and PSA on initial computed tomography scan admitted to an academic, urban, Level I trauma center from 2016 to 2021. Patients who had emergent splenectomy or died before discharge were excluded. Demographics, injury and computed tomography characteristics, and details regarding angiography, if pursued, were collected. The primary outcome was failure of nonoperative management (FNOM), as defined by need for delayed splenectomy for the EMBO group versus delayed splenectomy or embolization for the NO-EMBO group. RESULTS One hundred and fifty-six patients were in the final study population, of which 96 (61.5%) were in the EMBO group and 60 (38.5%) were in the NO-EMBO group. Patient demographics and mechanism of injury were similar between the two cohorts. The two cohorts had similar imaging findings, however, EMBO patients had more compartments with hemoperitoneum (2 versus 1, P < 0.01). Patients who underwent embolization had a lower FNOM rate (3.1% versus 13.3%, P = 0.02). CONCLUSIONS Splenic artery embolization in the setting of PSA is associated with lower rates of FNOM versus nonembolization. It is unclear if addressing the PSA itself with embolization drives the decreased FNOM rate.
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Affiliation(s)
- Navpreet K Dhillon
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Melike N Harfouche
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Kristy L Hawley
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Joseph J DuBose
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Texas
| | - Rosemary A Kozar
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland.
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Harfouche MN, Ghneim M, Nezami N, Vesselinov R, Diaz JJ. Greater cost without greater benefit: The need to refine transfer criteria for patients with severe acute pancreatitis. Pancreatology 2023; 23:784-788. [PMID: 37696729 DOI: 10.1016/j.pan.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/17/2023] [Accepted: 08/29/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Appropriate and timely care is essential in the management of severe acute pancreatitis (SAP). We hypothesized that transferred patients with SAP undergoing procedural intervention would have higher mortality compared to those managed directly at academic centers. METHODS This was a retrospective analysis of Maryland's statewide claims database from 2009 to 2022 of adult patients admitted with a primary diagnosis of SAP (acute pancreatitis with organ failure). Patients were divided into three groups: those admitted directly from the emergency room to academic facilities (AD), non-academic facilities (NA), or transferred to academic facilities (TR). Procedural intervention included endoscopic, percutaneous image-guided, or surgical. The primary outcome was in-hospital mortality. Secondary outcomes were admission costs, length of stay (LOS), and intensive care unit (ICU) admission. RESULTS There were 7,648 (48.9%) in the NA group, 6,682 (42.7%) in the AD group and 1,316 (8.4%) in the TR group. On regression analysis, odds of death were 0.57x lower in the NA group and 0.67x lower in the AD group compared to transfers (<0.001). Procedural intervention was not associated with increased mortality. Transferred patients had longer median LOS (11 vs NA = 5, AD = 6, p < 0.001), increased median cost of admission ($41k vs NA = $12k, AD = $17k, p < 0.001) and greater ICU admission (45.6% vs NA = 20.6%, AD = 23.9%, p < 0.001). CONCLUSION Transferred patients have greater burden of illness and cost of care without evidence of improved outcomes in the management of SAP regardless of procedural intervention. Transfer criteria for patients with SAP must be further refined to reduce unnecessary transfers.
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Affiliation(s)
| | - Mira Ghneim
- University of Maryland School of Medicine, United States
| | - Nariman Nezami
- University of Maryland School of Medicine, United States
| | | | - Jose J Diaz
- University of Southern Florida, Tampa, United States
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Harfouche MN, Feliciano DV, Kozar RA, DuBose JJ, Scalea TM. A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database. J Am Coll Surg 2023; 236:1208-1216. [PMID: 36847370 DOI: 10.1097/xcs.0000000000000669] [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: 03/01/2023]
Abstract
BACKGROUND Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.
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Affiliation(s)
- Melike N Harfouche
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - David V Feliciano
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Rosemary A Kozar
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Joseph J DuBose
- Dell Medical School, University of Texas at Austin, Austin, TX (DuBose)
| | - Thomas M Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
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Harfouche MN, Nigam R, Efron DT, Diaz JJ. Surgical Stabilization of Rib Fractures in Severe Injury Is Not Associated With Worse Outcomes. J Surg Res 2023; 284:106-113. [PMID: 36563451 DOI: 10.1016/j.jss.2022.11.053] [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: 03/01/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION This study aimed to determine whether surgical stabilization of rib fractures (SSRF) is associated with worse outcomes in individuals with multicompartmental injuries. MATERIALS AND METHODS A retrospective review of a prospective trauma registry was performed for adult blunt trauma patients (aged ≥ 18 y) with Injury Severity Score ≥ 15 and radiographic evidence of rib fractures (2015-2020). Individuals without concomitant head, abdomen/pelvis, or lower extremity Abbreviated Injury Scale scores ≥ 3 were excluded. Propensity match on demographic and clinical variables was performed comparing patients treated nonoperatively (NO) to those undergoing SSRF. A chart review was performed for additional data. Primary outcome was hospital length of stay (LOS). Secondary outcomes were in-hospital mortality, intensive care unit LOS, and duration of mechanical ventilation. RESULTS One thousand nine hundred ninety three patients fit the inclusion criteria (NO = 1,951, SSRF = 42). After matching, there were 98 in the NO group and 42 in the SSRF group. Mean age was 51 y, 61.4% were male, and 71.4% were of White race. Median time to fixation was 5 d. The SSRF group had more severe chest trauma as evidenced by a higher RibScore (3.2 versus 1.7, P < 0.001) and had a longer LOS (18 versus 9 d, P < 0.001), intensive care unit LOS (13 versus 3 d, P = 0.007), and duration of mechanical ventilation (8 versus 2 d, P = 0.013) on univariate analysis. Multivariable regression analysis demonstrated no association between SSRF and these short-term outcomes. CONCLUSIONS Despite delayed average time to intervention, SSRF in a trauma-patient population with multicompartmental injuries and competing management priorities is not associated with worse short-term outcomes.
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Affiliation(s)
- Melike N Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland.
| | | | - David T Efron
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Harfouche MN, Dhillon NK, Hawley KL, DuBose JJ, Kozar RA, Feliciano DV, Scalea TM. Time to Splenic Angioembolization Does Not Impact Splenic Salvage Rates. Am Surg 2023:31348231161674. [PMID: 36878008 DOI: 10.1177/00031348231161674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
We aimed to determine whether early (<6 hours) vs delayed (≥6 hours) splenic angioembolization (SAE) after blunt splenic trauma (grades II-V) impacted splenic salvage rates at a level I trauma center (2016-2021). The primary outcome was delayed splenectomy by timing of SAE. Mean time of SAE was determined for those who failed vs those who had successful splenic salvage. We retrospectively identified 226 individuals, from which 76 (33.6%) were in the early group and 150 (66.4%) were in the delayed group. The early group had higher AAST grade, greater amount of hemoperitoneum on CT, and 3.9x greater odds of undergoing delayed splenectomy (P = .046). Time to embolization was shorter in the group that failed splenic salvage (5 vs 10 hours, P = .051). On multivariate analysis, timing of SAE had no effect on splenic salvage. This study supports performing SAE on an urgent rather than emergent basis in stable patients after blunt splenic injury.
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Affiliation(s)
- Melike N Harfouche
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Navpreet K Dhillon
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristy L Hawley
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph J DuBose
- Department of Surgery, Dell Medical School, 21976University of Texas at Austin, Austin, TX, USA
| | - Rosemary A Kozar
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Hawley KL, Dhillon NK, DuBose JJ, Kozar RA, Scalea TM, Harfouche MN. Surveillance Imaging Associated With Delayed Splenectomy in High-Grade Blunt Splenic Trauma. Am Surg 2023:31348231157844. [PMID: 36802823 DOI: 10.1177/00031348231157844] [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: 02/19/2023]
Abstract
This retrospective, single-site study at a level I trauma center (2016-2021) sought to determine whether repeat CT had an impact on clinical decision making after splenic angioembolization following blunt splenic trauma (grades II-V). The primary outcome was need for intervention after subsequent imaging (defined as angioembolization and/or splenectomy) by high- or low-grade injury. Of the 400 individuals examined, 78 (19.5%) underwent intervention after repeat CT, from which 17% were in the low-grade group (grades II and III) and 22% were in the high-grade group (grades IV and V). Individuals in the high-grade group were 3.6 times more likely to undergo delayed splenectomy than those in the low-grade group (P = .006). Delayed intervention after surveillance imaging in blunt splenic injury is driven mostly by the identification of new vascular lesions and leads to greater rates of splenectomy in high-grade injuries. Surveillance imaging should be considered for all AAST injury grades II or higher.
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Affiliation(s)
- Kristy L Hawley
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Navpreet K Dhillon
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Joseph J DuBose
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Rosemary A Kozar
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Melike N Harfouche
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
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Harfouche MN, Shields T, Curriero FC. Geospatial analysis of firearm injuries in an urban setting: Individual rather than community characteristics affect firearm injury risk. Am J Surg 2023; 225:1062-1068. [PMID: 36702734 DOI: 10.1016/j.amjsurg.2023.01.014] [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: 11/02/2022] [Revised: 01/09/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND The relationship between individual/socioeconomic characteristics and firearm injury risk in an urban center was evaluated. METHODS A hospital registry was used to identify individuals in Baltimore City who experienced interpersonal firearm injury in 2019 (FA). Injuries that did not satisfy this criterion were used as a comparison group (NF). Socioeconomic characteristics were linked to home address at the block group level. Regression analysis was used to determine predictors of firearm injury. Clusters of high and low firearm relative to non-firearm injuries were identified. RESULTS A total of 1293 individuals were included (FA = 277, NF = 1016). The FA group lived in communities with lower income (p = 0.005), higher poverty (p = 0.007), and more Black residents (p < 0.001). Individual level factors were stronger predictors of firearm injury than community factors on multivariate regression with Black race associated with 5x higher odds of firearm injury (p < 0.001). Firearm injury clustered in areas of low socioeconomic status. CONCLUSIONS Individual versus community factors have a greater influence on firearm injury risk. Prevention efforts should target young, Black men in urban centers.
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Affiliation(s)
- Melike N Harfouche
- University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA; Johns Hopkins University School of Public Health, 615 N Wolf St, Baltimore, MD, 21205, USA.
| | - Timothy Shields
- Johns Hopkins University School of Public Health, 615 N Wolf St, Baltimore, MD, 21205, USA.
| | - Frank C Curriero
- Johns Hopkins University School of Public Health, 615 N Wolf St, Baltimore, MD, 21205, USA.
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Harfouche MN, Walton EC, Richardson JB, Scalea TM. Implementation of an Outpatient Violence Intervention Program to Increase Service Uptake. Prev Sci 2022; 24:535-540. [PMID: 36006598 PMCID: PMC9403958 DOI: 10.1007/s11121-022-01428-7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/27/2022]
Abstract
Challenges in participant recruitment and retention limit the effectiveness of hospital-based violence intervention programs (HVIPs). This study aimed to determine if an outpatient violence intervention program (VIP) could be integrated into a trauma clinic and increase uptake of violence prevention services. Patients previously hospitalized for intent-to-harm being seen for outpatient follow-up were eligible. VIP counselors met with participants during their clinic visit, administered the survey, and offered violence prevention services (April to June 2019). Patients were followed for 6 months to assess involvement. The primary outcome of interest was long-term participation in the VIP, defined as uptake of services at 6 months, in comparison to inpatient recruitment. Out of 76 patients, 34 (44.7%) did not appear for their appointment. The remainder (n = 42) were offered participation in the study, of which 32 (76.2%) completed the survey. From the group offered VIP services, 57.1% expressed interest, and 5 (20.8%) ultimately took part yielding an overall participation rate of 11.9% at 6 months. The inpatient recruitment rate in 2019 was 2.4%. An outpatient VIP program can be integrated into a clinic setting but suffers from the same challenges faced by inpatient programs resulting in low rates of long-term participation in services. Although a high proportion of participants reported interest, actual engagement at 6 months was low. Reasons behind low participation in VIP services must be investigated.
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Affiliation(s)
- Melike N Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA.
| | - Erin C Walton
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
- Center for Injury Prevention and Policy, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Joseph B Richardson
- University of Maryland, College Park, USA
- Department of African American Studies, University of Maryland, College Park, MD, 20742, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
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Abstract
Despite significant interest in trauma to the spleen over the past 130 years, splenectomy remained the preferred approach to splenic injures in children till the late 1950s and even later in adults. With recognition of the immunologic importance of the spleen and improvements in diagnostic imaging and angioembolization, there are now four pathways for the child or adult admitted with a possible, likely, or diagnosed injury to the spleen. These include the following: (1) operation with splenectomy; (2) operation with splenorrhaphy or partial splenectomy; (3) nonoperative management (observation); and (4) nonoperative management with splenic arteriography and possible angioembolization. This review will focus on the latter two options.
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Affiliation(s)
- Melike N Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Navpreet K Dhillon
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David V Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, Maryland, USA
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15
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Abstract
We investigated whether the COVID-19 pandemic affected rates of interpersonal
violence (IV). A retrospective study was performed using city-wide crime data
and the trauma registry at one high-volume trauma center pre-pandemic [PP]
(March-October 2019) and during the pandemic [PA] (March-October 2020). The
proportion of trauma admissions attributable to IV remained unchanged from PP to
PA, but IV increased as a proportion of overall crime (34% to 41%, p<0.001).
Assaults decreased, but there was a proportionate increase in penetrating trauma
which was mostly attributable to firearms. Despite a reduction in admissions due
to IV in the first 4 months of the pandemic, the rates of violence subsequently
exceeded that of the same months in 2019. The cause of the observed increase of
IV is multi-factorial. Future studies aimed at identifying the root causes are
essential to mitigate violence during this ongoing health crisis.
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Affiliation(s)
| | | | | | - Jose J Diaz
- 12264University of Maryland Medical Center, Baltimore, MA, USA
| | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center, Baltimore, MA, USA
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16
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Harfouche MN, Madurska MJ, Elansary N, Abdou H, Lang E, DuBose JJ, Kundi R, Feliciano DV, Scalea TM, Morrison JJ. Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock. PLoS One 2022; 17:e0265778. [PMID: 35324991 PMCID: PMC8947416 DOI: 10.1371/journal.pone.0265778] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of trauma patients in shock undergoing REBOA versus no-REBOA. Methods This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000–2019). REBOA (R; 2015–2019) patients were propensity matched 2:1 to historic (H; 2000–2012) and contemporary (C; 2013–2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively. Results A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups. Conclusion In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
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Affiliation(s)
- Melike N. Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Joseph J. DuBose
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - David V. Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
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17
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Harfouche MN, Kauvar DS, Feliciano DV, Dubose JJ. Managing Vascular Trauma: Trauma Surgeons versus Vascular Surgeons. Am Surg 2022; 88:1420-1426. [DOI: 10.1177/00031348221080427] [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
Objectives Changes in vascular trauma care and trainee exposure to vascular surgery have raised questions regarding who should take care of vascular trauma patients. This study aimed to determine nationwide trends and perceptions regarding the management of vascular trauma amongst vascular and trauma surgeons. Material and Methods Online surveys were administered to trauma surgeons through the American Association for the Surgery of Trauma (AAST) and to vascular surgeons through the Vascular and Endovascular Surgery Society (VESS) and Western Vascular Society (WVS) in February 2021. Demographics, practice-related information, and interest in, experience and comfort level with vascular trauma were queried. Trainees and those practicing outside the United States were excluded. Results were analyzed using Stata/BE v16.1. Results 247 surgeons were included in the final study population, of which 163 (66%) were trauma surgeons (T) and 84 (34%) were vascular surgeons (V). Vascular surgeons were younger (46 v 51y, P < .001) and had fewer years in practice (10 v 17y, P < .001). Vascular surgeons had greater experience and comfort with managing vascular trauma, but less interest in both vascular and endovascular trauma care when compared to trauma surgeons. Inability to maintain skillset (27%) and unfamiliarity with techniques (32%) were the most common barriers to practicing vascular trauma cited by trauma surgeons. Discussion Despite significant interest in practicing vascular trauma amongst trauma surgeons compared to vascular surgeons, most feel unprepared to do so. Collaboration between vascular and trauma surgeons could close the experience gap and appeal to the interests of both groups.
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Affiliation(s)
- Melike N Harfouche
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - David V Feliciano
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Joseph J Dubose
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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18
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Ghneim MH, Kufera JA, Clark J, Harfouche MN, Hendrix CJ, Diaz JJ. Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland. Am Surg 2021; 88:439-446. [PMID: 34732080 DOI: 10.1177/00031348211048838] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.
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Affiliation(s)
- Mira H Ghneim
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, 137889University of Maryland Medical Center, Baltimore, MD, USA
| | - Joseph A Kufera
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, 137889University of Maryland Medical Center, Baltimore, MD, USA
| | - Jaclyn Clark
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melike N Harfouche
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cheralyn J Hendrix
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, 137889University of Maryland Medical Center, Baltimore, MD, USA
| | - Jose J Diaz
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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19
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Harfouche MN, Morrison J, Kundi R, DuBose JJ, Scalea TM. Open Balloon Tamponade and Hepatic Angiography for Hemorrhage Control of Transhepatic Gunshot Wounds in a Hybrid Trauma Operating Room Environment. JEVTM 2021. [DOI: 10.26676/jevtm.v40i(2).131] [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] [Indexed: 11/04/2022]
Abstract
The management of high-grade liver trauma is challenging and mortality rates are high. Balloon tamponade is a valuable tool for control of transhepatic penetrating injuries. We report three cases of hybrid management of penetrating liver trauma with balloon tamponade and hepatic angiography in a hybrid operating room environment. The combination of balloon tamponade with hepatic angioembolization provides an enhanced approach for the management of these injuries.
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20
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Abdou H, Du J, Harfouche MN, Patel N, Edwards J, Richmond M, Elansary N, Morrison JJ. Development of an Endovascular Model of Pelvic Hemorrhage Using Volumetric Computed Tomography Validation. J Endovasc Ther 2021; 28:614-622. [PMID: 34018880 DOI: 10.1177/15266028211016422] [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
PURPOSE Uncontrolled pelvic hemorrhage from trauma is associated with mortality rates above 30%. The ability of an intervention to reduce blood loss from pelvic trauma is paramount to its success. The objective of this study was to determine if computed tomography volumetric analysis could be used to quantify blood loss in a porcine endovascular pelvic hemorrhage model. MATERIALS AND METHODS Yorkshire swine under general anesthesia underwent balloon dilation and rupture of the profunda femoris artery, which was confirmed by digital subtraction angiography. Computed tomography angiography and postprocessing segmentation were performed to quantify pelvic hemorrhage volume at 5 and 30 minutes after injury. Continuous hemodynamic and iliofemoral flow data were obtained. Baseline and postinjury hemoglobin, hematocrit and lactate were collected. RESULTS Of 6 animals enrolled, 5 survived the 30-minute post-injury period. One animal died at 15 minutes. Median volume of pelvic hemorrhage was 141±106 cm3 at 5 minutes and 302±79 cm3 at 30 minutes with a 114% median increase in hematoma volume over 25 minutes (p=0.040). There was a significant decrease in mean arterial pressure (107 to 71 mm Hg, p=0.030) and iliofemoral flow (561 to 122 mL/min, p=0.014) at 30 minutes postinjury, but no significant changes in hemoglobin, hematocrit, or heart rate. CONCLUSION Computed tomography volumetric analysis can be used to quantify rate and volume of blood loss in a porcine endovascular pelvic hemorrhage model. Future studies can incorporate this approach when evaluating the effect of hemorrhage control interventions associated with pelvic fractures.
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Affiliation(s)
- Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan Du
- Georgetown University School of Medicine, Washington, DC, USA
| | - Melike N Harfouche
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Neerav Patel
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Michael Richmond
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Noha Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
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