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Anandalwar SP, O'Meara L, Vesselinov R, Zhang A, Baum JN, Cooper A, Decker C, Schroeppel T, Cai J, Cullinane D, Catalano RD, Bugaev N, LeClair M, Feather C, McBride K, Sams V, Leung PS, Olafson S, Callahan DS, Posluszny J, Moradian S, Estroff J, Hochman B, Coleman N, Goldenberg-Sandau A, Nahmias J, Rosenbaum K, Pasley J, Boll L, Hustad L, Reynolds J, Truitt M, Ghneim M. Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study. J Trauma Acute Care Surg 2024:01586154-990000000-00691. [PMID: 38595274 DOI: 10.1097/ta.0000000000004278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
INTRODUCTION To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.
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Affiliation(s)
- Seema P Anandalwar
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Lindsay O'Meara
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Roumen Vesselinov
- Department of Epidemiology & Public Health, University of Maryland Medical Center, Baltimore Maryland
| | - Ashling Zhang
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Amanda Cooper
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Cassandra Decker
- Department of Surgery, UCHealth Memorial Hospital, Colorado Springs
| | | | - Jenny Cai
- Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | | | - Nikolay Bugaev
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Madison LeClair
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | | | - Valerie Sams
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Pak Shan Leung
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samantha Olafson
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Devon S Callahan
- Department of Surgery, Allina Health/Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Joseph Posluszny
- Separtment of Surgery, Northwestern University, Evanston, Illinois
| | - Simon Moradian
- Separtment of Surgery, Northwestern University, Evanston, Illinois
| | - Jordan Estroff
- Department of Surgery, George Washington University, Washington D.C
| | - Beth Hochman
- Columbia University Irving Medical Center, New York, New York
| | - Natasha Coleman
- Columbia University Irving Medical Center, New York, New York
| | | | - Jeffry Nahmias
- University of California Irvine Medical Center, Irvine, California
| | | | | | | | | | | | | | - Mira Ghneim
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Schellenberg M, Owattanapanich N, Emigh B, Van Gent JM, Egodage T, Murphy PB, Ball CG, Spencer AL, Vogt KN, Keeley JA, Doris S, Beiling M, Donnelly M, Ghneim M, Schroeppel T, Bradford J, Breinholt CS, Coimbra R, Berndtson AE, Anding C, Charles MS, Rieger W, Inaba K. When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2024; 96:209-215. [PMID: 37872669 DOI: 10.1097/ta.0000000000004163] [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: 10/25/2023]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes. RESULTS In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046). CONCLUSION Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. LEVEL OF EVIDENCE Therapeutic and Care Management; Level III.
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Affiliation(s)
- Morgan Schellenberg
- From the Division of Acute Care Surgery (M.S., N.O., B.E., K.I.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Division of Acute Care Surgery (J.-M.V.G., W.R.), University of Texas Health Sciences Center at Houston, Houston, Texas; Division of Trauma (T.E.), Cooper University Hospital, Camden, New Jersey; Division of Acute Care Surgery (P.B.M.), Froedtert Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Acute Care Surgery (C.G.B.), Foothills Medical Center, University of Calgary, Calgary, Alberta; Division of Acute Care Surgery (A.L.S.), Atrium Health Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, North Carolina; Division of Acute Care Surgery (K.N.V.), London Health Sciences Center, University of Western Ontario, London, Ontario, Canada; Division of Trauma/Acute Care Surgery/Surgical Critical Care (J.A.K.), Harbor UCLA Medical Center, University of California Los Angeles, Los Angeles, California; Division of Acute Care Surgery (S.D.), Grant Medical Center, Columbus, Ohio; Division of Acute Care Surgery (M.B.), Oregon Health and Science University, Portland, Oregon; Division of Acute Care Surgery (M.D.), University of California Irvine, Irvine, California; Program in Trauma (M.G.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Division of Acute Care Surgery, UC Health Memorial Hospital (T.S.), University of Colorado Springs, Colorado Springs, Colorado; Division of Acute Care Surgery (J.B.), Dell Medical School, The University of Texas Austin, Austin, Texas; Division of Trauma, Acute Care Surgery, and Surgical Critical Care (C.S.B.), West Virginia University, Morgantown, West Virginia; Division of Acute Care Surgery (R.C.), Riverside University Health System Medical Center, University of California Riverside, Riverside; Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery (A.E.B.), University of California-San Diego, San Diego, California; Division of Acute Care Surgery (C.A.), Texas Tech University Health Sciences Center, Texas Tech University, Lubbock, Texas; and Division of Acute Care Surgery (M.S.C.), Ascension Medical Group St. John, Tulsa, Oklahoma
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Santos J, Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Grigorian A, Nahmias J. Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study. J Am Coll Surg 2023; 237:826-833. [PMID: 37703489 DOI: 10.1097/xcs.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification. STUDY DESIGN This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC). RESULTS Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%. CONCLUSIONS This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.
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Affiliation(s)
- Jeffrey Santos
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Patrick T Delaplain
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
- Department of Surgery, Boston Children's Hospital/Harvard Medical System, Boston, MA (Delaplain)
| | - Erika Tay-Lasso
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, CA (Biffl, Schaffer)
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD (Sundel, Ghneim)
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA (Costantini, Santorelli)
| | - Emily Switzer
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA (Switzer, Schellenberg)
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, CA (Keeley, Kim)
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (Want, Dhillon, Patel)
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Caitlin K Robinson
- Department of Surgery, Denver Health Medical Center, Denver, CO (Campion, Robinson)
| | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC (Kartiko, Quintana, Estroff)
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California Irvine, Irvine, CA (Kirby)
| | - Areg Grigorian
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
| | - Jeffry Nahmias
- From the Division of Trauma, Burns, Critical Care & Acute Care Surgery, Department of Surgery, University of California, Irvine, Orange, CA (Santos, Delaplain, Tay-Lasso, Grigorian, Nahmias)
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Powell EK, Lankford AS, Ghneim M, Rabin J, Haase DJ, Dahi S, Deatrick KB, Krause E, Bittle G, Galvagno SM, Scalea T, Tabatabai A. Decreased PRESET-Score corresponds with improved survival in COVID-19 veno-venous extracorporeal membrane oxygenation. Perfusion 2023; 38:1623-1630. [PMID: 36114156 PMCID: PMC9482881 DOI: 10.1177/02676591221128237] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The PREdiction of Survival on ECMO Therapy Score (PRESET-Score) predicts mortality while on veno-venous extracorporeal membrane oxygenation (VV ECMO) for acute respiratory distress syndrome. The aim of our study was to assess the association between PRESET-Score and survival in a large COVID-19 VV ECMO cohort. METHODS This was a single-center retrospective study of COVID-19 VV ECMO patients from 15 March 2020, to 30 November 2021. Univariable and Multivariable analyses were performed to assess patient survival and score differences. RESULTS A total of 105 patients were included in our analysis with a mean PRESET-Score of 6.74. Overall survival was 65.71%. The mean PRESET-Score was significantly lower in the survivor group (6.03 vs 8.11, p < 0.001). Patients with a PRESET-Score less than or equal to six had improved survival compared to those with a PRESET-Score greater than or equal to 8 (97.7% vs. 32.5%, p < 0.001). In a multivariable logistic regression, a lower PRESET-Score was also predictive of survival (OR 2.84, 95% CI 1.75, 4.63, p < 0.001). CONCLUSION We demonstrate that lower PRESET scores are associated with improved survival. The utilization of this validated, quantifiable, and objective scoring system to help identify COVID-19 patients with the greatest potential to benefit from VV-ECMO appears feasible. The incorporation of the PRESET-Score into institutional ECMO candidacy guidelines can help insure and improve access of this limited healthcare resource to all critically ill patients.
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Affiliation(s)
- Elizabeth K Powell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison S Lankford
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Obstetrics Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph Rabin
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher B Deatrick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric Krause
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Bittle
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Tabatabai
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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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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Ghneim M, Stein DM. Management of traumatic brain injury in older adults: What you need to know. J Trauma Acute Care Surg 2023; 95:780-789. [PMID: 37590010 DOI: 10.1097/ta.0000000000004118] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Mira Ghneim
- From the University of Maryland School of Medicine (M.G.), R Adams Cowley Shock Trauma Center; and University of Maryland School of Medicine (D.M.S.), R Adams Cowley Shock Trauma Center
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O'Meara L, Zhang A, Baum JN, Cooper A, Decker C, Schroeppel T, Cai J, Cullinane DC, Catalano RD, Bugaev N, LeClair MJ, Feather C, McBride K, Sams V, Leung PS, Olafson S, Callahan DS, Posluszny J, Moradian S, Estroff J, Hochman B, Coleman NL, Goldenberg-Sandau A, Nahmias J, Rosenbaum K, Pasley JD, Boll L, Hustad L, Reynolds J, Truitt M, Vesselinov R, Ghneim M. Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study. J Trauma Acute Care Surg 2023; 95:510-515. [PMID: 37349868 DOI: 10.1097/ta.0000000000004042] [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: 06/24/2023]
Abstract
BACKGROUND While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Lindsay O'Meara
- From the University of Maryland Medical Center (L.O.), Baltimore, Maryland; Mount Sinai South Nassau (J.N.B.), Oceanside, New York; Penn State Milton S. Hershey Medical Center (A.C.), Hershey, Pennsylvania; UCHealth Memorial Hospital (C.D.), Colorado Springs, Colorado; RWJMS, Rutgers at Newark (J.C.), Newark, New Jersey; Allina Health/Abbott Northwestern Hospital (D.S.C.), Minneapolis, Minnesota; Northwestern University (J.P.), Evanston, Illinois; George Washington University (J.E.), Washington, district of Columbia; Columbia University Irving Medical Center (B.H.), New York, New York; Cooper University (A.G.), Camden, New Jersey; Marshfield Clinic (D.C.C.), Marshfield, Wisconsin; Loma Linda University School of Medicine (R.D.C.), Loma Linda, California; Tufts Medical Center, Tuft University School of Medicine (N.B.), Boston, Massachusetts; Anne Arundel Medical Center (C.F.), Parole, Maryland; Memorial Health University Medical Center (K.M.), Savannah, Georgia; Brooke Army Medical Center (V.S.), Fort Sam Houston, Texas; Sidney Kimmel Medical College: Thomas Jefferson University (P.S.L.), Philadelphia, Pennsylvania; University of California Irvine Medical Center (J.N.), Irvine, California; McLaren Oakland Hospital (J.D.P.), Pontiac, Michigan; Sanford Health (L.H.), Sioux Falls, South Dakota; University of Kentucky Medical Center (J.R.), Lexington, Kentucky; and Methodist Medical Center (M.T.), Dallas, Texas
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Ghneim M, Kufera J, Zhang A, Penaloza-Villalobos L, Swentek L, Watras J, Smith A, Hahn A, Rodriguez Mederos D, Dickhudt TJ, Laverick P, Cunningham K, Norwood S, Fernandez L, Jacobson LE, Williams JM, Lottenberg L, Azar F, Shillinglaw W, Slivinski A, Nahmias J, Donnelly M, Bala M, Egodage T, Zhu C, Udekwu PO, Norton H, Dunn JA, Baer R, McBride K, Santos AP, Shrestha K, Metzner CJ, Murphy JM, Schroeppel TJ, Stillman Z, O'Connor R, Johnson D, Berry C, Ratner M, Reynolds JK, Humphrey M, Scott M, Hickman ZL, Twelker K, Legister C, Glass NE, Siebenburgen C, Palmer B, Semon GR, Lieser M, McDonald H, Bugaev N, LeClair MJ, Stein D. Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial. J Trauma Acute Care Surg 2023; 95:516-523. [PMID: 37335182 DOI: 10.1097/ta.0000000000004095] [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: 06/21/2023]
Abstract
OBJECTIVE This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Mira Ghneim
- From the R Adams Cowley Shock Trauma Center (M.G., D.S.), Program in Trauma, Department of Surgery, University of Maryland School of Medicine; National Study Center for Trauma and Emergency Medical Systems, Program in Trauma, Center for Shock, Trauma and Anesthesiology Research (J.K.), University of Maryland School of Medicine; University of Maryland School of Medicine (A.Z.); Department of Surgery (L.P.-V., L.S.), Loma Linda University Medical Center; Inova Fairfax Hospital (J.W.); LSUHCS (A.S.); Ochsner Medical Center (A.H.); Broward Health Medical Center (D.R.M., T.J.D.); Atrium Health Carolinas Medical Center (P.L., K.C.); University of Texas Health Science Center (S.N., L.F.); Ascension St. Vincent Hospital (L.E.J., J.M.W.); St. Mary's Medical Center (L.L., F.A.), Florida Atlantic University, Schmidt College of Medicine; Mission Hospital (W.S., A.S.); University of California, Irvine (J.N., M.D.); Hadassah Medical Center and Faculty of Medicine (M.B.), Hebrew University of Jerusalem; Cooper University Health Care (T.E.); Cooper University Health Care (C.Z.); WakeMed Health and Hospitals (P.O.U., H.N.); Medical Center of the Rockies (J.A.D.), University of Colorado Health North; Orthopedic Center of the Rockies (R.B.); Memorial University Medical Center (K.M.); Texas Tech University Health Sciences Center (A.P.S., K.S.); Spartanburg Regional Medical Center (C.J.M., J.M.M.); Memorial Hospital Central (T.J.S., Z.S.); Yale School of Medicine (R.O., D.J.); NYU Grossman School of Medicine (C.B., M.R.,); University of Kentucky (J.K.R., M.H.); St. Mary's Medical Center (M.S.), Essentia Health; NYC Health + Hospitals/Elmhurst (Z.L.H., K.T.), Icahn School of Medicine at Mount Sinai; Rutgers New Jersey Medical School (C.L., N.E.G.); Kettering Health Main Campus (C.S., B.P.); Wright State University Boonshoft School of Medicine (G.R.S.); Research Medical Center (M.L., H.M.); Tufts Medical Center (N.B.), Tuft University School of Medicine; and Tufts Medical Center (M.J.L.)
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9
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Stey AM, Ghneim M, Gurney O, Santos AP, Rattan R, Abahuje E, Baskaran A, Nahmias J, Richardson J, Zakrison TL, Baily ZD, Haut ER, Chaudhary M, Joseph B, Zarzaur B, Hendershot K. Creation of standardized tools to evaluate reporting in health research: Population Reporting Of Gender, Race, Ethnicity & Sex (PROGRES). PLOS Glob Public Health 2023; 3:e0002227. [PMID: 37676874 PMCID: PMC10484436 DOI: 10.1371/journal.pgph.0002227] [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] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/11/2023] [Indexed: 09/09/2023]
Abstract
Despite increasing diversity in research recruitment, research finding reporting by gender, race, ethnicity, and sex has remained up to the discretion of authors. This study developped and piloted tools to standardize the inclusive reporting of gender, race, ethnicity, and sex in health research. A modified Delphi approach was used to develop standardized tools for the inclusive reporting of gender, race, ethnicity, and sex in health research. Health research, social epidemiology, sociology, and medical anthropology experts from 11 different universities participated in the Delphi process. The tools were pilot tested on 85 health research manuscripts in top health research journals to determine inter-rater reliability of the tools. The tools each spanned five dimensions for both sex and gender as well as race and ethnicity: Author inclusiveness, Participant inclusiveness, Nomenclature reporting, Descriptive reporting, and Outcomes reporting for each subpopulation. The sex and gender tool had a median score of 6 and a range of 1-15 out of 16 possible points. The percent agreement between reviewers piloting the sex and gender tool was 82%. The interrater reliability or average Cohen's Kappa was 0.54 with a standard deviation of 0.33 demonstrating moderate agreement. The race and ethnicity tool had a median score of 1 and a range of 0-15 out of 16 possible points. Race and ethnicity were both reported in only 25.8% of studies evaluated. Most studies that reported race reported only the largest subgroups; White, Black, and Latinx. The percent agreement between reviewers piloting the race and ethnicity tool was 84 and average Cohen's Kappa was 0.61 with a standard deviation of 0.38 demonstrating substantial agreement. While the overall dimension scores were low (indicating low inclusivity), the interrater reliability measures indicated moderate to substantial agreement for the respective tools. Efforts in recruitment alone will not provide more inclusive literature without improving reporting.
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Affiliation(s)
- Anne M. Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Mira Ghneim
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Onaona Gurney
- Department of Surgery, New York University Langone Health, Brooklyn, NY, United States of America
| | - Ariel P. Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, United States of America
| | - Rishi Rattan
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, United States of America
| | - Egide Abahuje
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Archit Baskaran
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA, United States of America
| | - Joseph Richardson
- Department of African American Studies, University of Maryland, College Park, MD, United States of America
| | - Tanya L. Zakrison
- Section of Trauma and Acute Care Surgery, University of Chicago, Chicago, IL, United States of America
| | - Zinzi D. Baily
- Soffer Clinical Research Center, University of Miami, Miami, FL, United States of America
| | - Elliott R. Haut
- Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University, Baltimore, MD, United States of America
| | - Mihir Chaudhary
- Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University, Baltimore, MD, United States of America
| | - Bellal Joseph
- Department of Surgery, Division of Trauma, Critical Care, Emergency Surgery and Burns, College of Medicine, University of Arizona, Tucson, AZ, United States of America
| | - Ben Zarzaur
- Department of Surgery, University of Wisconsin, Madison, WI, United States of America
| | - Kimberly Hendershot
- Department of Surgery, Division of Acute Care Surgery, University of Alabama Birmingham, Birmingham, AL, United States of America
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10
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St John A, Murray R, Cooper L, Diaz J, Ghneim M. Cecal-Colon Intussusception due to Appendiceal Mucinous Adenocarcinoma. Am Surg 2023; 89:3822-3825. [PMID: 37222408 DOI: 10.1177/00031348231175489] [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: 05/25/2023]
Abstract
Intussusception is a rare presentation in adults and describes when one portion of the intestine telescopes into another portion. Intussusception is associated with malignancies serving as the lead point in adults. Appendiceal mucinous neoplasms are uncommon tumors often incidentally discovered during appendectomy procedures to manage acute appendicitis. Here we present a case report of an instance of mucinous adenocarcinoma of the appendix that manifested as a large bowel obstruction with intussusception limited to the colon, underscoring the possibility of concurrent intussusception and mucinous neoplasms. The case highlights the importance of meticulous diagnostic evaluation and management, particularly without well-defined treatment protocols. Appropriate diagnostic workup and management, including surgical intervention, are critical for patient outcomes and overall prognosis. The study recommends that patients diagnosed with confirmed or suspected appendiceal neoplasms undergo upfront oncologic resection where aggressive malignancy is a concern. Colonoscopy should be performed postoperatively for all patients to identify synchronous lesions.
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Affiliation(s)
- Ace St John
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rhaya Murray
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Laura Cooper
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jose Diaz
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Mira Ghneim
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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11
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Hosseinpour H, El-Qawaqzeh K, Magnotti LJ, Bhogadi SK, Ghneim M, Nelson A, Spencer AL, Colosimo C, Anand T, Ditillo M, Joseph B. The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities. Am J Surg 2023; 226:271-277. [PMID: 37230872 DOI: 10.1016/j.amjsurg.2023.05.017] [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] [Received: 03/30/2023] [Revised: 04/27/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients. METHODS Analysis of 2017-2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition. RESULTS We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001). CONCLUSIONS This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.
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Affiliation(s)
- Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Mira Ghneim
- R. Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, Baltimore, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
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12
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Choron RL, Teichman A, Bargoud C, Sciarretta JD, Smith R, Hanos D, Afif IN, Beard JH, Dhillon NK, Zhang A, Ghneim M, Devasahayam RJ, Gunter OL, Smith AA, Sun B, Cao CS, Reynolds JK, Hilt LA, Holena DN, Chang G, Jonikas M, Echeverria-Rosario K, Fung NS, Anderson A, Dumas RP, Fitzgerald CA, Levin JH, Trankiem CT, Yoon J, Blank J, Hazelton JP, McLaughlin CJ, Al-Aref R, Kirsch JM, Howard DS, Scantling DR, Dellonte K, Vella M, Hopkins B, Shell C, Udekwu PO, Wong EG, Joseph B, Lieberman H, Ramsey WA, Stewart CH, Alvarez C, Berne JD, Nahmias J, Puente I, Patton JH, Rakitin I, Perea L, Pulido O, Ahmed H, Keating J, Kodadek LM, Wade J, Henry R, Schreiber MA, Benjamin AJ, Khan A, Mann LK, Mentzer CJ, Mousafeiris V, Mulita F, Reid-Gruner S, Sais E, Foote C, Palacio CH, Argandykov D, Kaafarani H, Coyle S, Macor M, Bover Manderski MT, Narayan M, Seamon MJ. Outcomes Among Trauma Patients with Duodenal Leak Following Primary vs Complex Repair of Duodenal Injuries: An EAST Multicenter Trial. J Trauma Acute Care Surg 2023:01586154-990000000-00340. [PMID: 37072889 DOI: 10.1097/ta.0000000000003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Duodenal leak is a feared complication of repair and innovative, complex repairs with adjunctive measures(CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak is sparse and its impact on duodenal leak outcomes nonexistent. We hypothesized primary repair alone (PRA) would be associated with decreased duodenal leak rates, however CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS A retrospective, multicenter analysis from 35 Level-1 trauma centers included patients older than 14 with operative, traumatic duodenal injuries(1/2010-12/2020). The study sample compared duodenal operative repair strategy: primary repair alone(PRA) vs CRAM(any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS The sample(n = 861) was primarily young(33 years) male(84%) with penetrating injuries(77%); 523 underwent PRA and 338 underwent CRAM. CRAM were more critically injured than PRA and had higher leak rates(CRAM 21% vs PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more IR drains, prolonged NPO and LOS, greater mortality, and more readmissions than PRA(all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, NPO duration, need for IR drainage, HLOS, or mortality between PRA leak vs CRAM leak patients(all p > 0.05). CRAM leaks had longer antibiotic duration, more GI complications, and longer duration until leak resolution(all p < 0.05). PRA was associated with 60% lower odds of leak, whereas injury grade II-IV, damage control, and BMI had higher odds of leak(all p < 0.05). There were no leaks among patients with grade IV-V injuries repaired by PRA. CONCLUSIONS CRAM did not prevent duodenal leaks and moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest CRAM is not a protective operative duodenal repair strategy and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE IV, Multicenter retrospective comparative study.
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13
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Dhillon NK, Kufera J, Ghneim M. Emergency General Surgery Procedures in Older Adults: Where You Live Matters! Am Surg 2023:31348231160838. [PMID: 36861456 DOI: 10.1177/00031348231160838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND Neighborhood location and its built environment are important social determinants of health that impact health outcomes. Older adults (OAs) represent the fastest growing population in the United States with many requiring emergency general surgery procedures (EGSPs). The aim of this study was to evaluate whether neighborhood location, represented by zip code, influences mortality and disposition in OAs undergoing EGSPs in Maryland. METHODS A retrospective review was undertaken of hospital encounters in the Maryland Health Services Cost Review Commission from 2014 to 2018 of OAs undergoing EGSPs. Older adults residing in the 50 most affluent (MANs) and 50 least affluent (LANs) neighborhoods based on zip codes were compared. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index, complications, mortality, and discharge to a higher level of care. RESULTS Of the 8661 OAs analyzed, 2362 (27.3%) resided in MANs and 6299 (72.7%) in LANs. Older adults in LANs were more likely to undergo EGSPs, had higher APR-SOI and APR-ROM, and experienced more complications, discharge to higher level of care, and mortality. Living in LANs was independently associated with discharge to higher level of care (OR 1.56, 95% CI: 1.38-1.77, P < .001) and increased mortality (OR 1.35, 95% CI: 1.07-1.71, P = .01). DISCUSSION Mortality and quality of life in OAs undergoing EGSPs are dependent on environmental factors likely determined by neighborhood location. These factors need to be defined and incorporated in predictive models of outcomes. Public health opportunities to improve outcomes for those who are socially disadvantaged are necessary.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph Kufera
- 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
| | - Mira Ghneim
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, 137889R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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14
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Ghneim M, Adams S, Stein DM. Frailty Assessment in the Older Adult Surgical Patient-Crucial Questions for the Future. JAMA Surg 2023; 158:483-484. [PMID: 36811899 DOI: 10.1001/jamasurg.2022.8350] [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: 02/24/2023]
Affiliation(s)
- Mira Ghneim
- R. Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Sasha Adams
- Acute Care Surgery, Department of Surgery, McGovern Medical School, UTHealth at Houston, Houston, Texas
| | - Deborah M Stein
- R. Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, Baltimore
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15
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Hughes JM, Brown RT, Fanning J, Raj M, Bisson ANS, Ghneim M, Kritchevsky SB. Achieving and sustaining behavior change for older adults: A Research Centers Collaborative Network workshop report. Gerontologist 2022; 63:gnac173. [PMID: 36473052 PMCID: PMC10474593 DOI: 10.1093/geront/gnac173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Indexed: 09/04/2023] Open
Abstract
Modifying unhealthy behaviors and/or environments may improve or maintain an older adult's health. However, achieving and sustaining behavior change is challenging and depends upon clinical, social, psychological, and political domains. In an effort to highlight the multidisciplinary nature of behavior change, the NIA Research Centers Collaborative Network (RCCN) held a two-day workshop, Achieving and sustaining behavior change for older adults. The workshop was informed by the socioecological model and designed to initiate dialogue around individual, community, and systems-level determinants of behavior change. This paper summarizes key topics presented during the workshop, discusses opportunities for future research, education, and training, and recommends how each of the six NIA research centers may pursue work in behavior change for older adults.
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Affiliation(s)
- Jaime M Hughes
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Rebecca T Brown
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Fanning
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Minakshi Raj
- Department of Kinesiology and Community Health, University of Illinois, Champaign, Illinois, USA
| | - Alycia N S Bisson
- Department of Kinesiology and Community health, University of Illinois Urbana Champaign, Champaign, Illinois, USA
| | - Mira Ghneim
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen B Kritchevsky
- Sticht Center on Healthy Aging and Alzheimer’s Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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16
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Delaplain PT, Tay-Lasso E, Biffl WL, Schaffer KB, Sundel M, Behdin S, Ghneim M, Costantini TW, Santorelli JE, Switzer E, Schellenberg M, Keeley JA, Kim DY, Wang A, Dhillon NK, Patel D, Campion EM, Robinson CK, Kartiko S, Quintana MT, Estroff JM, Kirby KA, Nahmias J. Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography. JAMA Surg 2022; 157:771-778. [PMID: 35830194 DOI: 10.1001/jamasurg.2022.2770] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures Presence of HVI diagnosed at the time of operative intervention. Results A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.
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Affiliation(s)
- Patrick T Delaplain
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Erika Tay-Lasso
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California
| | - Margaret Sundel
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Samar Behdin
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Mira Ghneim
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego
| | - Emily Switzer
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Morgan Schellenberg
- Los Angeles County + USC Medical Center, Division of Acute Care Surgery, University of Southern California, Los Angeles
| | - Jessica A Keeley
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California
| | - Andrew Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Deven Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Megan T Quintana
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Jordan M Estroff
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Katharine A Kirby
- Center for Statistical Consulting, Department of Statistics, University of California, Irvine
| | - Jeffry Nahmias
- Division of Trauma, Burns, & Surgical Critical Care, University of California, Irvine
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Kim KT, Clark J, Ghneim M, Feliciano DV, Diaz JJ, Harfouche M. Not All Fluid Collections Are Created Equal: Clinical Course and Outcomes of Pancreatic Pseudocysts and Acute Peripancreatic Fluid Collections Requiring Intervention. Am Surg 2022:31348221078955. [DOI: 10.1177/00031348221078955] [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: 11/15/2022]
Abstract
Background Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. Methods Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition. Results Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups ( P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups ( P = .04). Conclusion Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.
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Affiliation(s)
- Kevin T Kim
- University of Maryland School of Medicine, Baltimore, ML, USA
| | - Jaclyn Clark
- University of Maryland School of Medicine, Baltimore, ML, USA
| | - Mira Ghneim
- University of Maryland School of Medicine, Baltimore, ML, USA
| | | | - Jose J Diaz
- University of Maryland School of Medicine, Baltimore, ML, USA
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18
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Jinadasa SP, Ghneim M, Aicher BO, Kundi R, Karwowski J, Diaz JJ, DuBose JJ. Hybrid Management of Acute Portal Vein Thrombosis Complicated by Mesenteric Ischemia. JEVTM 2022. [DOI: 10.26676/jevtm.v5i3.210] [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
Treatment for portal vein thrombosis complicated by mesenteric ischemia can be treated in the operating room following a hybrid approach. This allows for efficient care of the patient, avoids the need for transhepatic cannulation for obtaining a venogram and placing a thrombolysis catheter, and obviates the need to obtain percutaneous venous access.
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19
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Chow JH, Richards JE, Galvagno SM, Coleman PJ, Lankford AS, Hendrix C, Dunitz J, Ibrahim I, Ghneim M, Tanaka KA, Scalea TM, Mazzeffi MA, Hu P. The Algorithm Examining the Risk of Massive Transfusion (ALERT) Score Accurately Predicts Massive Transfusion at the Scene of Injury and on Arrival to the Trauma Bay: A Retrospective Analysis. Shock 2021; 56:529-536. [PMID: 34524267 DOI: 10.1097/shk.0000000000001772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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 Massive transfusion (MT) is required to resuscitate traumatically injured patients with complex derangements. Scoring systems for MT typically require laboratory values and radiological imaging that may delay the prediction of MT. STUDY DESIGN The Trauma ALgorithm Examining the Risk of massive Transfusion (Trauma ALERT) study was an observational cohort study. Prehospital and admission ALERT scores were constructed with logistic regression of prehospital and admission vitals, and FAST examination results. Internal validation was performed with bootstrap analysis and cross-validation. RESULTS The development cohort included 2,592 patients. Seven variables were included in the prehospital ALERT score: systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), respiratory rate (RR), SpO2, motor Glasgow Coma Scale (GCS) score, and penetrating mechanism. Eight variables from 2,307 patients were included in the admission ALERT score: admission SBP, HR, RR, GCS score, temperature, FAST examination result, and prehospital SBP and DBP.The area under the receiving operator characteristic curve for the prehospital and admission models were 0.754 (95% bootstrapped CI 0.735-0.794, P < 0.001) and 0.905 (95% bootstrapped CI 0.867-0.923, P < 0.001), respectively. The prehospital ALERT score had equivalent diagnostic accuracy to the ABC score (P = 0.97), and the admission ALERT score outperformed both the ABC and the prehospital ALERT scores (P < 0.0001). CONCLUSION The prehospital and admission ALERT scores can accurately predict massive transfusion in trauma patients without the use of time-consuming laboratory studies, although prospective studies need to be performed to validate these findings. Early identification of patients who will require MT may allow for timely mobilization of scarce resources and could benefit patients by making blood products available for treating hemorrhagic shock.
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Affiliation(s)
- Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, Dist of Columbia
| | - Justin E Richards
- Division of Critical Care, Department of Anesthesiology, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Samuel M Galvagno
- Division of Critical Care, Department of Anesthesiology, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Patrick J Coleman
- Division of Critical Care, Department of Anesthesiology, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Allison S Lankford
- Division of Critical Care, Department of Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Cheralyn Hendrix
- Division of Critical Care, Department of Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Jackson Dunitz
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Mira Ghneim
- Division of Critical Care, Department of Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Kenichi A Tanaka
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Thomas M Scalea
- Division of Critical Care, Department of Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Michael A Mazzeffi
- Division of Critical Care, Department of Anesthesiology, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Peter Hu
- Division of Critical Care, Department of Anesthesiology, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
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20
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Ghneim M, Albrecht J, Brasel K, Knight A, Liveris A, Watras J, Michetti CP, Haan J, Lightwine K, Winfield RD, Adams SD, Podbielski J, Armen S, Zacko JC, Nasrallah FS, Schaffer KB, Dunn JA, Smoot B, Schroeppel TJ, Stillman Z, Cooper Z, Stein DM. Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000733. [PMID: 34395918 PMCID: PMC8311332 DOI: 10.1136/tsaco-2021-000733] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Mira Ghneim
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Jennifer Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ariel Knight
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Anna Liveris
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
- Department of Surgery, Albert Einstein School, Bronx, New York, USA
| | - Jill Watras
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | | | - James Haan
- Department of Trauma Services, Ascension Via Christi, Wichita, Kansas, USA
| | - Kelly Lightwine
- Department of Trauma Services, Ascension Via Christi, Wichita, Kansas, USA
| | | | - Sasha D Adams
- Department of Surgery, McGovern Medical School, Houston, Texas, USA
| | | | - Scott Armen
- Departments of Surgery and Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - J Christopher Zacko
- Departments of Surgery and Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Julie A Dunn
- Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
| | - Brittany Smoot
- Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
| | - Thomas J Schroeppel
- Trauma and Acute Care Surgery, University of Colorado Health - South, Colorado Springs, Colorado, USA
| | - Zachery Stillman
- UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Deborah M Stein
- Department of Surgery, University of California, San Francisco, CA, USA
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21
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Nahmias J, Zakrison TL, Haut ER, Gurney O, Joseph B, Hendershot K, Ghneim M, Stey A, Hoofnagle MH, Bailey Z, Rattan R, Richardson JB, Santos AP, Zarzaur B. Call to Action on the Categorization of Sex, Gender, Race, and Ethnicity in Surgical Research. J Am Coll Surg 2021; 233:316-319. [PMID: 33964401 DOI: 10.1016/j.jamcollsurg.2021.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 01/11/2023]
Affiliation(s)
- Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA.
| | | | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine
| | - Onaona Gurney
- Department of Surgery, New York University, New York, NY
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Kimberly Hendershot
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Mira Ghneim
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, Baltimore
| | - Anne Stey
- Department of Surgery, Northwestern University, Chicago, IL
| | - Mark H Hoofnagle
- Department of Surgery, Section of Acute and Critical Care Surgery, Washington University, St Louis, MO
| | | | - Rishi Rattan
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Joseph B Richardson
- Department of African-American Studies, University of Maryland, College Park, MD
| | - Ariel P Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Ben Zarzaur
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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22
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Marsh AM, Betzold R, Rueda M, Morrow M, Lottenberg L, Borrego R, Ghneim M, DuBose JJ, Morrison JJ, Azar FK. Clinical Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Management of Hemorrhage Control: Where Are We Now? Curr Surg Rep 2021. [DOI: 10.1007/s40137-021-00285-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Lauerman MH, Haase DJ, Teeter W, Kufera J, Ghneim M, Betzold R, Scalea T, Murthi S. Surgical Intensivist-Led Training in Critical Care Ultrasound Improves Performance. Am Surg 2020; 87:1238-1244. [PMID: 33345585 DOI: 10.1177/0003134820972984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows. METHODS This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included. RESULTS Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest (P < .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest (P < .001). CONCLUSION SI-led training improves CCUS competence and knowledge despite the breadth of CCUS.
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Affiliation(s)
- Margaret H Lauerman
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - Daniel J Haase
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - William Teeter
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - Joseph Kufera
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - Mira Ghneim
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - Richard Betzold
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - Thomas Scalea
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
| | - Sarah Murthi
- Division of Trauma and Critical Care, 137889R Adams Cowley Shock Trauma Center, University of Maryland, USA
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24
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Ghneim M, Diaz JJ. Dementia and the Critically Ill Older Adult. Crit Care Clin 2020; 37:191-203. [PMID: 33190770 DOI: 10.1016/j.ccc.2020.08.010] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dementia is a terminal illness that leads to progressive cognitive and functional decline. As the elderly population grows, the incidence of dementia in hospitalized older adults increases and is associated with poor short-term and long-term outcomes. Delirium is associated with an accelerated cognitive decline in hospitalized patients with dementia. The first step in the management of dementia is accurate and early diagnosis. Evidence-based management guidelines in the setting of critical illness and dementia are lacking. The cornerstone of management is defining goals of care early in the course of hospitalization and using palliative care and hospice when deemed appropriate.
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Affiliation(s)
- Mira Ghneim
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, 22 South Green Street, S4D07, Baltimore, MD 21201, USA.
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, 22 South Green Street, S4D07, Baltimore, MD 21201, USA
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25
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Isbell C, Cohn SM, Inaba K, O'Keeffe T, De Moya M, Demissie S, Ghneim M, Davis ML. Cirrhosis, Operative Trauma, Transfusion, and Mortality: A Multicenter Retrospective Observational Study. Cureus 2018; 10:e3087. [PMID: 30324043 PMCID: PMC6171781 DOI: 10.7759/cureus.3087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: In trauma patients with cirrhosis who require laparotomy, little data exists to establish clinical predictors of the outcome. We sought to determine the prognosticators of mortality in this population. Methods: We performed a 10-year review at four, busy Level I trauma centers of patients with cirrhosis identified during trauma laparotomy. We compared vital signs, laboratory values, and transfusion requirements for those who survived versus those who died. A linear regression was then conducted to determine the variables associated with death in this population. Results: A total of 66 patients were included and 47% (31/66) died. The model for end-stage liver disease (MELD) score was low (7.8 in Lived, 10.2 in Died). Packed red blood cell (PRBC) transfusion at six hours was greater in those who died; those receiving > 6 units of PRBCs at 6 hours had an increased likelihood of death (odds ratio OR 5.8 (95% CI 1.9, 17.4)). All patients receiving ≥ 17 units of PRBCs died. We found an association between lower preoperative platelets (PLTs), higher preoperative international normalized ratio (INR) and partial thromboplastin time (PTT), lower preoperative pH (presence of profound acidemia), increased intraoperative crystalloid use, and increased intraoperative blood product administration to be associated with death (p < 0.05). Conclusions: Cirrhotic trauma patients requiring laparotomy should be considered to have a high chance of mortality if they receive six or more PRBCs, are acidotic (pH ≤ 7.25) at the time of hospital arrival, or have coagulopathy at the time of admission (INR > 1.2, PTT > 40).
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Affiliation(s)
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
| | | | | | - Marc De Moya
- Surgery, Medical College of Wisconsin, Wisconsin, USA
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26
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Angel M, Ghneim M, Song J, Brocker J, Tipton PH, Davis M. The Effects of a Rapid Response Team on Decreasing Cardiac Arrest Rates and Improving Outcomes for Cardiac Arrests Outside Critical Care Areas. Medsurg Nurs 2016; 25:153-158. [PMID: 27522841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A retrospective study was conducted to determine the effects of a well-functioning rapid response team (RRT) within one facility. A well-functioning RRT was associated with fewer cardiac arrests outside critical care settings and decreased critical care length of stay.
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