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Collie BL, Lyons NB, O'Neil CF, Ramsey WA, Lineen EB, Schulman CI, Proctor KG, Meizoso JP, Namias N, Ginzburg E. When is it safe to start thromboprophylaxis after splenic angioembolization? Surgery 2024; 175:1418-1423. [PMID: 38418296 DOI: 10.1016/j.surg.2024.01.001] [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: 11/14/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. METHODS All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. RESULTS In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]). CONCLUSION This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.
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Affiliation(s)
- Brianna L Collie
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL.
| | - Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Christopher F O'Neil
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Walter A Ramsey
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Edward B Lineen
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Carl I Schulman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Kenneth G Proctor
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Jonathan P Meizoso
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Nicholas Namias
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Enrique Ginzburg
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
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Collie BL, Emami S, Lyons NB, Ramsey WA, O'Neil CF, Meizoso JP, Ginzburg E, Pizano LR, Schulman CI, Parker BM, Namias N, Proctor KG. Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients. J Surg Res 2024; 298:379-384. [PMID: 38669784 DOI: 10.1016/j.jss.2024.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/23/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival. METHODS Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05. RESULTS In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89). CONCLUSIONS This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.
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Affiliation(s)
- Brianna L Collie
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida.
| | - Shaheen Emami
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicole B Lyons
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Walter A Ramsey
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Christopher F O'Neil
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Jonathan P Meizoso
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Enrique Ginzburg
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Louis R Pizano
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Carl I Schulman
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Brandon M Parker
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Kenneth G Proctor
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
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Ramsey WA, Huerta CT, O'Neil CF, Stottlemyre RL, Saberi RA, Gilna GP, Lyons NB, Collie BL, Parker BM, Perez EA, Sola JE, Proctor KG, Namias N, Thorson CM, Meizoso JP. Admission to a Verified Pediatric Trauma Center is Associated With Improved Outcomes in Severely Injured Children. J Pediatr Surg 2024; 59:488-493. [PMID: 37993397 DOI: 10.1016/j.jpedsurg.2023.10.064] [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: 05/24/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Previous studies have shown improved survival for severely injured adult patients treated at American College of Surgeons verified level I/II trauma centers compared to level III and undesignated centers. However, this relationship has not been well established in pediatric trauma centers (PTCs). We hypothesize that severely injured children will have lower mortality at verified level I/II PTCs compared to centers without PTC verification. METHODS All patients 1-15 years of age with ISS >15 in the 2017-2019 American College of Surgeons Trauma Quality Programs (ACS TQP) dataset were reviewed. Patients with pre-hospital cardiac arrest, burns, and those transferred out for ongoing inpatient care were excluded. Logistic regression models were used to assess the effects of pediatric trauma center verification on mortality. RESULTS 16,301 patients were identified (64 % male, median ISS 21 [17-27]), and 60 % were admitted to verified PTCs. Overall mortality was 6.0 %. Mortality at centers with PTC verification was 5.1 % versus 7.3 % at centers without PTC verification (p < 0.001). After controlling for injury mechanism, sex, age, pediatric-adjusted shock index (SIPA), ISS, arrival via interhospital transfer, and adult trauma center verification, pediatric level I/II trauma center designation was independently associated with decreased mortality (OR 0.72, 95 % CI 0.61-0.85). CONCLUSIONS Treatment at ACS-verified pediatric trauma centers is associated with improved survival in critically injured children. These findings highlight the importance of PTC verification in optimizing outcomes for severely injured pediatric patients and should influence trauma center apportionment and prehospital triage. LEVEL OF EVIDENCE Level IV - Retrospective review of national database.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | | | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Brianna L Collie
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Brandon M Parker
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA.
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Lyons NB, Berg A, Collie BL, Meizoso JP, Sola JE, Thorson CM, Proctor KG, Namias N, Pizano LR, Marttos AC, Sciarretta JD. Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center. Trauma Surg Acute Care Open 2024; 9:e001263. [PMID: 38347895 PMCID: PMC10860056 DOI: 10.1136/tsaco-2023-001263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Introduction Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes. Methods This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts. Results 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities. Conclusion Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center. Level of evidence Level IV, retrospective study.
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Affiliation(s)
- Nicole B Lyons
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Arthur Berg
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Brianna L Collie
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan P Meizoso
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Juan E Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chad M Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Louis R Pizano
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Antonio C Marttos
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jason D Sciarretta
- Trauma/Surgical Critical Care at Grady Memorial Hospital, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Ramsey WA, O'Neil CF, Shatz CD, Lyons NB, Cohen BL, Saberi RA, Gilna GP, Meizoso JP, Pizano LR, Schulman CI, Proctor KG, Namias N. Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber. J Surg Res 2024; 294:106-111. [PMID: 37866065 DOI: 10.1016/j.jss.2023.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/25/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Ballistic injuries cause both a temporary and permanent cavitation event, making them far more destructive and complex than other penetrating trauma. We hypothesized that global injury scoring and physiologic parameters would fail to capture the lethality of gunshot wounds (GSW) compared to other penetrating mechanisms. METHODS The 2019 American College of Surgeons Trauma Quality Programs participant use file was queried for the mortality rate for GSW and other penetrating mechanisms. A binomial logistic regression model ascertained the effects of sex, age, hypotension, tachycardia, mechanism, Glasgow Coma Scale, ISS, and volume of blood transfusion on the likelihood of mortality. Subgroup analyses examined isolated injuries by body regions. RESULTS Among 95,458 cases (82% male), GSW comprised 46.4% of penetrating traumas. GSW was associated with longer hospital length of stay (4 [2-9] versus 3 [2-5] days), longer intensive care unit length of stay (3 [2-6] versus 2 [2-4] days), and more ventilator days (2 [1-4] versus 2 [1-3]) compared to stab wounds, all P < 0.001. The model determined that GSW was linked to increased odds of mortality compared to stab wounds (odds ratio 4.19, 95% confidence interval 3.55-4.93). GSW was an independent risk factor for acute kidney injury, acute respiratory distress syndrome, venous thromboembolism, sepsis, and surgical site infection. CONCLUSIONS Injury scoring systems based on anatomical or physiological derangements fail to capture the lethality of GSW compared to other mechanisms of penetrating injury. Adjustments in risk stratification and reporting are necessary to reflect the proportion of GSW seen at each trauma center. Improved classification may help providers develop quality processes of care. This information may also help shape public discourse on this highly lethal mechanism.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida.
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Connor D Shatz
- University of Miami Miller School of Medicine, Miami, Florida
| | - Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
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Melmer PD, Taylor R, Vera L, Wong D, Santos AP, Chung T, Sola JR, Castater CA, Nguyen J, Nottingham JM, Berg AF, Sleeman D, Namias N, Daley BJ, Procter L, Aboutanos MB, Davis JM, Koganti D, Sciarretta JD. Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study. J Surg Educ 2023; 80:1687-1692. [PMID: 37442698 DOI: 10.1016/j.jsurg.2023.06.025] [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] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/08/2023] [Accepted: 06/17/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.
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Affiliation(s)
| | - Ryan Taylor
- University of Tennessee Medical Center Knoxville, Tennessee
| | - Luis Vera
- University of Texas Health Science Center, Houston, Texas
| | - Dayton Wong
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ariel P Santos
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Tina Chung
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | | | | | | | | | - Arthur F Berg
- University of Miami Ryder Trauma Center, Miami, Florida
| | - Danny Sleeman
- University of Miami Ryder Trauma Center, Miami, Florida
| | | | - Brian J Daley
- University of Tennessee Medical Center Knoxville, Tennessee
| | - Levi Procter
- Virginia Commonwealth University Health, Richmond, Virginia
| | | | - John M Davis
- South Shore University Hospital Northwell Health, Bay Shore, New York
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Berg A, Lyons NB, Badami A, Reynolds J, Pizano L, Pust GD, Meizoso J, Namias N, Yeh DD. Statistical Power of Randomized Controlled Trials in Trauma Surgery. J Am Coll Surg 2023; 237:731-736. [PMID: 37417653 DOI: 10.1097/xcs.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery. STUDY DESIGN A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance. RESULTS In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8). CONCLUSIONS A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting.
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Affiliation(s)
- Arthur Berg
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Nicole B Lyons
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Abbasali Badami
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - John Reynolds
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Louis Pizano
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Gerd Daniel Pust
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Jonathan Meizoso
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Nicholas Namias
- From the Department of Trauma and Surgical Critical Care, Jackson Memorial Hospital, Miami, FL (Berg, Lyons, Badami, Reynolds, Pizano, Pust, Meizoso, Namias)
| | - Daniel Dante Yeh
- and the Department of Trauma and Surgical Critical Care, Denver Health, Denver, CO (Yeh)
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Thompson L, Cohen BL, Wolde T, Yeh DD, Ramsey WA, Byers PM, Namias N, Meizoso JP. Open Versus Laparoscopic Appendectomy: A Post Hoc Analysis of the EAST Appendicitis MUSTANG Study. Surg Infect (Larchmt) 2023; 24:613-618. [PMID: 37646633 DOI: 10.1089/sur.2023.109] [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: 09/01/2023] Open
Abstract
Background: We sought to understand which factors are associated with open appendectomy as final operative approach. We hypothesize that higher American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) grade is associated with open appendectomy. Patients and Methods: Post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated and Gangrenous (MUSTANG) prospective appendicitis database was performed. All adults (age >18) undergoing appendectomy were stratified by final operative approach: laparoscopic or open appendectomy (including conversion from laparoscopic). Univariable analysis was performed to compare group characteristics and outcomes, and multivariable logistic regression was performed to identify demographic, clinical, or radiologic factors associated with open appendectomy. Results: A total of 3,019 cases were analyzed. One hundred seventy-five (5.8%) patients underwent open appendectomy, including 127 converted from laparoscopic to open. The median age was 37 (25) years and 53% were male. Compared with the laparoscopic group, open appendectomy patients had more comorbidities, higher proportion of symptoms greater than 96 hours, and higher AAST EGS grade. Moreover, on intraoperative findings, the open appendectomy group had a higher incidence of perforated and gangrenous appendicitis with purulent contamination, abscess/phlegmon, and purulent abdominal/pelvic fluid. On multivariable analysis controlling for comorbidities, clinical and imaging AAST grade, duration of symptoms, and intra-operative findings, only AAST Clinical Grade 5 appendicitis was independently associated with open appendectomy (odds ratio [OR], 5.63; 95% confidence interval [CI], 1.24-25.55; p = 0.025). Conclusions: In the setting of appendicitis, generalized peritonitis (AAST Clinical Grade 5) is independently associated with greater odds of open appendectomy.
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Affiliation(s)
- Lauren Thompson
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
- Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Tizeta Wolde
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - D Dante Yeh
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Patricia M Byers
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
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Ross SW, Campion E, Jensen AR, Gray L, Gross T, Namias N, Goodloe JM, Bulger EM, Fischer PE, Fallat ME. Prehospital and emergency department pediatric readiness for injured children: A statement from the American College of Surgeons Committee on Trauma Emergency Medical Services Committee. J Trauma Acute Care Surg 2023; 95:e6-e10. [PMID: 37125944 DOI: 10.1097/ta.0000000000003997] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
ABSTRACT Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.
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Affiliation(s)
- Samuel Wade Ross
- From the Division of Acute Care Surgery, Department of Surgery (S.W.R.), F.H. "Sammy" Ross, Jr. Trauma Center, Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, North Carolina; Division of GI, Trauma, and Endocrine Surgery, Department of Surgery (E.C.), University of Colorado, Denver, Colorado; Division of Pediatric Surgery, Department of Surgery (A.R.J.), UCSF School of Medicine, San Francisco, California; Department of Pediatrics (L.G.), The University of Texas at Austin Dell Medical School, Austin, Texas; Department of Pediatrics (T.G.), Children's Hospital New Orleans, Tulane University School of Medicine; LSU Health Sciences Center (T.G.), New Orleans, Louisiana; Division of Trauma, Burns, and Surgical Critical Care, Daughtry Family Department of Surgery (N.N.), Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, Florida; Department of Emergency Medicine (J.M.G.), University of Oklahoma School of Community Medicine, Tulsa, Oklahoma; Division of Trauma, Burns, and Critical Care, Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Division of Trauma Surgical Critical Care, Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; and Hiram C. Polk, Jr. Department of Surgery (M.E.F.), University of Louisville and Norton Children's Hospital, Louisville, Kentucky
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Sperry JL, Cotton BA, Luther JF, Cannon JW, Schreiber MA, Moore EE, Namias N, Minei JP, Wisniewski SR, Guyette FX. Whole Blood Resuscitation and Association with Survival in Injured Patients with an Elevated Probability of Mortality. J Am Coll Surg 2023; 237:206-219. [PMID: 37039365 PMCID: PMC10344433 DOI: 10.1097/xcs.0000000000000708] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Low-titer group O whole blood (LTOWB) resuscitation is becoming common in both military and civilian settings and may represent the ideal resuscitation intervention. We sought to characterize the safety and efficacy of LTOWB resuscitation relative to blood component resuscitation. STUDY DESIGN A prospective, multicenter, observational cohort study was performed using 7 trauma centers. Injured patients at risk of massive transfusion who required both blood transfusion and hemorrhage control procedures were enrolled. The primary outcome was 4-hour mortality. Secondary outcomes included 24-hour and 28-day mortality, achievement of hemostasis, death from exsanguination, and the incidence of unexpected survivors. RESULTS A total of 1,051 patients in hemorrhagic shock met all enrollment criteria. The cohort was severely injured with >70% of patients requiring massive transfusion. After propensity adjustment, no significant 4-hour mortality difference across LTOWB and component patients was found (relative risk [RR] 0.90, 95% CI 0.59 to 1.39, p = 0.64). Similarly, no adjusted mortality differences were demonstrated at 24 hours or 28 days for the enrolled cohort. When patients with an elevated prehospital probability of mortality were analyzed, LTOWB resuscitation was independently associated with a 48% lower risk of 4-hour mortality (relative risk [RR] 0.52, 95% CI 0.32 to 0.87, p = 0.01) and a 30% lower risk of 28-day mortality (RR 0.70, 95% CI 0.51 to 0.96, p = 0.03). CONCLUSIONS Early LTOWB resuscitation is safe but not independently associated with survival for the overall enrolled population. When patients were selected with an elevated probability of mortality based on prehospital injury characteristics, LTOWB was independently associated with a lower risk of mortality starting at 4 hours after arrival through 28 days after injury.
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Affiliation(s)
- Jason L Sperry
- From the Department of Surgery, University of Pittsburgh, Pittsburgh, PA (Sperry)
| | - Bryan A Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, TX (Cotton)
| | - James F Luther
- University of Pittsburgh School of Public Health, Pittsburgh, PA (Luther, Wisniewski)
| | - Jeremy W Cannon
- Department of Surgery, University of Pennsylvania, Philadelphia, PA (Cannon)
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR (Schreiber)
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Health Sciences Center, Denver, CO (Moore)
| | - Nicholas Namias
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL (Namias)
| | - Joseph P Minei
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Minei)
| | - Stephen R Wisniewski
- University of Pittsburgh School of Public Health, Pittsburgh, PA (Luther, Wisniewski)
| | - Frank X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (Guyette)
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Chammas M, Abdul Jawad K, Pust GD, Rattan R, Namias N, Aicher BO, Bruns BR, Yeh DD. Association Between Fecal Contamination and Outcomes After Emergent General Surgery Colorectal Resection: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma (EAST) Multicenter Study. Surg Infect (Larchmt) 2023. [PMID: 37498199 DOI: 10.1089/sur.2022.256] [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: 07/28/2023] Open
Abstract
Background: The impact of fecal contamination on clinical outcomes in patients undergoing emergent colorectal resection is unclear. We hypothesized that fecal contamination is associated with worse clinical outcomes regardless of operative technique. Patients and Methods: This is a post hoc analysis for an Eastern Association for the Surgery of Trauma-sponsored multicenter study that prospectively enrolled emergency general surgery patients undergoing urgent/emergent colorectal resection. Subjects were categorized according to presence versus absence of intra-operative fecal contamination. Propensity score matching (1:1) by age, weight, Charlson comorbidity index, pre-operative vasopressor use, and method of colonic management (primary anastomosis [ANST] vs. ostomy [STM]) was performed. χ2 analysis was then performed to compare the composite outcome (surgical site infection and fascial dehiscence). Results: A total of 428 subjects were included, of whom 147 (34%) had fecal contamination. Propensity score matching (1:1) resulted in a total of 147 pairs. After controlling for operative technique, fecal contamination was still associated with higher odds of the composite outcome (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.45-4.2; p = 0.001). Conclusions: In patients undergoing urgent/emergent colorectal resection, fecal contamination, regardless of operative technique, is associated with worse clinical outcomes. Selection bias is possible, thus randomized controlled trials are needed to confirm or refute a causal relation.
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Affiliation(s)
- Majid Chammas
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Khaled Abdul Jawad
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Brittany O Aicher
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Brandon R Bruns
- Division of Trauma and Acute Care Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - D Dante Yeh
- Division of Trauma, Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, Colorado, USA
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12
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Lyons NB, Cohen BL, O'Neil CF, Ramsey WA, Proctor KG, Namias N, Meizoso JP. Short Versus Long Antibiotic Duration for Necrotizing Soft Tissue Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2023. [PMID: 37222708 DOI: 10.1089/sur.2023.037] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly spreading, life-threatening infections that require emergent surgical intervention with immediate antibiotic initiation. However, there is no consensus regarding duration of antibiotic therapy after source control. We hypothesized that a short course of antibiotic therapy is as effective as a long course of antibiotic therapy after final debridement for NSTI. Methods: A systematic review of the literature was performed using PubMed, Embase, and Cochrane Library from inception to November 2022. Observational studies comparing short (≤7 days) versus long (>7 days) antibiotic duration for NSTI were included. Primary outcome was mortality and secondary outcomes included limb amputation and Clostridium difficile infection (CDI). Cumulative analysis was performed with Fisher exact test. Meta-analysis was performed using a fixed effects model and heterogeneity was assessed using Higgins I2. Results: A total of 622 titles were screened and four observational studies evaluating 532 patients met inclusion criteria. Mean age was 52 years, 67% were male, 61% had Fournier gangrene. There was no difference in mortality when comparing short to long duration antibiotic agents on both cumulative analysis (5.6% vs. 4.0%; p = 0.51) and meta-analysis (relative risk, 0.9; 95% confidence interval, 0.8-1.0; I2 0; p = 0.19). There was no significant difference in rates of limb amputation (11% vs. 8.5%; p = 0.50) or CDI (20.8% vs. 13.3%; p = 0.14). Conclusions: Short duration antibiotic therapy may be as effective as longer duration antibiotic therapy for NSTI after source control. Further high-quality data such as randomized clinical trials are required to create evidence-based guidelines.
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Affiliation(s)
- Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
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13
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Ramsey WA, O'Neil CF, Corona AM, Cohen BL, Lyons NB, Meece MS, Saberi RA, Gilna GP, Satahoo SS, Kaufman JI, Schulman CI, Namias N, Proctor KG, Pizano LR. Burn Excision Within 48 Hours Portends Better Outcomes Than Standard Management: A Nationwide Analysis. J Trauma Acute Care Surg 2023:01586154-990000000-00330. [PMID: 37038260 DOI: 10.1097/ta.0000000000003951] [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: 04/12/2023]
Abstract
BACKGROUND Previous studies have debated the optimal time to perform excision and grafting of second- and third-degree burns. The current consensus is that excision should be performed before the sixth hospital day. We hypothesize that patients who undergo excision within 48 hours have better outcomes. METHODS The ACS Trauma Quality Programs (ACS TQP) dataset was used to identify all patients with at least 10% total body surface area (TBSA) second- and third-degree burns from years 2017-2019. Patients with other serious injuries (any AIS >3), severe inhalational injury, pre-hospital cardiac arrest, and interhospital transfers were excluded. ICD-10 procedure codes were used to ascertain time of first excision. Patients who underwent first excision within 48 hours of admission (early excision) were compared to those who underwent surgery 48-120 hours from admission (standard therapy). Propensity score matching was performed to control for age and TBSA burned. RESULTS 2,270 patients (72% male) were included in the analysis. Median age was 37 (23-55) years. Early excision was associated with shorter hospital length of stay (LOS), and ICU LOS (Table 2). Complications including deep venous thrombosis, pulmonary embolism, ventilator-associated pneumonia, and catheter-associated urinary tract infection were significantly lower with early excision. There was no significant difference in mortality. CONCLUSIONS Performance of excision within 48 hours is associated with shorter hospital LOS and fewer complications than standard therapy. We recommend taking patients for operative debridement and temporary or, when feasible, permanent coverage within 48 hours. Prospective trials should be performed to verify the advantages of this treatment strategy. LEVEL OF EVIDENCE Level III - Retrospective Cohort Study.
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Affiliation(s)
| | | | - Andrew M Corona
- University of Miami Miller School of Medicine, Miami, Florida, USA
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14
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Ramsey WA, O'Neil CF, Ramdev RA, Sleeman EA, Danton GH, Kaufman JI, Pizano LR, Meizoso JP, Proctor KG, Namias N. Illuminating the Use of Trauma Whole-Body CT Scan During the Global Contrast Shortage. J Am Coll Surg 2023; 236:937-942. [PMID: 36728386 DOI: 10.1097/xcs.0000000000000551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI). STUDY DESIGN All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared. RESULTS The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality. CONCLUSIONS Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.
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Affiliation(s)
- Walter A Ramsey
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Christopher F O'Neil
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Rajan A Ramdev
- University of Miami Miller School of Medicine (Ramdev, Sleeman), Miami, FL
| | - Ella A Sleeman
- University of Miami Miller School of Medicine (Ramdev, Sleeman), Miami, FL
| | - Gary H Danton
- Department of Radiology (Danton), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Joyce I Kaufman
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Louis R Pizano
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Jonathan P Meizoso
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Kenneth G Proctor
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Nicholas Namias
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
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15
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Chammas M, Pust GD, Meizoso JP, Ramsay IA, Ke H, Rattan R, Namias N, Crandall M, Yeh DD. Firearm Legislation - The Association between Neighboring States and Crude Death Rates. J Trauma Acute Care Surg 2023:01586154-990000000-00317. [PMID: 36973873 DOI: 10.1097/ta.0000000000003952] [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: 03/29/2023]
Abstract
BACKGROUND Few studies have examined the impact of interstate differences in firearm laws on state-level firearm mortality. We aim to study the association between neighboring states' firearm legislation and firearm-related crude death rate (CDR). METHODS The CDC Web-based Injury Statistics Query and Reporting System (WISQARS) was queried for adult all-intent (accidental, suicide, and homicide) firearm-related CDR among the 50 states from 2012 to 2020. States were divided into five cohorts based on the Giffords Law Center Annual Gun Law Scorecard and two groups were constructed: Strict (A, B, C) and Lenient (D, F). We examined the effect of 1) a single incongruent neighbor, defined as "Different" if the state is bordered by ≥1 state with a grade score difference > 1, and 2) the average grade of all neighboring states, defined as "Different" if the average of all neighboring states resulted in a grade score difference > 1. RESULTS Strict states with similar average neighbors had significantly lower CDR compared to Strict states with different average neighbors (2.98 [1.91-5.06] vs. 3.87 [2.37-5.94], p = 0.02) while Lenient states with similar average neighbors had significantly higher CDR compared to Lenient states with different average neighbors (6.02 [4.56-8.11] vs. 4.7 [3.95-5.35], p = 0.002). Lenient states surrounded by all similar Lenient states had the highest CDR, which was significantly higher than Lenient states with ≥1 different neighbor (6.52 [5.09-8.96] vs. 5.19 [3.85-6.61], p < 0.001). However, Strict states with ≥1 different neighbor did not have higher CDR compared to Strict states surrounded by all similar Strict states (3.39 [2.17-5.35] vs. 3.14 [1.91-5.38], p = 0.5). CONCLUSION We report a lopsided neighboring effect whereby Lenient states may benefit from at least 1 Strict neighbor while Strict states may be adversely affected only when surrounded by mostly Lenient neighbors. These findings may assist policymakers regarding the efficacy of their own state's legislation in the context of incongruent neighboring states. LEVEL OF EVIDENCE IV, retrospective observational.
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Ramsey WA, O'Neil CF, Saberi RA, Meece MS, Gilna GP, Kaufman JI, Lieberman HM, Lineen EB, Meizoso JP, Pizano LR, Satahoo SS, Danton GH, Proctor KG, Namias N. Examining the Definition of Ventilator-Associated Pneumonia in the Trauma Setting: A Single-Center Analysis. Surg Infect (Larchmt) 2023; 24:322-326. [PMID: 36944154 DOI: 10.1089/sur.2022.272] [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: 03/23/2023] Open
Abstract
Background: Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP. Patients and Methods: The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence. Results: Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ = -0.071; sensitivity, 64.3%; specificity, 28.6%). Conclusions: Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Matthew S Meece
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Joyce I Kaufman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Howard M Lieberman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Edward B Lineen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Shevonne S Satahoo
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gary H Danton
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
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17
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Meizoso JP, Sauaia A, Namias N, Manning RJ, Pieracci FM. Duration of Antibiotic Therapy for Early VAP Trial: Study Protocol for a Surgical Infection Society Multicenter, Pragmatic, Randomized Clinical Trial of Four versus Seven Days of Definitive Antibiotic Therapy for Early Ventilator-Associated Pneumonia in Surgical Patients. Surg Infect (Larchmt) 2023; 24:163-168. [PMID: 36730717 DOI: 10.1089/sur.2022.362] [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: 02/04/2023] Open
Abstract
Background: Current guidelines recommend a seven-day course of antibiotic therapy for patients with ventilator-associated pneumonia (VAP). However, clinical and microbiologic resolution of infection may occur much sooner than seven days, particularly in patients with early VAP. Shortening the course of antibiotic therapy for early VAP likely results in lower antibiotic-associated complications, but it is unclear whether VAP recurrence rates will be higher in patients receiving fewer days of therapy. We propose to compare four days versus seven days of antibiotic therapy for early VAP in surgical patients in a multicenter, pragmatic, randomized clinical trial. Patients and Methods: Eligible patients admitted to a surgical intensive care unit with early VAP, defined as VAP occurring within two to seven days of intubation, will be randomized to receive four or seven days of antibiotic therapy. The two primary outcomes are: VAP recurrence, defined as VAP occurring two to 14 days after completion of initial therapy and antibiotic-free days, defined as the number of days without receiving any antibiotic agents within 30 days from completion of initial therapy. Data will be analyzed using both intention-to-treat and per-protocol strategies. Power analysis was performed assuming non-inferiority of four days vs. seven days for VAP recurrence and superiority of four days versus seven days for antibiotic-free days. The total sample size to detect a 10% difference between groups with 80% power and assuming a 10% dropout rate is 458 patients. Three separate data analyses are planned throughout the trial and sample size will be re-calculated at each interim analysis. Conclusions: The Duration of Antibiotic Therapy for Early VAP (DATE) Trial will enroll surgical patients with early VAP to analyze whether a shorter duration of antibiotic therapy results in similar clinical outcomes while decreasing antibiotic exposure.
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Affiliation(s)
- Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Angela Sauaia
- Colorado School of Public Health, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Denver, Aurora, Colorado, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Ronald J Manning
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Fredric M Pieracci
- Department of Surgery, University of Colorado Denver, Aurora, Colorado, USA
- Ernest E. Moore Shock Trauma Center, Denver Health Medical Center, Denver, Colorado, USA
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18
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Knowlton LM, Butler WJ, Dumas RP, Bankhead BK, Meizoso JP, Bruns B, Van Gent JM, Kaafarani HMA, Martin MJ, Namias N, Stein DM, Tadlock MD, Martin RS, Staudenmayer KL, Gurney JM. Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development. Trauma Surg Acute Care Open 2023; 8:e001049. [PMID: 36866105 PMCID: PMC9972450 DOI: 10.1136/tsaco-2022-001049] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/11/2023] [Indexed: 03/03/2023] Open
Abstract
Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois). This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee, and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of five real-life mentor-mentee pairs. They addressed the following realms of mentorship: clinical, research, executive leadership and career development, mentorship through professional societies, and mentorship for military-trained surgeons. Recommendations, as well as pearls and pitfalls, are summarized below.
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Affiliation(s)
- Lisa Marie Knowlton
- Division of General Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California, USA,Stanford University School of Medicine, Department of Surgery, Stanford, California, USA
| | | | | | - Brittany K Bankhead
- Division of Trauma, Burns, and Critical Care, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Brandon Bruns
- Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Jan-Michael Van Gent
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC USC Medical Center, Los Angeles, California, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Deborah M. Stein
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, US Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
| | - R Shayn Martin
- Department of Surgery, Division of Acute Care Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristan L Staudenmayer
- Division of General Surgery, Section of Acute Care Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer M Gurney
- Department of Trauma Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
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19
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Ramsey WA, O'Neil CF, Fils AJ, Botero-Fonnegra C, Saberi RA, Gilna GP, Pizano LR, Parker BM, Proctor KG, Schulman CI, Namias N, Meizoso JP. Improved Survival for Severely Injured Patients Receiving Massive Transfusion at US Teaching Hospitals: A Nationwide Analysis. J Trauma Acute Care Surg 2023; 94:672-677. [PMID: 36749659 DOI: 10.1097/ta.0000000000003895] [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: 02/08/2023]
Abstract
BACKGROUND Previous studies have shown improved survival for patients treated at American College of Surgeons (ACS) verified level I trauma centers compared to level II, level III, and undesignated centers. This mortality difference is more pronounced in severely injured patients. However, a survival benefit for severely injured trauma patients has not been established at teaching institutions compared to non-teaching centers. As massive transfusion (MT) is associated with high mortality, we hypothesize that patients receiving MT have lower mortality at teaching hospitals than at non-teaching hospitals. METHODS All adult ACS Trauma Quality Improvement Program-eligible patients who underwent MT, defined as >10 units of packed red blood cells in the first 4 hours after arrival, in the 2019 ACS Trauma Quality Programs participant use file were eligible. Patients with severe head injury (AIS Head ≥3), prehospital cardiac arrest, and interhospital transfers were excluded. Logistic regression models were used to assess the effects of trauma center hospital teaching status on the adjusted odds of 3-hour, 6-hour, and 24-hour mortality. RESULTS 1,849 patients received MT [81% male, median ISS 26 (18-35)], 72% were admitted to level I trauma centers, and 28% were admitted to level II centers. Overall hospital mortality was 41%; 17% of patients died in 3 hours, 25% in 6 hours and 33% in 24 hours. Teaching hospitals were associated with decreased 3-hour (OR 0.45, 95% CI 0.27-0.75), 6-hour (OR 0.37, 95% CI 0.24-0.56), 24-hour (OR 0.50, 95% CI 0.34-0.75), and overall mortality (OR 0.66, 95% CI 0.44-0.98), compared to non-teaching hospitals, controlling for sex, age, heart rate, injury severity, injury mechanism, and trauma center verification level. CONCLUSIONS Severely injured patients requiring MT experience significantly lower mortality at teaching hospitals compared to non-teaching hospitals, independently of trauma center verification level. LEVEL OF EVIDENCE Level III: Retrospective comparative study.
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Affiliation(s)
| | | | - Aaron J Fils
- University of Miami Miller School of Medicine, Miami, Florida, USA
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20
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Chammas M, Byerly S, Lynde J, Mantero A, Saberi R, Gilna G, Pust GD, Rattan R, Namias N, Crandall M, Yeh DD. Association Between Child Access Prevention and State Firearm Laws With Pediatric Firearm-Related Deaths. J Surg Res 2023; 281:223-227. [PMID: 36206582 DOI: 10.1016/j.jss.2022.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/27/2022] [Accepted: 08/27/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION We aim to study the association between state child access prevention (CAP) and overall firearm laws with pediatric firearm-related mortality. METHODS The Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System was queried for pediatric (aged < 18 y) all-intent (accidental, suicide, and homicide) firearm-related crude death rates (CDRs) among the 50 states from 1999 to 2019. States were into three groups: Always CAP (throughout the 20-year period), Never CAP, and New CAP (enacted CAP during study period). We used the Giffords Law Center Annual Gun Law Scorecard (A, B, C, D, F) to group states into strict (A, B) and lenient (C, D, F) firearm laws. A scatter plot was constructed to display state CDR based on CAP laws by year. The top 10 states by CDR per year were tabulated based on CAP law status. Wilcoxon rank-sum was used to compare CDR between strict and lenient scorecard states in 2019. RESULTS There were 12 Always CAP, 21 Never CAP, and 17 New CAP states from 1999 to 2019. No states changed from CAP laws to no CAP laws. Never CAP and New CAP states dominated the high outliers in CDR compared to Always CAP. The top 10 states with the highest CDR per year were most commonly Never CAP. Strict firearm laws states had lower median CDR in 2019 than lenient states (0.79 [0-1.67] versus 2.59 [1.66-3.53], P = 0.007). CONCLUSIONS Stricter overall gun laws are associated with three-fold lower all-intent pediatric firearm-related deaths. For 2 decades, the 10 states with the highest CDR were almost universally those without CAP laws. Our findings support the RAND Gun Policy in America initiative's claims on the importance of CAP laws in reducing suicide, unintentional deaths, and violent crime among children, but more research is needed.
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Affiliation(s)
- Majid Chammas
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida.
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jennifer Lynde
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Alejandro Mantero
- Department of Public Health Sciences, University of Miami, Miami, Florida
| | - Rebecca Saberi
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Gareth Gilna
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Gerd Daniel Pust
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Rishi Rattan
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Nicholas Namias
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Marie Crandall
- Department of Surgery, University of Florida Health-Jacksonville, Jacksonville, Florida
| | - D Dante Yeh
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
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21
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Yeh DD, Hatton GE, Pedroza C, Pust G, Mantero A, Namias N, Kao LS. Complex And Simple Appendicitis: REstrictive or Liberal postoperative Antibiotic eXposure (CASA RELAX) using Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR): study protocol for a randomized controlled trial. Trauma Surg Acute Care Open 2022; 7:e000931. [PMID: 36148315 PMCID: PMC9486380 DOI: 10.1136/tsaco-2022-000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Objectives After appendectomy for simple or complicated appendicitis, the optimal duration of postoperative antibiotics (postop abx) is unclear and great practice variability exists. We propose to compare restrictive versus liberal postop abx using a hierarchical composite endpoint which includes patient-centered outcomes and accounts for duration of antibiotic exposure. Methods/Design Participants with simple or complicated appendicitis undergoing appendectomy are randomly assigned to either restricted or liberal strategy. Eligible subjects declining randomization will be recruited to enroll in an observation only cohort. The primary endpoint is an ordinal scale of mutually exclusive clinical outcomes with within-category rankings determined by duration of antibiotic exposure. Subjects in both randomized and observation only cohorts will be analyzed as intention-to-treat, per-protocol, and as-treated. Exploratory Bayesian analyses will be performed. Conclusion The complex and simple appendicitis: restrictive or liberal postoperative antibiotic exposure multicenter randomized controlled trial will enroll surgical appendectomy patients and seeks to analyze if a strategy of restricted (compared with liberal) postoperative antibiotics results in similar clinical outcomes with the benefit of reduced antibiotic exposure. Trial registration number NCT05002829.
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Affiliation(s)
- Daniel Dante Yeh
- Surgery, Ernest E. Moore Shock Trauma Center / Denver Health, Denver, Colorado, USA
| | - Gabrielle E Hatton
- Department of Surgery, McGovern Medical School at UT Health Houston, Houston, Texas, USA
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at UT Health Houston, Houston, Texas, USA
| | - Gerd Pust
- Surgery, Jackson Memorial Hospital, Miami, Florida, USA
| | - Alejandro Mantero
- University of Miami Biostatistics Collaboration and Consulting Core, Miami, Florida, USA
| | | | - Lillian S Kao
- Department of Surgery, McGovern Medical School at UT Health Houston, Houston, Texas, USA
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22
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Chammas M, Pust GD, Hatton G, Pedroza C, Kao L, Rattan R, Namias N, Yeh DD. Outcomes of Restricted versus Liberal Post-Operative Antibiotic Use in Patients Undergoing Appendectomy: A DOOR/RADAR Post Hoc Analysis of the EAST Appendicitis MUSTANG Study. Surg Infect (Larchmt) 2022; 23:489-494. [PMID: 35647893 DOI: 10.1089/sur.2021.287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: There is no consensus on the duration of antibiotic use after appendectomy. We hypothesized that restricted antibiotic use is associated with better clinical outcomes. Patients and Methods: We performed a post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America-Acute, Perforated, and Gangrenous (MUSTANG) study using the desirability of outcome ranking/response adjusted for duration of antibiotic risk (DOOR/RADAR) framework. Three separate datasets were analyzed based on restricted versus liberal post-operative antibiotic groups: simple appendicitis (no vs. yes); complicated appendicitis, only four days (≤24 hours vs. 4 days); and complicated appendicitis, four or more days (≤24 hours vs. ≥4 days). Patients were assigned to one of seven mutually exclusive DOOR categories RADAR ranked within each category. DOOR/RADAR score pairwise comparisons were performed between all patients. Each patient was assigned either 1, 0, or -1 if they had better, same, or worse outcomes than the other patient in the pair, respectively. The sum of these numbers (cumulative comparison score) was calculated for each patient and the group medians of individual sums were compared by Wilcoxon rank sum. Results: For simple appendicitis, the restricted group had higher median sums than the liberal group (552 [552,552] vs. -1,353 [-1,353, -1,353], p < 0.001). For both complicated appendicitis analyses, the restricted group had higher median sums than the liberal: only 4 (196 [23,196] vs. -121 [-121, -121], p < 0.02) and 4 or more (660 [484,660] vs -169 [-444,181], p < 0.001). Conclusions: Restricted post-operative antibiotic use in patients after appendectomy is a dominant strategy when considering treatment effectiveness and antibiotic exposure.
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Affiliation(s)
- Majid Chammas
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gabrielle Hatton
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Claudia Pedroza
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Lillian Kao
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - D Dante Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
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23
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Abstract
BACKGROUND Nearly half of pediatric homicides younger than 5 years are attributable to child abuse. Parents are most commonly the perpetrators, but less is known about incidents involving biological versus surrogate parents. We sought to evaluate the characteristics of fatal child abuse involving biological and surrogate parents using the Georgia National Violent Death Reporting System, which we believe may differ in demographics and incident characteristics. METHODS This database was used to examine all homicides of children younger than 18 years from 2011 to 2017. Demographics and incident characteristics were analyzed using the existing National Violent Death Reporting System variables and incident narratives. Nonparametric and χ2 tests were used to compare fatal child abuse incidents involving biological and surrogate parents (e.g., adoptive, foster, step-parents, intimate partners of biological parent). RESULTS There were 452 pediatric homicides and 219 cases of fatal child abuse. Of all cases of fatal child abuse, 60% involved biological and 29% involved surrogate parents. Compared with children killed by biological parents, children killed by surrogate parents were older (4 vs. 3 years), more often male (71% vs. 51%), more likely to survive the initial injury and present to the emergency department before death (96% vs. 69%), and less likely to have a medical comorbidity (2% vs. 11%; all p < 0.05). Surrogate parents were more likely to be male (90% vs. 48%) and use a firearm (20% vs. 13%) to inflict the injury, both p < 0.05. The race/ethnicity of the child was not associated with the parent's relationship. CONCLUSION Child abuse accounts for half of all pediatric homicides. Parents are the most common perpetrators of fatal child abuse, but surrogate parent perpetrators are almost exclusively male and more likely to use firearms. Most children have a history of abuse, leaving an opportunity to intervene on potentially preventable deaths if abuse is identified in a timely fashion. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level III.
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Affiliation(s)
- Maxwell J Presser
- From the Department of Surgery, (M.J.P., H.J.Q.); Division of Pediatric Surgery, Department of Surgery (E.A.P., J.E.S., C.M.T.), and Division of Trauma and Acute Care Surgery, Department of Surgery (N.N.), University of Miami, Miller School of Medicine, Miami, Florida
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24
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Chammas M, Abdul Jawad K, Saberi RA, Gilna G, Urrechaga EM, Cioci A, Rattan R, Pust GD, Namias N, Yeh DD. Role of Empiric Antifungal Therapy in Patients with Perforated Peptic Ulcers. Surg Infect (Larchmt) 2022; 23:174-177. [PMID: 35021885 DOI: 10.1089/sur.2021.286] [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: 11/13/2022] Open
Abstract
Background: It is unclear if the addition of antifungal therapy for perforated peptic ulcers (PPU) leads to improved outcomes. We hypothesized that empiric antifungal therapy is associated with better clinical outcomes in critically ill patients with PPU. Patients and Methods: The 2001-2012 Medical Information Mart for Intensive Care (MIMIC-III) database was searched for patients with PPU and the included subjects were divided into two groups depending on receipt of antifungal therapy. Propensity score matching by surgical intervention, mechanical ventilation (MV), and vasopressor administration was then performed and clinically important outcomes were compared. Multiple logistic regression was performed to calculate the odds of a composite end point (defined as "alive, hospital-free, and infection-free at 30 days"). Results: A total of 89 patients with PPU were included, of whom 52 (58%) received empiric antifungal therapy. Propensity score matching resulted in 37 pairs. On logistic regression controlling for surgery, vasopressors, and MV, receipt of antifungal therapy was not associated with higher odds (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.5-4.7; p = 0.4798) of the composite end point. Conclusions: In critically ill patients with perforated peptic ulcer, receipt of antifungal therapy, regardless of surgical intervention, was not associated with improved clinical outcomes. Selection bias is possible and therefore randomized controlled trials are required to confirm/refute causality.
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Affiliation(s)
- Majid Chammas
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Khaled Abdul Jawad
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Rebecca A Saberi
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gareth Gilna
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Eva M Urrechaga
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Alessia Cioci
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Daniel Dante Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
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25
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Schulman CI, Namias N, Pizano L, Rodriguez-Menocal L, Aickara D, Guzman W, Candanedo A, Maranda E, Beirn A, Badiavas EV. The effect of mesenchymal stem cells improves the healing of burn wounds: a phase 1 dose-escalation clinical trial. Scars Burn Heal 2022; 8:20595131211070783. [PMID: 35781931 PMCID: PMC9247372 DOI: 10.1177/20595131211070783] [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: 12/01/2022] Open
Abstract
Background Stem cell therapy holds promise to improve healing and stimulate tissue
regeneration after burn injury. Preclinical evidence has supported this;
however, clinical studies are lacking. We examined the application of bone
marrow-derived mesenchymal stem cells (BM-MSC) to deep second-degree burn
injuries using a two-dose escalation protocol. Methods Ten individuals aged 18 years or older with deep second-degree burn wounds
were enrolled. The first five patients were administered 2.5 × 10³
BM-MSC/cm2 to their wounds. After safety of the initial dose
level was assessed, a second group of five patients was treated with a
higher concentration of 5 × 10³ allogeneic BM-MSC/cm2. Safety was
assessed clinically and by evaluating cytokine levels in mixed recipient
lymphocyte/donor BM-MSC reactions (INFγ, IL-10 and TNFα). At each visit, we
performed wound measurements and assessed wounds using a Patient and
Observer Scar Assessment Scale (POSAS). Results All patients responded well to treatment, with 100% closure of wounds and
minimal clinical evidence of fibrosis. No adverse reactions or evidence of
rejection were observed for both dose levels. Patients receiving the first
dose concentration had a wound closure rate of 3.64 cm2/day.
Patients receiving the second dose concentration demonstrated a wound
closure rate of 10.47 cm2/day. The difference in healing rates
between the two groups was not found to be statistically significant
(P = 0.17). Conclusion BM-MSC appear beneficial in optimising wound healing in patients with deep
second-degree burn wounds. Adverse outcomes were not observed when
administering multiple doses of allogeneic BM-MSC. Lay Summary Thermal injuries are a significant source of morbidity and mortality,
constituting 5%–20% of all injuries and 4% of all deaths. Despite overall
improvements in the management of acutely burned patients, morbidities
associated with deeper burn injuries remain commonplace. Burn patients are
too often left with significant tissue loss, scarring and contractions
leading to physical loss of function and long-lasting psychological and
emotional impacts. In previous studies, we have demonstrated the safety and efficacy of
administering bone marrow-derived mesenchymal stem cells (BM-MSC) to chronic
wounds with substantial improvement in healing and evidence of tissue
regeneration. In this report, we have examined the application of BM-MSC to
deep second-degree burn injuries in patients. The aim of the present phase I/II clinical trial was to examine the safety
and efficacy of administering allogeneic BM-MSC to deep second-degree burns.
We utilised two different dose levels at concentrations 2.5 × 103
and 5 × 103 cells/cm2. Patients with deep
second-degree burn wounds up to 20% of the total body surface area were
eligible for treatment. Allogeneic BM-MSC were applied to burn wounds
topically or by injection under transparent film dressing <7 days after
injury. Patients were followed for at least six months after treatment. Using two dose levels allowed us to gain preliminary information as to
whether different amounts of BM-MSC administered to burn wounds will result
in significant differences in safety/ clinical response. Once the safety and
dose-response analysis were completed, we evaluated the efficacy of
allogeneic stem cell therapy in the treatment of deep second-degree burn
wounds. In this study, we examined the role of allogeneic BM-MSC treatment in
patients with deep second-degree burn injuries, in a dose-dependent manner.
No significant related adverse events were reported. Safety was evaluated
both clinically and by laboratory-based methods. Efficacy was assessed
clinically through evidence of re-pigmentation, hair follicle restoration
and regenerative change. While these findings are encouraging, more studies
will be needed to better establish the benefit of BM-MSC in the treatment of
burn injuries.
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Affiliation(s)
- Carl I Schulman
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Nicholas Namias
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Louis Pizano
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Luis Rodriguez-Menocal
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Divya Aickara
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Wellington Guzman
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Ambar Candanedo
- Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL, USA
| | - Eric Maranda
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Audrey Beirn
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Evangelos V Badiavas
- Department of Dermatology and Cutaneous Surgery. Leonard M Miller School of Medicine, University of Miami, Interdisciplinary Stem Cell Institute, Miami, FL, USA
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Urrechaga EM, Byerly SE, Lee EE, Cioci AC, Rattan R, Proctor KG, Namias N, Ginzburg E. Traumatic Gluteal Artery Injuries: A Marker of Injury Severity. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Urrechaga EM, Cioci AC, Parreco JP, Gilna GP, Saberi RA, Yeh DD, Zakrison TL, Namias N, Rattan R. The hidden burden of unplanned readmission after emergency general surgery. J Trauma Acute Care Surg 2021; 91:891-897. [PMID: 34225343 DOI: 10.1097/ta.0000000000003325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals. METHODS The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals. RESULTS Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days. CONCLUSION Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Eva M Urrechaga
- From the Division of Trauma and Acute Care Surgery, Dewitt-Daughtry Family Department of Surgery (E.M.U., A.C.C., G.P.G., R.A.S., D.D.Y., N.N., R.R.), University of Miami Miller School of Medicine, Miami; Department of Trauma (J.P.P.), Lawnwood Regional Medical Center, Fort Pierce, Florida; and Department of Trauma and Acute Care Surgery (T.L.Z.), University of Chicago, Chicago, Illinois
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Abdul Jawad K, Qian S, Vasileiou G, Larentzakis A, Rattan R, Dodgion C, Kaafarani H, Zielinski M, Namias N, Yeh DD. Microbial Epidemiology of Acute and Perforated Appendicitis: A Post-Hoc Analysis of an EAST Multicenter Study. J Surg Res 2021; 269:69-75. [PMID: 34520984 DOI: 10.1016/j.jss.2021.07.026] [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: 01/21/2021] [Revised: 07/13/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are significant practice variations in antibiotic treatment for appendicitis, ranging from short-course narrow spectrum to long-course broad-spectrum. We sought to describe the modern microbial epidemiology of acute and perforated appendicitis in adults to help inform appropriate empiric coverage and support antibiotic stewardship initiatives. METHODS This is a post-hoc secondary analysis of the Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) which prospectively enrolled adult patients (age ≥ 18 years) diagnosed with appendicitis between January 2017 and June 2018 across 28 centers in the United States. We included all subjects with positive microbiologic cultures during primary or secondary (rescue after medical failure) appendectomy or percutaneous drainage. Culture yield was compared between low- and high-grade appendicitis as per the AAST classification. RESULTS A total of 3,471 patients were included: 230 (7%) had cultures performed, and 179/230 (78%) had positive results. Cultures were less likely to be positive in grade 1 compared to grades 3, 4, or 5 appendicitis with 2/18 (11%) vs 61/70 (87%) (p < .001). Only 1 subject had grade 2 appendicitis and culture results were negative. E. coli was the most common pathogen and cultured in 29 (46%) of primary appendectomy samples, 16 (50%) of secondary, and 44 (52%) of percutaneous drainage samples. CONCLUSION Culturing low-grade appendicitis is low yield. E. coli is the most commonly cultured microbe in acute and perforated appendicitis. This data helps inform empiric coverage for both antibiotics alone and as an adjunct to operative or percutaneous intervention.
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Affiliation(s)
- Khaled Abdul Jawad
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, Florida.
| | - Sinong Qian
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, Florida
| | - Georgia Vasileiou
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, Florida
| | - Andreas Larentzakis
- Division of Foregut Surgery, Department of Surgery, University of Athens School of Medicine, Athens, Greece
| | - Rishi Rattan
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, Florida
| | - Chris Dodgion
- Division of Trauma & Critical Care, Department of Surgery, Froedtert Hospital / Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Haytham Kaafarani
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital / Harvard Medical School, Boston, Massachusetts
| | - Martin Zielinski
- Division of Trauma & Critical Care, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nicholas Namias
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, Florida
| | - D Dante Yeh
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, Florida
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Sussman MS, Ryon EL, Urrechaga EM, Cioci AC, Herrington TJ, Pizano LR, Garcia GD, Namias N, Wetstein PJ, Buzzelli MD, Gross KR, Proctor KG. The Key to Combat Readiness Is a Strong Military-Civilian Partnership. Mil Med 2021; 186:571-576. [PMID: 33394041 DOI: 10.1093/milmed/usaa565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/15/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR). METHODS Over a 3-year period, all FRSTs were surveyed at one civilian center. RESULTS Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics. CONCLUSIONS This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Emily L Ryon
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Alessia C Cioci
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Tyler J Herrington
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Louis R Pizano
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - George D Garcia
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Nicholas Namias
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Paul J Wetstein
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Mark D Buzzelli
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Kirby R Gross
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
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Abdul Jawad K, Urrechaga E, Cioci A, Zhang H, Byerly S, Rattan R, Pust GD, Namias N, Yeh DD. Discordance in Appendicitis Grading and the Association with Outcomes: A Post-Hoc Analysis of an EAST Multicenter Study. J Surg Res 2021; 265:259-264. [PMID: 33964635 DOI: 10.1016/j.jss.2021.02.048] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/05/2021] [Accepted: 02/27/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) appendicitis severity grading criteria use independent subscales for radiologists (Rad), surgeons (Surg), and pathologists (Path). We reviewed the EAST Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database to determine rates of discordance and clinical consequences of inaccuracy. MATERIALS AND METHODS A confusion matrix was constructed for pairs among Rad, Surg, and Path. Accuracy was reported using chronologically latest diagnosis as gold standard. "Concordance" (C) was achieved when both agreed on the severity grade and "Discordance"(D) when they disagreed. A composite endpoint("COMP"= 30-d incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED[Emergency Department] visit, hospital readmission, and mortality) was compared between C versus D groups via χ2 test with Bonferroni correction to define statistical significance(P = 0.05/9 = 0.005). RESULTS For each pair and diagnosis, subjects were categorized as C or D and compared for the incidence of COMP. Incidence of COMP for Surg and/or Path in C versus D: 16% versus. 26% (p = 0.006, NS by Bonferroni) for acute (A), 39% versus 33% (p = 0.39) for gangrenous (G), and 48% versus 37% (p = 0.035, NS by Bonferroni) for perforated (P). For Rad and/or Path in C versus. D: 17% versus 42% (p < 0.001) for A, 27% versus 31% (p = 0.95) for G, and 56% versus 48% (p = 0.48) for P. For C versus D: 17% versus 40% (p < 0.001) for A, 36% versus 26% (p = 0.43) for G, and 51% versus 39% (p = 0.29) for P. CONCLUSIONS In appendicitis treated by appendectomy, surgeons are most accurate at diagnosing acute appendicitis and least accurate at diagnosing gangrenous. Radiologists are less accurate for all categories. When the surgeon is wrong, clinical outcomes are not significantly worse. However, when the radiologist is wrong about acute appendicitis, patients have worse clinical outcomes.
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Affiliation(s)
- Khaled Abdul Jawad
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida.
| | - Eva Urrechaga
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Alessia Cioci
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Hang Zhang
- Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, Florida
| | - Saskya Byerly
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - D Dante Yeh
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
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Qian S, Vasileiou G, Pust GD, Zakrison T, Rattan R, Zielinski M, Ray-Zack M, Zeeshan M, Namias N, Yeh DD. Prophylactic Drainage after Appendectomy for Perforated Appendicitis in Adults: A Post Hoc Analysis of an EAST Multi-Center Study. Surg Infect (Larchmt) 2021; 22:780-786. [PMID: 33877912 DOI: 10.1089/sur.2019.258] [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: 12/28/2022] Open
Abstract
Background: We sought to assess the efficacy of prophylactic abdominal drainage to prevent complications after appendectomy for perforated appendicitis. Methods: In this post hoc analysis of a prospective multi-center study of appendicitis in adults (≥ 18 years), we included patients with perforated appendicitis diagnosed intra-operatively. The 634 subjects were divided into groups on the basis of receipt of prophylactic drains. The demographics and outcomes analyzed were surgical site infection (SSI), intra-abdominal abscess (IAA), Clavien-Dindo complications, secondary interventions, and hospital length of stay (LOS). Multivariable logistic regression for the cumulative 30-day incidence of IAA was performed controlling for age, Charlson Comorbidity Index (CCI), antibiotic duration, presence of drains, and Operative American Association for the Surgery of Trauma (AAST) Grade. Results: In comparing the Drain (n = 159) versus No-Drain (n = 475) groups, there was no difference in the frequency of male gender (61% versus 55%; p = 0.168), weight (87.9 ± 27.9 versus 83.8 ± 23.4 kg; p = 0.071), Alvarado score (7 [6-8] versus 7 [6-8]; p = 0.591), white blood cell (WBC) count (14.8 ± 4.8 versus 14.9 ± 4.5; p = 0.867), or CCI (1 [0-3] versus 1 [0-2]; p = 0.113). The Drain group was significantly older (51 ± 16 versus 48 ± 17 years; p = 0.017). Drain use increased as AAST EGS Appendicitis Operative Severity Grade increased: Grade 3 (62/311; 20%), Grade 4 (46/168; 27%), and Grade 5 (51/155; 33%); p = 0.007. For index hospitalization, the Drain group had a higher complication rate (43% versus 28%; p = 0.001) and longer LOS (4 [3-7] versus 3 [1-5] days; p < 0.001). We could not detect a difference between the groups in the incidence of SSI, IAA, or secondary interventions. There was no difference in 30-day emergency department visits, re-admissions, or secondary interventions. Multi-variable logistic regression showed that only AAST Grade (odds ratio 2.7; 95% confidence interval7 1.5-4.7; p = 0.001) was predictive of the cumulative 30-day incidence of IAA. Conclusions: Prophylactic drainage after appendectomy for perforated appendicitis in adults is not associated with fewer intra-abdominal abscesses but is associated with longer hospital LOS. Increasing AAST EGS Appendicitis Operative Grade is a strong predictor of intra-abdominal abscess.
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Affiliation(s)
- Sinong Qian
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Georgia Vasileiou
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Gerd Daniel Pust
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Tanya Zakrison
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Rishi Rattan
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | | | - Mohamed Ray-Zack
- Department if Surgery, University of Arizona College of Medicine, Tucson, Arizona USA
| | - Muhammad Zeeshan
- New York Medical College-Westchester Medical Center, Valhalla, New York, USA
| | - Nicholas Namias
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
| | - D Dante Yeh
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida USA
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Mulder MB, Sussman MS, Eidelson SA, Gross KR, Buzzelli MD, Batchinsky AI, Schulman CI, Namias N, Proctor KG. Heart Rate Complexity in US Army Forward Surgical Teams During Pre Deployment Training. Mil Med 2021; 185:e724-e733. [PMID: 32722768 DOI: 10.1093/milmed/usz434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/28/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION For trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC. MATERIALS AND METHODS A prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise. RESULTS Baseline HR, CO, HRV, and HRC averaged 72 ± 11b/min, 5.6 ± 1.2 L/min, 48 ± 24 ms, and 1.9 ± 0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P < 0.05. CONCLUSIONS Various forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.
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Affiliation(s)
- Michelle B Mulder
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Matthew S Sussman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Sarah A Eidelson
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Kirby R Gross
- U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Mark D Buzzelli
- U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Andriy I Batchinsky
- Extracorporeal Life Support Capability Area, Battlefield Health & Trauma Center for Human Integrative Physiology, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, JBSA Fort Sam Houston, TX 78234-6315.,The Geneva Foundation, Tacoma, WA 98402
| | - Carl I Schulman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136.,U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Nicholas Namias
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Kenneth G Proctor
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136.,U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
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Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg 2021; 36:1450-1457. [PMID: 33586229 DOI: 10.1111/jocs.15406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In trauma patients, the recognition of fibrinolysis phenotypes has led to a re-evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis-generating study was to fill that gap. METHODS Seventy-eight cardiac surgery patients were retrospectively reviewed. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (0.8%-3.0%), and hyperfibrinolytic (>3%) based on thromboelastogram. RESULTS The population was 65 ± 10-years old, 74% male, average body mass index of 29 ± 5 kg/m2 . Fibrinolytic phenotypes were distributed as physiologic = 45% (35 of 78), hypo = 32% (25 of 78), and hyper = 23% (18 of 78). There was no obvious effect of age, gender, race, or ethnicity on this distribution; 47% received AF. For AF versus no AF, the time with chest tube was longer (4 [1] vs. 3 [1] days, p = .037), and all-cause morbidity was more prevalent (51% vs. 25%, p = .017). However, when these two groups were further stratified by phenotypes, there were within-group differences in the percentage of patients with congestive heart failure (p = .022), valve disease (p = .024), on-pump surgery (p < .0001), estimated blood loss during surgery (p = .015), transfusion requirement (p = .015), and chest tube output (p = .008), which highlight other factors along with AF that might have affected all-cause morbidity. CONCLUSION This is the first description of the prevalence of three different fibrinolytic phenotypes and their potential influence on cardiac surgery patients. The use of AF was associated with increased morbidity, but because of the small sample size and treatment allocation bias, additional confirmatory studies are necessary. We hope these present findings open the dialog on whether it is safe to administer AFs to cardiac surgery patients who are normo- or hypofibrinolytic.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Alessia C Cioci
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Rahul S Iyengar
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tyler J Herrington
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Emily L Ryon
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - David L Galbut
- Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tomas A Salerno
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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Pust G, Kateregga A, Oad M, Olvera R, Garcia G, Lieberman H, Marttos A, Yeh D, Namias N, Motola I. 1067: Arterial Catheter Simulation Training for Residents Improves Confidence in Knowledge and Skills. Crit Care Med 2021. [DOI: 10.1097/01.ccm.0000730156.32234.a0] [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: 11/25/2022]
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Pust G, Kateregga A, Oad M, Olvera R, Garcia G, Lieberman H, Marttos A, Yeh D, Namias N, Motola I. 1070: Central Venous Catheter Simulation Training Improves Residents’ Confidence in Knowledge and Skills. Crit Care Med 2021. [DOI: 10.1097/01.ccm.0000730168.19398.c6] [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: 11/25/2022]
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Rattan R, Cioci AC, Urréchaga EM, Chatoor MS, Krocker JD, Johnson DL, Curcio GJ, Namias N, Yeh DD, Ginzburg E, Parreco JP. Readmission for venous thromboembolism after emergency general surgery is underreported and influenced by insurance status. J Trauma Acute Care Surg 2021; 90:64-72. [PMID: 33003019 DOI: 10.1097/ta.0000000000002954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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 Prior studies of venous thromboembolism (VTE) after emergency general surgery (EGS) are not nationally representative nor do they fully capture readmissions to different hospitals. We hypothesized that different-hospital readmission accounted for a significant number of readmissions with VTE after EGS and that predictive factors would be different for same- and different-hospital readmissions. METHODS The 2014 Nationwide Readmissions Database was queried for nonelective EGS hospitalizations. The outcomes were readmission to the index or different hospitals within 180 days with VTE. Multivariate logistic regressions identified risk factors for readmission to index and different hospitals with VTE, reported as odds ratios with their 95% confidence intervals. Patients were excluded if during the index admission they expired, developed a VTE, had a vena cava filter placed, or did not have at least 180 days of follow-up. RESULTS Of 1,584,605 patients meeting inclusion criteria, 1.3% (n = 20,963) of patients were readmitted within 180 days with a VTE. Of these, 28% (n = 5,866) were readmitted to a different hospital. Predictors overall for readmission with VTE were malignancy, prolonged hospitalization, age, and being publicly insured. However, predictors for readmission to a different hospital are based on hospital characteristics, including for-profit status, or procedure type. CONCLUSIONS Nearly one in three readmissions with VTE after EGS occurs at a different hospital and may be missed by current quality metrics that only capture same-hospital readmission. Such metrics may underestimate for-profit hospital postoperative VTE rates relative to public and nonprofit hospitals, potentially affecting benchmarking and reimbursement. Postdischarge VTE rate is associated with insurance status. These findings have implications for policy and prevention programming design. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Rishi Rattan
- From the DeWitt Daughtry Family Department of Surgery, Miller School of Medicine (R.R., A.C.C., E.M.U., J.D.K., N.N., D.D.Y., E.G.), University of Miami; Jackson Memorial Hospital (M.S.C., D.L.J.), Miami; Department of Surgery, College of Medicine (G.J.C.), University of South Florida, Tampa; and Department of Surgery, College of Medicine (J.P.P.), Florida State University, Tallahassee, Florida
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Mulder MB, Gilna GP, Iyengar RS, Quintana OD, Nardiello DC, Kaufman JI, Pizano LR, Namias N, Schulman CI, Proctor KG. Electrical Burns During Fruit Harvesting. J Burn Care Res 2020; 40:427-429. [PMID: 31051035 DOI: 10.1093/jbcr/irz050] [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: 11/14/2022]
Abstract
Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.
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Affiliation(s)
- Michelle B Mulder
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Gareth P Gilna
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Rahul S Iyengar
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Olga D Quintana
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Dawn C Nardiello
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Joyce I Kaufman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Louis R Pizano
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Carl I Schulman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Kenneth G Proctor
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
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Abdul Jawad K, Cioci A, Urrechaga E, Zhang H, Byerly S, Rattan R, Pust GD, Namias N, Yeh DD. Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study. Surg Infect (Larchmt) 2020; 22:463-468. [PMID: 33030398 DOI: 10.1089/sur.2020.219] [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: 01/26/2023] Open
Abstract
Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.
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Affiliation(s)
- Khaled Abdul Jawad
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Alessia Cioci
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eva Urrechaga
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hang Zhang
- Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, Florida, USA
| | - Saskya Byerly
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rishi Rattan
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | - D Dante Yeh
- Division of Trauma & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
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Sussman MS, Mulder MB, Ryon EL, Urrechaga EM, Lama GA, Bahga A, Eidelson SA, Lieberman HM, Schulman CI, Namias N, Proctor KG. Acute Kidney Injury Risk in Patients Treated with Vancomycin Combined with Meropenem or Cefepime. Surg Infect (Larchmt) 2020; 22:415-420. [PMID: 32783764 DOI: 10.1089/sur.2020.105] [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: 01/04/2023] Open
Abstract
Background: No previous studies have determined the incidence of acute kidney injury (AKI) in trauma patients treated with vancomycin + meropenem (VM) versus vancomycin + cefepime (VC). The purpose of this study was to fill this gap. Methods: A series of 99 patients admitted to an American College of Surgeons-verified level 1 trauma center over a two-year period who received VC or VM for >48 hours were reviewed retrospectively. Exclusion criteria were existing renal dysfunction or on renal replacement therapy. The primary outcome was AKI as defined by a rise in serum creatinine (SCr) to 1.5 times baseline. Multi-variable analysis was performed to control for factors associated with AKI (age, obesity, gender, length of stay [LOS], nephrotoxic agent(s), and baseline SCr), with significance defined as p < 0.05. Results: The study population was 50 ± 19 years old, 76% male, with a median LOS of 21 [range 15-39] days, and baseline SCr of 0.9 ± 0.2 mg/dL. Antibiotics, diabetes mellitus, and Injury Severity Score were independent predictors of AKI (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.4-12; OR 9.3; 95% CI 1-27; OR 1.2; 95% CI 1.023-1.985, respectively). The incidence of AKI was higher with VM than VC (10/26 [38%] versus 14/73 [19.1%]; p = 0.049). Conclusions: The renal toxicity of vancomycin is potentiated by meropenem relative to cefepime in trauma patients. We recommend caution when initiating vancomycin combination therapy, particularly with meropenem.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Michelle B Mulder
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Emily L Ryon
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Gabriel A Lama
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Amritpal Bahga
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Sarah A Eidelson
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Howard M Lieberman
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Carl I Schulman
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Nicholas Namias
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
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Byerly S, Vasileiou G, Qian S, Mantero A, Lee EE, Parks J, Mulder M, Pust DG, Rattan R, Lineen E, Byers P, Namias N, Yeh DD. Early Hypermetabolism is Uncommon in Trauma Intensive Care Unit Patients. JPEN J Parenter Enteral Nutr 2020; 46:771-781. [PMID: 32562287 DOI: 10.1002/jpen.1945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU). METHODS This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM). RESULTS Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m2 ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge. CONCLUSION Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.
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Affiliation(s)
- Saskya Byerly
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Georgia Vasileiou
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Sinong Qian
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Alejandro Mantero
- Department of Public Health, Division of Biostatistics, University of Miami, Miami, Florida, USA
| | - Eugenia E Lee
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Jonathan Parks
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Michelle Mulder
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Daniel G Pust
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Rishi Rattan
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Edward Lineen
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Patricia Byers
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - Nicholas Namias
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
| | - D Dante Yeh
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, Florida, USA
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Parreco J, Soe-Lin H, Parks JJ, Byerly S, Chatoor M, Buicko JL, Namias N, Rattan R. Comparing Machine Learning Algorithms for Predicting Acute Kidney Injury. Am Surg 2020. [DOI: 10.1177/000313481908500731] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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
Prior studies have used vital signs and laboratory measurements with conventional modeling techniques to predict acute kidney injury (AKI). The purpose of this study was to use the trend in vital signs and laboratory measurements with machine learning algorithms for predicting AKI in ICU patients. The eICU Collaborative Research Database was queried for five consecutive days of laboratory measurements per patient. Patients with AKI were identified and trends in vital signs and laboratory values were determined by calculating the slope of the least-squares-fit linear equation using three days for each value. Different machine learning classifiers (gradient boosted trees [GBT], logistic regression, and deep learning) were trained to predict AKI using the laboratory values, vital signs, and slopes. There were 151,098 ICU stays identified and the rate of AKI was 5.6 per cent. The best performing algorithm was GBT with an AUC of 0.834 ± 0.006 and an F-measure of 42.96 per cent ± 1.26 per cent. Logistic regression performed with an AUC of 0.827 ± 0.004 and an F-measure of 28.29 per cent ± 1.01 per cent. Deep learning performed with an AUC of 0.817 ± 0.005 and an F-measure of 42.89 per cent ± 0.91 per cent. The most important variable for GBT was the slope of the minimum creatinine (30.32%). This study identifies the best performing machine learning algorithms for predicting AKI using trends in laboratory values in ICU patients. Early identification of these patients using readily available data indicates that incorporating machine learning predictive models into electronic medical record systems is an inevitable requisite for improving patient outcomes.
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Affiliation(s)
- Joshua Parreco
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Hahn Soe-Lin
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | | | - Saskya Byerly
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Matthew Chatoor
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Jessica L. Buicko
- Division of Endocrine Surgery, Weil Cornell Medical Center, New York, New York
| | - Nicholas Namias
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Rishi Rattan
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Van Haren RM, Thorson CM, Valle EJ, Guarch GA, Jouria JM, Busko AM, Namias N, Livingstone AS, Proctor KG. Vasopressor Use during Emergency Trauma Surgery. Am Surg 2020. [DOI: 10.1177/000313481408000518] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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
Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. Vasopressors were administered to 225 patients (30%) during OR; 59 patients (8%) received multiple vasopressors. Patients who received vasopressors were older, more severely injured, had worse vital signs, and increased mortality rate (all P < 0.001). EPI was independently associated with mortality (odds ratio, 6.88; P = 0.001). If patients who received EPI were excluded, there was no difference in mortality between those who received vasopressors alone or in combination and those that did not (5 vs 6%, P = 0.523), although multiple markers of injury severity were worse. We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.
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Affiliation(s)
- Robert M. Van Haren
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Chad M. Thorson
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Evan J. Valle
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Gerardo A. Guarch
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Jassin M. Jouria
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Alexander M. Busko
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Alan S. Livingstone
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Kenneth G. Proctor
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
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Parreco J, Quiroz HJ, Willobee BA, Sussman M, Buicko JL, Rattan R, Namias N, Thorson CM, Sola JE, Perez EA. National Risk Factors for Child Maltreatment after Trauma: Failure to Prevent. Am Surg 2020. [DOI: 10.1177/000313481908500726] [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: 11/15/2022]
Abstract
The purpose of this study was to identify the risk factors for hospital readmission for child maltreatment after trauma, including admissions across different hospitals nationwide. The Nationwide Readmissions Database for 2010–2014 was queried for all patients younger than 18 years admitted for trauma. The primary outcome was readmission for child maltreatment. The secondary outcome was readmission for maltreatment presenting to a hospital different than the index admission hospital. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome. There were 608,744 admissions identified and 44,569 (7.32%) involved maltreatment at the index admission. Readmission for maltreatment was found in 1,948 (0.32%) patients and 368 (18.89%) presented to a different hospital. The highest risk for readmission for maltreatment was found in patients with maltreatment identified at the index admission (odds ratios (OR) 9.48 [8.35–10.76]). The strongest risk factor for presentation to a different hospital was found with the lowest median household income quartile (OR 3.50 [2.63–4.67]). The subgroup analysis identified 647 (0.11%) children with readmission for maltreatment that was missed during the index admission. The strongest risk factor for this outcome was Injury Severity Score > 15 (OR 3.29 [2.68–4.03]). This study demonstrates that a significant portion of admissions for trauma in children and teenagers could be misrepresented as not involving maltreatment. These index admissions could be the only chance for intervention for child maltreatment. Identifying these at-risk individuals is critical to prevention efforts.
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Affiliation(s)
- Joshua Parreco
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Hallie J. Quiroz
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Brent A. Willobee
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Mathew Sussman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jessica L. Buicko
- Division of Endocrine Surgery, Weil Cornell Medical Center, New York, New York
| | - Rishi Rattan
- Division of Trauma Surgery and Surgical Critical Care; and
| | | | - Chad M. Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan E. Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eduardo A. Perez
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Qian S, Vasileiou G, Dodgion C, Ray-Zack MD, Zakrison T, Rattan R, Namias N, Yeh DD. Narrow- versus Broad-Spectrum Antibiotics for Simple Acute Appendicitis Treated by Appendectomy: A Post Hoc Analysis of EAST MUSTANG Study. J Surg Res 2020; 254:217-222. [PMID: 32474194 DOI: 10.1016/j.jss.2019.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/25/2019] [Accepted: 04/03/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND We sought to compare the effectiveness of narrow- versus broad-spectrum antibiotics (abx) in preventing infectious complications in adults with acute appendicitis treated with appendectomy. METHODS In this post hoc analysis of a prospective multicenter observational study of appendicitis in adults (≥18 y) conducted from January 2017 to June 2018, we included only patients with simple appendicitis. Subjects were grouped based on receipt of broad-spectrum or narrow-spectrum abx before and/or after appendectomy. Outcomes compared were surgical site infection, intra-abdominal abscess, secondary interventions (percutaneous drainage or operation), emergency department (ED) visits, 30-d readmission, and hospital length of stay. RESULTS A total of 2336 subjects were analyzed. In comparing narrow (n = 778) versus broad (n = 1558) groups, there were no differences in male sex (53% versus 54%, P = 0.704), white blood cell (13.0 ± 3.9 versus 13.4 ± 4.5, P = 0.05), Alvarado score (6 [5-7] versus 6 [5-7], P = 0.25), or Charlson comorbidity index (0 [0-1] versus 0 [0-1], P = 0.09). A total of 688 (29%) received postoperative abx, [184 (24%) narrow and 504 (32%) broad, P < 0.001] for a median 5 [2-7] d [42 (23%) narrow and 235 (47%) broad, P < 0.001]. There were no significant differences between narrow and broad groups in surgical site infection, intra-abdominal abscess, secondary interventions, ED visits, or hospital readmissions. CONCLUSIONS Significant practice variation in duration and spectrum of antibiotic adjunct for surgical treatment of simple acute appendicitis treatment is evident, and broad-spectrum abx did not offer clinical advantages over narrow-spectrum abx. Restriction of antibiotic spectrum should be considered, although randomized trials are required to overcome selection bias.
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Affiliation(s)
- Sinong Qian
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida.
| | - Georgia Vasileiou
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida
| | - Chris Dodgion
- Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Tanya Zakrison
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida
| | - Rishi Rattan
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida
| | - D Dante Yeh
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida
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Quiroz HJ, Martinez R, Parikh PP, Parreco JP, Namias N, Velazquez OC, Rattan R. Hidden Readmissions after Carotid Endarterectomy and Stenting. Ann Vasc Surg 2020; 68:132-140. [PMID: 32335250 DOI: 10.1016/j.avsg.2020.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Historically, carotid procedures incur a readmission rate of approximately 6%; however, these studies are not nationally representative and are limited to tracking only the index hospitals. We sought to evaluate a nationally representative database for readmission rates (including different hospitals) after both carotid endarterectomy (CEA) and carotid artery stenting (CAS) and determine risk factors for poor outcomes including postoperative mortality and myocardial infarction. METHODS This study was a retrospective analysis utilizing the 2010-2014 Nationwide Readmissions Database to query patients aged >18 years undergoing CEA or CAS. Outcomes included initial admission mortality, and 30-day readmission, including mortality and myocardial infarction (MI). Univariable analysis of 39 demographic, clinical, and hospital variables was conducted with significance set at P < 0.05. Significant variables were included in a multivariable logistic regression to identify independent risk factors for readmission. Results were weighted for national estimates. RESULTS There were 527,622 patients undergoing carotid procedures and 13% (n = 69,187) underwent CAS. The 30-day readmission rate was 7% (n = 35,782), and of those, 25% (n = 8,862) were readmitted to a different hospital. When controlling for other factors, CAS was a risk factor for mortality at both index admission (odds ratio [OR] 2.29 [2.11-2.49]) and 30-day readmission (OR 1.48 [1.3-1.69]) and 30-day readmissions at both index hospital (OR 1.11 [1.07-1.14]) and different hospital (OR 1.38 [1.29-1.48]). Readmission to a different hospital increased mortality risk (OR 1.45 [1.29-1.63]) but did not have an effect on MI. Postoperative infections comprised 15% of readmissions while 6% of all readmissions were for stroke. CONCLUSIONS Previously unreported, one in 4 readmissions after carotid procedures occur at a different hospital and this fragmentation of care could increase mortality risk after carotid procedures particularly for CAS which was also an independent risk factor for postoperative mortality and readmissions. Further validation is required to decrease unnecessary hospital after carotid procedures.
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Affiliation(s)
- Hallie J Quiroz
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Rennier Martinez
- Department of Surgery, University of Miami Palm Beach Campus, Atlantis, FL
| | - Punam P Parikh
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Joshua P Parreco
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Nicholas Namias
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Omaida C Velazquez
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Rishi Rattan
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
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Parreco J, Sussman MS, Crandall M, Ebler DJ, Lee E, Namias N, Rattan R. Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma. J Surg Res 2020; 250:59-69. [PMID: 32018144 DOI: 10.1016/j.jss.2019.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/27/2019] [Accepted: 12/27/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals. METHODS The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury. RESULTS There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05). CONCLUSIONS This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.
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Affiliation(s)
- Joshua Parreco
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Matthew S Sussman
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida.
| | - Marie Crandall
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, Florida
| | - David J Ebler
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, Florida
| | - Eugenia Lee
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
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Parreco J, Soe-Lin H, Byerly S, Lu N, Ruiz G, Yeh DD, Namias N, Rattan R. Multi-Center Outcomes of Chlorhexidine Oral Decontamination in Intensive Care Units. Surg Infect (Larchmt) 2020; 21:659-664. [PMID: 31928384 DOI: 10.1089/sur.2019.172] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The efficacy of oral chlorhexidine (oCHG) for decontamination in intensive care unit (ICU) patients is controversial. The purpose of this study was to evaluate the effect of oCHG decontamination on the incidence of pneumonia, sepsis, and death in ICU patients. Methods: The Philips eICU database version 2.0 was queried for patients admitted to the ICU for ≥48 hours in 2014-2015. The primary outcome of interest was death in the ICU. Secondary outcomes were a diagnosis of pneumonia or sepsis. Patients with pneumonia or sepsis diagnosed within the first 48 hours of ICU admission were excluded from the outcome analyses. Univariable analysis was performed comparing age, gender, race, severity of illness scores, hospital characteristics, and oCHG order. Multivariable logistic regression was performed using univariable results with p < 0.05. Results: Of the 64,904 patients from 186 hospitals, 22.1% (n = 14,333) had oCHG ordered. The overall mortality rate was 6.9% (n = 4,449) and the mortality rate in patients receiving oCHG was 10.6% (n = 1,518; p < 0.001). After controlling for confounding factors, oCHG remained an independent risk factor for death (odds ratio [OR] 1.25; 95% confidence interval [CI] 1.16-1.34). After excluding patients with an early diagnosis of pneumonia, the overall pneumonia incidence was 2.6% (n = 1,431) and the incidence in patients having oCHG was 4.2% (n = 517; p < 0.001). However, multivariable logistic regression revealed no significant difference in the risk of pneumonia with oCHG (OR 0.97; 95% CI 0.85-1.09). After excluding patients with an early diagnosis of sepsis, the overall rate of sepsis was 1.8% (n = 949) and for patients with oCHG, the rate was 3.3% (n = 388; p < 0.001). After controlling for other confounders, oCHG remained an independent risk factor for sepsis (OR 1.37; 95% CI 1.19-1.59). Conclusions: A chlorhexidine mouthwash order is associated with increased odds of death and sepsis without decreased odds of pneumonia in a heterogeneous cohort of ICU patients. Additional studies are needed to understand better the effect of oCHG on outcomes.
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Affiliation(s)
- Joshua Parreco
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Hahn Soe-Lin
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Saskya Byerly
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Ning Lu
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gabriel Ruiz
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - D Dante Yeh
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Nicholas Namias
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Rishi Rattan
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, USA
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Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-Induced Changes in Compensatory Reserve and Heart Rate Complexity. Aerosp Med Hum Perform 2019; 90:1009-1015. [PMID: 31747997 DOI: 10.3357/amhp.5460.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND: Portable noninvasive Heart Rate Complexity (HRC) and Compensatory Reserve Measurement (CRM) monitors have been developed to triage supine combat casualties. Neither monitor has been tested in upright individuals during physical exercise. This study tests the hypothesis that exercise evokes proportional changes in HRC and CRM.METHODS: Two instruments monitored volunteers (9 civilian and 11 soldiers) from the Army Trauma Training Department (ATTD) before, during, and following physical exercise. One recorded heart rate (HR, bpm), cardiac output (CO, L · min-1), heart rate variability (HRV, root mean square of successive differences, ms), and HRC (Sample Entropy, unitless). The other recorded HR, pulse oximetry (Spo₂, %), and CRM (%).RESULTS: Baseline HR, CO, HRV, HRC, and CRM averaged 72 ± 1 bpm, 5.6 ± 1.2 L · min-1, 48 ± 24 ms, 1.9 ± 0.5, and 85 ± 10% in seated individuals. Exercise evoked peak HR and CO at > 200% of baseline, while HRC and CRM were simultaneously decreased to minimums that were ≤ 50% of baseline (all P < 0.001). HRV changes were variable and unreliable. Spo₂ remained consistently above 95%. During a 60 min recovery, HR and CRM returned to baseline on parallel tracks (t1/2=11 ± 8 and 18 ± 14 min), whereas HRC recovery was slower than either CRM or HR (t1/2=40 ± 18 min, both P < 0.05).DISCUSSION: Exercise evoked qualitatively similar changes in CRM and HRC. CRM recovered incrementally faster than HRC, suggesting that vasodilation, muscle pump, and respiration compensate faster than cardiac autonomic control in young, healthy volunteers. Both HRC and CRM appear to provide reliable, objective, and noninvasive metrics of human performance in upright exercising individuals.Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-induced changes in compensatory reserve and heart rate complexity. Aerosp Med Hum Perform. 2019; 90(12):1009-1015.
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Abstract
The definition of sepsis continues to be as dynamic as the management strategies used to treat this. Sepsis-3 has replaced the earlier systemic inflammatory response syndrome (SIRS)-based diagnoses with the rapid Sequential Organ Failure Assessment (SOFA) score assisting in predicting overall prognosis with regards to mortality. Surgeons have an important role in ensuring adequate source control while recognizing the threat of carbapenem-resistance in gram-negative organisms. Rapid diagnostic tests are being used increasingly for the early identification of multi-drug-resistant organisms (MDROs), with a key emphasis on the multidisciplinary alert of results. Novel, higher generation antibiotic agents have been developed for resistance in ESKCAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) organisms while surgeons have an important role in the prevention of spread. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial has challenged the previous paradigm of length of antibiotic treatment whereas biomarkers such as procalcitonin are playing a prominent role in individualizing therapy. Several novel therapies for refractory septic shock, while still investigational, are gaining prominence rapidly (such as vitamin C) whereas others await further clinical trials. Management strategies presented as care bundles continue to be updated by the Surviving Sepsis Campaign, yet still remain controversial in its global adoption. We have broadened our temporal and epidemiologic perspective of sepsis by understanding it both as an acute, time-sensitive, life-threatening illness to a chronic condition that increases the risk of mortality up to five years post-discharge. Artificial intelligence, machine learning, and bedside scoring systems can assist the clinician in predicting post-operative sepsis. The public health role of the surgeon is key. This includes collaboration and multi-disciplinary antibiotic stewardship at a hospital level. It also requires controlling pharmaceutical sales and the unregulated dispensing of antibiotic agents globally through policy initiatives to control emerging resistance through prevention.
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Affiliation(s)
- Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Haytham Kaafarani
- Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Boston, Massachusetts
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Heather Evans
- Division of General & Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Tanya L Zakrison
- Section for Trauma and Acute Care Surgery, The University of Chicago Medicine, Chicago, Illinois
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50
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Vasileiou G, Eid AI, Qian S, Pust GD, Rattan R, Namias N, Larentzakis A, Kaafarani HMA, Yeh DD. Appendicitis in Pregnancy: A Post-Hoc Analysis of an EAST Multicenter Study. Surg Infect (Larchmt) 2019; 21:205-211. [PMID: 31687887 DOI: 10.1089/sur.2019.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objective: To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18-45 years). Methods: This was a post-hoc analysis of a prospectively collected database (January 2017-June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes. Results: Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 ± 8 years at a median gestational age of 15 (range 10-23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days. Conclusion: Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.
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Affiliation(s)
- Georgia Vasileiou
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Ahmed I Eid
- Department of Emergency and Traumatology, Tanta University, Tanta, Egypt
| | - Sinong Qian
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Gerd D Pust
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Rishi Rattan
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Andreas Larentzakis
- 1st Propaedeutic Surgical Clinic, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Haytham M A Kaafarani
- Department of Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - D Dante Yeh
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
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