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Ayoung-Chee PR, Gore AV, Bruns B, Knowlton LM, Nahmias J, Davis KA, Leichtle S, Ross SW, Scherer LR, Velopulos C, Martin RS, Staudenmayer KL. Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective. J Trauma Acute Care Surg 2024:01586154-990000000-00699. [PMID: 38706096 DOI: 10.1097/ta.0000000000004347] [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: 05/07/2024]
Abstract
ABSTRACT The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the healthcare system - the patient, the healthcare organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.
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Affiliation(s)
| | - Amy V Gore
- Department of Surgery, Rutgers New Jersey Medical School
| | - Brandon Bruns
- Department of Surgery, University of Texas, Southwestern Medical Center
| | - Lisa M Knowlton
- Department of Surgery, Stanford University School of Medicine
| | | | | | - Stefan Leichtle
- Department of Surgery, University of Virginia School of Medicine
| | - Samuel W Ross
- Department of Surgery, Wake Forest School of Medicine
| | - L R Scherer
- Department of Surgery, Idaho College of Osteopathic Medicine
| | - Catherine Velopulos
- Department of Surgery, University of Colorado Denver, Anschutz Medical Campus
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Knowlton LM, Scott JW, Dowzicky P, Murphy P, Davis KA, Staudenmayer K, Martin RS. Financial Toxicity Part II: A Practical Guide to Measuring and Tracking Long-Term Financial Outcomes Among Acute Care Surgery Patients. J Trauma Acute Care Surg 2024:01586154-990000000-00649. [PMID: 38439149 DOI: 10.1097/ta.0000000000004310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Lisa M Knowlton
- Department of Surgery, Stanford University School of Medicine, Section of Acute Care Surgery, Stanford, CA
| | - John W Scott
- Department of Surgery, Division of Trauma, Burn, & Critical Care Surgery, University of Washington, Seattle, WA
| | - Phillip Dowzicky
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Chicago, Chicago, IL
| | - Patrick Murphy
- Department of Surgery, Division of Trauma/Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kimberly A Davis
- Department of Surgery, Division of General Surgery, Section of Acute Care Surgery, Yale University, New Haven, CT
| | - Kristan Staudenmayer
- Department of Surgery, Stanford University School of Medicine, Section of Acute Care Surgery, Stanford, CA
| | - R Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
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Stettler GR, Crouse DS, Velazquez GA, Martin RS. Challenges in acute care surgery: management of severe proximal blunt aortic injury. Trauma Surg Acute Care Open 2024; 9:e001249. [PMID: 38405020 PMCID: PMC10884259 DOI: 10.1136/tsaco-2023-001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- Gregory R Stettler
- Department of Surgery, Division of Acute Care Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David S Crouse
- Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gabriela A Velazquez
- Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - R Shayn Martin
- Department of Surgery, Division of Acute Care Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Khanna AK, Garcia JO, Saha AK, Harris L, Baruch M, Martin RS. Agreement between cardiac output estimation with a wireless, wearable pulse decomposition analysis device and continuous thermodilution in post cardiac surgery intensive care unit patients. J Clin Monit Comput 2024; 38:139-146. [PMID: 37458916 DOI: 10.1007/s10877-023-01059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/07/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE Pulse Decomposition Analysis (PDA) uses integration of the systolic area of a distally transmitted aortic pulse as well as arterial stiffness estimates to compute cardiac output. We sought to assess agreement of cardiac output (CO) estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CCO) and a wireless, wearable noninvasive device, (Vitalstream, Caretaker Medical, Charlottesville, VA), that utilizes the Pulse Decomposition Analysis (CO-PDA) method in postoperative cardiac surgery patients in the intensive care unit. METHODS CO-CCO measurements were compared with post processed CO-PDA measurements in prospectively enrolled adult cardiac surgical intensive care unit patients. Uncalibrated CO-PDA values were compared for accuracy with CO-CCO via a Bland-Altman analysis considering repeated measurements and a concordance analysis with a 10% exclusion zone. RESULTS 259.7 h of monitoring data from 41 patients matching 15,583 data points were analyzed. Mean CO-CCO was 5.55 L/min, while mean values for the CO-PDA were 5.73 L/min (mean of differences +- SD 0.79 ± 1.11 L/min; limits of agreement - 1.43 to 3.01 L/min), with a percentage error of 37.5%. CO-CCO correlation with CO-PDA was moderate (0.54) and concordance was 0.83. CONCLUSION Compared with the CO-CCO Swan-Ganz, cardiac output measurements obtained using the CO-PDA were not interchangeable when using a 30% threshold. These preliminary results were within the 45% limits for minimally invasive devices, and pending further robust trials, the CO-PDA offers a noninvasive, wireless solution to complement and extend hemodynamic monitoring within and outside the ICU.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Julio O Garcia
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Amit K Saha
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Lynnette Harris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | | | - R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Weaver AA, Ronning IN, Armstrong W, Miller AN, Kiani B, Shayn Martin R, Beavers KM, Stitzel JD. Computed tomography assessment of pelvic bone density: Associations with age and pelvic fracture in motor vehicle crashes. Accid Anal Prev 2023; 193:107291. [PMID: 37716194 PMCID: PMC10591932 DOI: 10.1016/j.aap.2023.107291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023]
Abstract
Motor vehicle crash (MVC) occupants routinely get a computed tomography (CT) scan to screen for internal injury, and this CT can be leveraged to opportunistically derive bone mineral density (BMD). This study aimed to develop and validate a method to measure pelvic BMD in CT scans without a phantom, and examine associations of pelvic BMD with age and pelvic fracture incidence in seriously injured MVC occupants from the Crash Injury Research and Engineering Network (CIREN) study. A phantom-less muscle-fat calibration technique to measure pelvic BMD was validated using 45 quantitative CT scans with a bone calibration phantom. The technique was then used to measure pelvic BMD from CT scans of 252 CIREN occupants (ages 16+) in frontal MVCs who had sustained either abdominal or pelvic injury. Pelvic BMD was analyzed in relation to age and pelvic fracture incidence. In the validation set, phantom-based calibration vs. phantom-less muscle-fat calibration yielded similar BMD values at the anterior superior iliac spine (ASIS; R2 = 0.95, p < 0.001) and iliac crest (R2 = 0.90, p < 0.001). Pelvic BMD was measured in 150 female and 102 male CIREN occupants aged 16-89, and 25% of these occupants sustained pelvic fracture. BMD at the ASIS and iliac crest declined with age (p < 0.001). For instance, iliac crest BMD decreased an average of 25 mg/cm3 per decade of age. The rate of iliac crest BMD decline was 7.6 mg/cm3 more per decade of age in occupants with pelvic fracture compared to those not sustaining pelvic fracture. Findings suggest pelvic BMD may be a contributing risk factor for pelvic fracture in MVCs.
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Affiliation(s)
- Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575. N. Patterson Ave., Winston-Salem, NC 27101, United States.
| | - Isaac N Ronning
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575. N. Patterson Ave., Winston-Salem, NC 27101, United States; University of British Columbia, 2329 West Mall, Vancouver, BC V6T 1Z4, Canada
| | - William Armstrong
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575. N. Patterson Ave., Winston-Salem, NC 27101, United States.
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, 600 S. Euclid Ave., St. Louis, MO 63110, United States.
| | - Bahram Kiani
- Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157, United States.
| | - R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157, United States.
| | - Kristen M Beavers
- Department of Health and Exercise Science, Wake Forest University, Worrell Professional Center, Winston-Salem, NC 27109, United States.
| | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest University School of Medicine, 575. N. Patterson Ave., Winston-Salem, NC 27101, United States.
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Scott JW, Knowlton LM, Murphy P, Neiman PU, Martin RS, Staudenmayer K. Financial toxicity after trauma and acute care surgery: From understanding to action. J Trauma Acute Care Surg 2023; 95:800-805. [PMID: 37125781 DOI: 10.1097/ta.0000000000003979] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
ABSTRACT Gains in inpatient survival over the last five decades have shifted the burden of major injuries and surgical emergencies from the acute phase to their long-term sequelae. More attention has been placed on evaluation and optimization of long-term physical and mental health; however, the impact of major injuries and surgical emergencies on long-term financial well-being remains a critical blind spot for clinicians and researchers. The concept of financial toxicity encompasses both the objective financial consequences of illness and medical care as well as patients' subjective financial concerns. In this review, representatives of the Healthcare Economics Committee from the American Association for the Surgery of Trauma (1) provide a conceptual overview of financial toxicity after trauma or emergency surgery, (2) outline what is known regarding long-term economic outcomes among trauma and emergency surgery patients, (3) explore the bidirectional relationship between financial toxicity and long-term physical and mental health outcomes, (4) highlight policies and programs that may mitigate financial toxicity, and (5) identify the current knowledge gaps and critical next steps for clinicians and researchers engaged in this work.
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Affiliation(s)
- John W Scott
- From the Department of Surgery (J.W.S.), Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery (L.M.K., K.S.), Stanford University School of Medicine, Stanford, California; Department of Surgery (P.M.), Division of Trauma/Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (P.U.N.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and Department of Surgery (R.S.M.), Wake Forest School of Medicine, Winston-Salem, North Carolina
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Gibbs KW, Forbes JL, Harrison KJ, Krall JT, Isenhart AA, Taylor SP, Martin RS, O'Connell NS, Bakhru RN, Palakshappa JA, Files DC. A Pragmatic Pilot Trial Comparing Patient-Triggered Adaptive Pressure Control to Patient-Triggered Volume Control Ventilation in Critically Ill Adults. Respir Care 2023; 68:1331-1339. [PMID: 36944477 PMCID: PMC10506635 DOI: 10.4187/respcare.10803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Patient-triggered adaptive pressure control (APC) continuous mandatory ventilation (CMV) (APC-CMV) has been widely adopted as an alternative ventilator mode to patient-triggered volume control (VC) CMV (VC-CMV). However, the comparative effectiveness of the 2 ventilator modes remains uncertain. We sought to explore clinical and implementation factors pertinent to a future definitive randomized controlled trial assessing APC-CMV versus VC-CMV as an initial ventilator mode strategy. The research objectives in our pilot trial tested clinician adherence and explored clinical outcomes. METHODS In a single-center pragmatic sequential cluster crossover pilot trial, we enrolled all eligible adults with acute respiratory failure requiring mechanical ventilation admitted during a 9-week period to the medical ICU. Two-week time epochs were assigned a priori in which subjects received either APC-CMV or VC-CMV The primary outcome of the trial was feasibility, defined as 80% of subjects receiving the assigned mode within 1 h of initiation of ICU ventilation. The secondary outcome was proportion of the first 24 h on the assigned mode. Finally, we surveyed clinician stakeholders to understand potential facilitators and barriers to conducting a definitive randomized trial. RESULTS We enrolled 137 subjects who received 152 discreet episodes of mechanical ventilation during time epochs assigned to APC-CMV (n = 61) and VC-CMV (n = 91). One hundred and thirty-one episodes were included in the prespecified primary outcome. One hundred and twenty-six (96%) received the assigned mode within the first hour of ICU admission (60 of 61 subjects assigned APC-CMV and 66 of 70 assigned VC-CMV). VC-CMV subjects spent a lower proportion of first 24 h (84% [95% CI 78-89]) on the assigned mode than APC-CMV recipients (95% [95% CI 91-100]). Mixed-methods analyses identified preconceived perceptions of subject comfort by clinicians and need for real-time education to address this concern. CONCLUSIONS In this pilot pragmatic, sequential crossover trial, unit-wide allocation to a ventilator mode was feasible and acceptable to clinicians.
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Affiliation(s)
- Kevin W Gibbs
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Jonathan L Forbes
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kelsey J Harrison
- Department of Respiratory Care, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jennifer Tw Krall
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Aubrae A Isenhart
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephanie P Taylor
- Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Internal Medicine, Wake Forest School of Medicine, Charlotte, North Carolina
| | - R Shayn Martin
- Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, North Carolina
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Rita N Bakhru
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jessica A Palakshappa
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
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8
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Khanna AK, Nosow L, Sands L, Saha AK, Agashe H, Harris L, Martin RS, Marchant B. Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients. J Clin Monit Comput 2023; 37:559-565. [PMID: 36269451 PMCID: PMC10068656 DOI: 10.1007/s10877-022-00924-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Abstract
We sought to assess agreement of cardiac output estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CTD) and a novel pulse wave analysis (PWA) method that performs an analysis of multiple beats of the arterial blood pressure waveform (CO-MBA) in post-operative cardiac surgery patients. PAC obtained CO-CTD measurements were compared with CO-MBA measurements from the Argos monitor (Retia Medical; Valhalla, NY, USA), in prospectively enrolled adult cardiac surgical intensive care unit patients. Agreement was assessed via Bland-Altman analysis. Subgroup analysis was performed on data segments identified as arrhythmia, or with low CO (less than 5 L/min). 927 hours of monitoring data from 79 patients was analyzed, of which 26 had arrhythmia. Mean CO-CTD was 5.29 ± 1.14 L/min (bias ± precision), whereas mean CO-MBA was 5.36 ± 1.33 L/min, (4.95 ± 0.80 L/min and 5.04 ± 1.07 L/min in the arrhythmia subgroup). Mean of differences was 0.04 ± 1.04 L/min with an error of 38.2%. In the arrhythmia subgroup, mean of differences was 0.14 ± 0.90 L/min with an error of 35.4%. In the low CO subgroup, mean of differences was 0.26 ± 0.89 L/min with an error of 40.4%. In adult patients after cardiac surgery, including those with low cardiac output and arrhythmia CO-MBA is not interchangeable with the continuous thermodilution method via a PAC, when using a 30% error threshold.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Lillian Nosow
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lauren Sands
- University of Maryland School of Medicine, Baltimore, USA
| | - Amit K Saha
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | | | - Lynnette Harris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - R Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Bryan Marchant
- Section on Critical Care Medicine, Section on Cardiac Anesthesiology, Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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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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Appelbaum RD, Riera KM, Fram MR, Russell GB, Ii SPC, Martin RS, Hoth JJ, Mowery NT, Nunn AM. The COST of liver disease: The Cirrhosis Outcomes Score in Trauma Study. Injury 2023; 54:1374-1378. [PMID: 36774265 DOI: 10.1016/j.injury.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/28/2023] [Accepted: 02/01/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Cirrhosis in trauma patients is an indicator of poor prognosis, but current trauma injury grading systems do not take into account liver dysfunction as a risk factor. Our objective was to construct a simple clinical mortality prediction model in cirrhotic trauma patients: Cirrhosis Outcomes Score in Trauma (COST). METHODS Trauma patients with pre-existing cirrhosis or liver dysfunction who were admitted to our ACS Level I trauma center between 2013 and 2021 were reviewed. Patients with significant acute liver trauma (AAST Grade ≥ 3) or those that developed acute liver dysfunction while admitted were excluded. Demographics as well as ISS, MELD, complications, and mortality were evaluated. COST was defined as the sum of age, ISS, and MELD. Univariate and multivariable analysis was used to determine independent predictors of mortality. The area under the receiver operating curve (AUROC) was calculated to assess the ability of COST to predict mortality. RESULTS A total of 318 patients were analyzed of which the majority were males 214 (67.3%) who suffered blunt trauma 305 (95.9%). Mortality at 30-days, 60-days, and 90-days was 20.4%, 23.6%, and 25.5%, respectively. COST was associated with inpatient, 30-day, and 90-day mortality on regression analyses and the AUROC for COST predicting mortality at these respective time points was 0.810, 0.801, and 0.813. CONCLUSION Current trauma injury grading systems do not take into account liver dysfunction as a risk factor. COST is highly predictive of mortality in cirrhotic trauma patients. The simplicity of the score makes it useful in guiding clinical care and in optimizing goals of care discussions. Future studies to validate this prediction model are required prior to clinical use.
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Affiliation(s)
- Rachel D Appelbaum
- Vanderbilt University Medical Center, Vanderbilt University School of Medicine, USA.
| | - Katherine M Riera
- Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, USA.
| | - Madeline R Fram
- Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, USA.
| | - Gregory B Russell
- Atrium Health Wake Forest Baptist, Department of Biostatistics and Data Science, Wake Forest University School of Medicine, USA.
| | | | - R Shayn Martin
- Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, USA.
| | - J Jason Hoth
- Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, USA.
| | - Nathan T Mowery
- Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, USA.
| | - Andrew M Nunn
- Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, USA.
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Gibbs KW, Forbes JL, O’Connell NS, Martin RS, Bakhru RN, Palakshappa JA, Files DC. Excess Tidal Volume Ventilation in Critically Ill Adults Receiving Adaptive Pressure Control: A Cohort Study. Ann Am Thorac Soc 2022; 19:1942-1945. [PMID: 35622413 PMCID: PMC9667801 DOI: 10.1513/annalsats.202203-200rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Kevin W. Gibbs
- Wake Forest School of MedicineWinston-Salem, North Carolina
| | | | | | | | - Rita N. Bakhru
- Wake Forest School of MedicineWinston-Salem, North Carolina
| | | | - D. Clark Files
- Wake Forest School of MedicineWinston-Salem, North Carolina
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Armstrong W, Costa C, Poveda L, Miller AN, Ambrosini A, Hsu FC, Kiani B, Martin RS, Stitzel JD, Weaver AA. Effects of muscle quantity and bone mineral density on injury and outcomes in older adult motor vehicle crash occupants. Traffic Inj Prev 2022; 23:S86-S91. [PMID: 36190765 PMCID: PMC9839521 DOI: 10.1080/15389588.2022.2124864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
Objectives: Quantify the independent and combined effects of abdominal muscle quantity and lumbar bone mineral density (BMD) on injury risk and in-hospital outcomes in severely injured motor vehicle crash (MVC) occupants ages 50 and older.Methods: Skeletal muscle area measurements of MVC occupants were obtained through semi-automated segmentation of an axial computed tomography (CT) slice at the L3 vertebra. An occupant height-normalized Skeletal Muscle Index (SMI) was calculated - a defining metric of sarcopenia and low muscle mass (sarcopenia thresholds: <38.5 cm2/m2 females; <52.4 cm2/m2 males). Lumbar BMD was obtained using a validated, phantomless CT calibration method (osteopenia threshold: <145 mg/cm3). SMI and BMD values were used to categorize occupants, and logistic regression was used to associate sarcopenia, osteopenia, and osteosarcopenia predictors to injury outcomes (e.g., Injury Severity Score (ISS), maximum Abbreviated Injury Scale (MAIS) score, fractures) and hospital outcomes (e.g., length of stay, ICU days).Results: Of the 336 occupants, 210 (63%) were female (mean ± SD: age 66.3 ± 10.6). SMI was 41.7 ± 8.0 cm2/m2 in females and 51.2 ± 10.8 cm2/m2 in males. Based on SMI, 40% of females and 55% of males were classified as sarcopenic. BMD was 163.2 ± 38.3 mg/cm3 in females and 164.1 ± 35.4 mg/cm3 in males, with 41% of females and 33% of males classified as osteopenic. Prevalence of both conditions (osteosarcopenia) was similar between females (21%) and males (22%). Incidence of low SMI and BMD increased with age. Sarcopenic individuals were less likely to sustain a MAIS 2+ thorax injury and had longer ICU stays. Osteopenic individuals were more likely to sustain upper extremity injuries and fractures, and were less likely to be discharged to a rehabilitation facility. Osteosarcopenic individuals were less likely to be ventilated or admitted to the ICU but tended to spend more time on the ventilator if placed on one.Conclusions: Osteosarcopenia was not associated with any injury outcomes, but sarcopenia was associated with thoracic injury and osteopenia was associated with upper extremity injury incidence. Sarcopenia was only associated with ICU length of stay, while osteopenia was only associated with discharge destination. Osteosarcopenia was associated with likelihood of being ventilated, being admitted to the ICU, and with increased length of ventilation.
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Affiliation(s)
- William Armstrong
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Ave., Winston-Salem, NC 27101, USA
| | - Casey Costa
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Ave., Winston-Salem, NC 27101, USA
| | - Luis Poveda
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Ave., Winston-Salem, NC 27101, USA
| | - Anna N. Miller
- Department of Orthopedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 S. Euclid Ave, St. Louis, MO 63110
| | - Alexander Ambrosini
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Ave., Winston-Salem, NC 27101, USA
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, 525 Vine St., Winston-Salem, NC 27101, USA
| | - Bahram Kiani
- Department of Radiology, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157
| | - R. Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157
| | - Joel D. Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Ave., Winston-Salem, NC 27101, USA
| | - Ashley A. Weaver
- Department of Biomedical Engineering, Wake Forest School of Medicine, 575 N. Patterson Ave., Winston-Salem, NC 27101, USA
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13
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Schieffer S, Costa C, Gawdi R, Devane K, Ronning IN, Hartka T, Martin RS, Kiani B, Miller AN, Hsu FC, Stitzel JD, Weaver AA. Body mass index influence on lap belt position and abdominal injury in frontal motor vehicle crashes. Traffic Inj Prev 2022; 23:494-499. [PMID: 36037019 DOI: 10.1080/15389588.2022.2113782] [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: 02/22/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE As obesity rates climb, it is important to study its effects on motor vehicle safety due to differences in restraint interaction and biomechanics. Previous studies have shown that an abdominal seatbelt sign (referred hereafter as seatbelt sign) sustained from motor vehicle crashes (MVCs) is associated with abdominal trauma when located above the anterior superior iliac spine (ASIS). This study investigates whether placement of the lap belt causing a seatbelt sign is associated with abdominal organ injury in occupants with increased body mass index (BMI). We hypothesized that higher BMI would be associated with a higher incidence of superior placement of the lap belt to the ASIS level, and a higher incidence of abdominal organ injury. METHODS A retrospective data analysis was performed using 230 cases that met inclusion criteria (belted occupant in a frontal collision that sustained at least one abdominal injury) from the Crash Injury Research and Engineering Network (CIREN) database. Computed tomography (CT) scans were rendered to visualize fat stranding to determine the presence of a seatbelt sign. 146 positive seatbelt signs were visualized. ASIS level was measured by adjusting the transverse slice of the CT to the visualized ASIS level, which was used to determine seatbelt sign location as superior, on, or inferior to the ASIS. RESULTS Obese occupants had a significantly higher incidence of superior belt placement (52%) vs on-ASIS placement (24%) compared to their normal (27% vs 67%) BMI counterparts (p < 0.001). Notable trends included obese occupants with superior placement having less abdominal organ injury incidence than those with on-ASIS belt placement (42% superior placement vs 55% on-ASIS). In non-obese occupants, there was a higher incidence of abdominal organ injury with superior lap belt placement compared to on-ASIS placement counterparts (Normal BMI: 62% vs 41%, Overweight: 57% vs 43%). CONCLUSIONS In CIREN occupants with abdominal injury, those with obesity are more prone to positioning the lap belt superior to the ASIS, though the impact on abdominal injury incidence remains a key point for continued exploration into how occupant BMI affects crash safety and belt design.
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Affiliation(s)
- Sydney Schieffer
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Casey Costa
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Rohin Gawdi
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karan Devane
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Isaac N Ronning
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas Hartka
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - R Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Bahram Kiani
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Martin RS, Lester ELW, Ross SW, Davis KA, Tres Scherer LR, Minei JP, Staudenmayer KL. Value in acute care surgery, Part 1: Methods of quantifying cost. J Trauma Acute Care Surg 2022; 92:e1-e9. [PMID: 34570063 DOI: 10.1097/ta.0000000000003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.
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Affiliation(s)
- R Shayn Martin
- From the Department of Surgery (R.S.M.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Surgery (E.L.W.L.), University of Alberta, Edmonton, Alberta, Canada; Department of Surgery (S.W.R.), Atrium Health, Charlotte, NC; Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; North Star Pediatric Surgery (L.R.T.S.), Carmel, Indiana; Department of Surgery (J.P.M.), University of Texas Southwestern Medical School, Dallas, Texas; and Department of Surgery (K.L.S.), Stanford School of Medicine, Stanford, California
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15
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Costa C, Gaewsky JP, Stitzel JD, Gayzik FS, Hsu FC, Martin RS, Miller AN, Weaver AA. Development and implementation of a time- and computationally-efficient methodology for reconstructing real-world crashes using finite element modeling to improve crash injury research investigations. Comput Methods Biomech Biomed Engin 2021; 25:1332-1349. [PMID: 34866520 DOI: 10.1080/10255842.2021.2009469] [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: 10/19/2022]
Abstract
Eleven Crash Injury Research and Engineering Network (CIREN) frontal crashes were reconstructed using a novel, time-efficient methodology involving a simplified vehicle model. Kinematic accuracy was assessed using novel kinematic scores between 0-1 and chest injury was assessed using literature-defined injury metric time histories. The average kinematic score across all simulations was 0.87, indicating good kinematic accuracy. Time histories for chest compression, rib strain, shoulder belt force, and steering column force discerned the most causative components of chest injury in all cases. Abbreviated Injury Scale (AIS) 2+ and AIS 3+ chest injury risk functions using belt force identified chest injury with 81.8% success.
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Affiliation(s)
- Casey Costa
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Elemance, LLC, Clemmons, North Carolina, USA
| | - F Scott Gayzik
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Elemance, LLC, Clemmons, North Carolina, USA
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - R Shayn Martin
- Department of Trauma Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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16
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Schieffer S, Costa C, Hartka T, Stitzel JD, Shayn Martin R, Kiani B, Miller AN, Weaver AA. The relationship of body mass index, belt placement, and abdominopelvic injuries in motor vehicle crashes: A Crash Injury Research and Engineering Network (CIREN) study. Traffic Inj Prev 2021; 22:S146-S148. [PMID: 34663141 DOI: 10.1080/15389588.2021.1982596] [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] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Obesity has important implications for motor vehicle safety due to altered crash injury responses from increased mass and improper seatbelt placement. Abdominal seatbelt signs (ASBS) above the anterior superior iliac spine (ASIS) in motor vehicle crashes (MVCs) often correlate with abdominopelvic trauma. We investigated the relationship of body mass index (BMI), lap belt placement, and the incidence of abdominopelvic injury using computed tomography (CT) evaluation for subcutaneous ASBS mark and its location relative to the ASIS. METHODS A retrospective analysis of 235 Crash Injury Research and Engineering Network (CIREN) cases and their associated abdominal injuries was conducted. CT Scans were analyzed to visualize fat stranding. 150 positive ASBS were found and their ASBS mark location was classified as superior, on, or inferior to the ASIS. RESULTS Obese occupants had a higher incidence rate of belt placement superior to the ASIS, and occupants with normal BMI had a higher incidence of proper belt placement (p < 0.05). Trends of interest developed, notably that non-obese occupants with superior belt placement had increased incidence of internal abdominopelvic organ injury compared to those with proper belt placement (Normal BMI: 53.3% superior vs 39.4% On-ASIS, Overweight: 47.8% superior vs 34.7% On-ASIS). CONCLUSIONS Utilizing CT scans to confirm ASBS and lap belt placement relative to the ASIS, superior belt placement above the ASIS was associated with elevated BMI and a trend of increasing incidence of internal abdominopelvic organ injury.
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Affiliation(s)
- Sydney Schieffer
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Casey Costa
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas Hartka
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - R Shayn Martin
- Department of Trauma Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Bahram Kiani
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Garland-Kledzik M, Gaffley M, Crouse D, Conrad C, Miller P, Martin RS. Effects of a More Restrictive Transfusion Trigger in Trauma Patients. Am Surg 2019; 85:409-413. [PMID: 31043203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Since the Transfusion Requirements in Critical Care trial, studies have shown that acutely ill patients can drift as a low as 5 g/dL. This study reviews a transfusion trigger change to 6.5 g/dL, which we hypothesize will conserve resources and improve quality of care. This is a retrospective chart review at an urban Level I trauma center from January through December 2015 after our trauma service changed the transfusion trigger from 7 to 6.5 g/dL. Outcomes in patients before (TT7) and after (TT6.5) the change in transfusion threshold were then compared. One hundred thirty-one discrete patients were included in this trial, with 285 instances of a hemoglobin of 7 g/dL or less and 178 transfusions. Seventy-two patients were before the change in threshold and 59 after. There was no change in length of hospital stay, ICU stay, ventilator days, mortality, and organ system failure after change in the transfusion threshold. After initiation of a more conservative threshold, 72 units of blood were saved. Decreased transfusion threshold was associated with no worse outcomes associated with decreased resource utilization.
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18
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Abstract
Since the Transfusion Requirements in Critical Care trial, studies have shown that acutely ill patients can drift as a low as 5 g/dL. This study reviews a transfusion trigger change to 6.5 g/dL, which we hypothesize will conserve resources and improve quality of care. This is a retrospective chart review at an urban Level I trauma center from January through December 2015 after our trauma service changed the transfusion trigger from 7 to 6.5 g/dL. Outcomes in patients before (TT7) and after (TT6.5) the change in transfusion threshold were then compared. One hundred thirty-one discrete patients were included in this trial, with 285 instances of a hemoglobin of 7 g/dL or less and 178 transfusions. Seventy-two patients were before the change in threshold and 59 after. There was no change in length of hospital stay, ICU stay, ventilator days, mortality, and organ system failure after change in the transfusion threshold. After initiation of a more conservative threshold, 72 units of blood were saved. Decreased transfusion threshold was associated with no worse outcomes associated with decreased resource utilization.
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Affiliation(s)
| | - Michaela Gaffley
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David Crouse
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Collin Conrad
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Preston Miller
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - R. Shayn Martin
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
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19
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Doud AN, Schoell SL, Talton JW, Barnard RT, Petty JK, Meredith JW, Martin RS, Stitzel JD, Weaver AA. Predicting Pediatric Patients Who Require Care at a Trauma Center: Analysis of Injuries and Other Factors. J Am Coll Surg 2017; 226:70-79.e8. [PMID: 29174350 DOI: 10.1016/j.jamcollsurg.2017.09.018] [Citation(s) in RCA: 5] [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] [Received: 07/10/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Triage decision correctness for children in motor vehicle crashes can be affected by occult injuries. There is a need to develop a transfer score (TS) metric for children that can help quantify the likelihood that an injury is present that would require transfer to a trauma center (TC) from a non-TC, and improve triage decision making. Ultimately, the TS metric might be useful in an advanced automatic crash notification algorithm, which uses vehicle telemetry data to predict the risk of serious injury after a motor vehicle crash using an approach that includes metrics to describe injury severity, time sensitivity, and predictability. STUDY DESIGN Transfer score metrics were calculated in 4 pediatric age groups (0 to 4, 5 to 9, 10 to 14, 15 to 18 years) for the most frequent motor vehicle crash injuries using the proportions of children transferred to a TC or managed at a non-TC using the National Inpatient Sample years 1998 to 2007. To account for the maximum Abbreviated Injury Scale (MAIS) injury, a co-injury adjusted transfer score (TSMAIS) was calculated. The TS and TSMAIS range from 0 to 1, with 1 indicating highly transferred injuries. RESULTS Injuries in younger patients were more likely to be transferred (median TS 0.48, 0.35, 0.25, and 0.23 for 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years, respectively). Injuries more likely to be transferred in younger children occurred in the thorax and abdomen. Regardless of age, spine (median TSMAIS 0.59), head (median TSMAIS 0.48), and thorax (median TSMAIS 0.46) injuries had the highest frequency for transfer. CONCLUSIONS The TS metrics quantitatively describe age-specific transfer practices for children with particular injuries. This information can be useful in advanced automatic crash notification systems to alert first responders to the possibility of occult injuries and reduce undertriage of commonly missed injuries.
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Affiliation(s)
- Andrea N Doud
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - Samantha L Schoell
- Wake Forest University School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Jennifer W Talton
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ryan T Barnard
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - John K Petty
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - J Wayne Meredith
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - R Shayn Martin
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - Joel D Stitzel
- Wake Forest University School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Ashley A Weaver
- Wake Forest University School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC.
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20
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Sparks JL, Crouch DL, Sobba K, Evans D, Zhang J, Johnson JE, Saunders I, Thomas J, Bodin S, Tonidandel A, Carter J, Westcott C, Martin RS, Hildreth A. Association of a Surgical Task During Training With Team Skill Acquisition Among Surgical Residents: The Missing Piece in Multidisciplinary Team Training. JAMA Surg 2017; 152:818-825. [PMID: 28538983 DOI: 10.1001/jamasurg.2017.1085] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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
Importance The human patient simulators that are currently used in multidisciplinary operating room team training scenarios cannot simulate surgical tasks because they lack a realistic surgical anatomy. Thus, they eliminate the surgeon's primary task in the operating room. The surgical trainee is presented with a significant barrier when he or she attempts to suspend disbelief and engage in the scenario. Objective To develop and test a simulation-based operating room team training strategy that challenges the communication abilities and teamwork competencies of surgeons while they are engaged in realistic operative maneuvers. Design, Setting, and Participants This pre-post educational intervention pilot study compared the gains in teamwork skills for midlevel surgical residents at Wake Forest Baptist Medical Center after they participated in a standardized multidisciplinary team training scenario with 3 possible levels of surgical realism: (1) SimMan (Laerdal) (control group, no surgical anatomy); (2) "synthetic anatomy for surgical tasks" mannequin (medium-fidelity anatomy), and (3) a patient simulated by a deceased donor (high-fidelity anatomy). Interventions Participation in the simulation scenario and the subsequent debriefing. Main Outcomes and Measures Teamwork competency was assessed using several instruments with extensive validity evidence, including the Nontechnical Skills assessment, the Trauma Management Skills scoring system, the Crisis Resource Management checklist, and a self-efficacy survey instrument. Participant satisfaction was assessed with a Likert-scale questionnaire. Results Scenario participants included midlevel surgical residents, anesthesia providers, scrub nurses, and circulating nurses. Statistical models showed that surgical residents exposed to medium-fidelity simulation (synthetic anatomy for surgical tasks) team training scenarios demonstrated greater gains in teamwork skills compared with control groups (SimMan) (Nontechnical Skills video score: 95% CI, 1.06-16.41; Trauma Management Skills video score: 95% CI, 0.61-2.90) and equivalent gains in teamwork skills compared with high-fidelity simulations (deceased donor) (Nontechnical Skills video score: 95% CI, -8.51 to 6.71; Trauma Management Skills video score: 95% CI, -1.70 to 0.49). Conclusions and Relevance Including a surgical task in operating room team training significantly enhanced the acquisition of teamwork skills among midlevel surgical residents. Incorporating relatively inexpensive, medium-fidelity synthetic anatomy in human patient simulators was as effective as using high-fidelity anatomies from deceased donors for promoting teamwork skills in this learning group.
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Affiliation(s)
| | | | - Kathryn Sobba
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Douglas Evans
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | | | | | - Ian Saunders
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | - John Thomas
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Sarah Bodin
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | | | - Jeff Carter
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Carl Westcott
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | - R Shayn Martin
- Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Amy Hildreth
- Wake Forest Baptist Health, Winston Salem, North Carolina
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21
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Miller PR, Chang MC, Hoth JJ, Hildreth AN, Wolfe SQ, Gross JL, Martin RS, Carter JE, Meredith JW, D'Agostino R. Predicting Mortality and Independence at Discharge in the Aging Traumatic Brain Injury Population Using Data Available at Admission. J Am Coll Surg 2017; 224:680-685. [PMID: 28263858 DOI: 10.1016/j.jamcollsurg.2016.12.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients. STUDY DESIGN Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes. RESULTS Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p < 0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality). CONCLUSIONS These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.
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Affiliation(s)
- Preston R Miller
- Department of Surgery, Wake Forest University, Winston-Salem, NC.
| | - Michael C Chang
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - J Jason Hoth
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Amy N Hildreth
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC
| | - Jessica L Gross
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - R Shayn Martin
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Jeffrey E Carter
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - J Wayne Meredith
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Ralph D'Agostino
- Wake Forest Health Science Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC
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22
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Petri MA, Martin RS, Scheinberg MA, Furie RA. Assessments of fatigue and disease activity in patients with systemic lupus erythematosus enrolled in the Phase 2 clinical trial with blisibimod. Lupus 2016; 26:27-37. [PMID: 27353505 DOI: 10.1177/0961203316654767] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 01/08/2016] [Accepted: 04/20/2016] [Indexed: 11/15/2022]
Abstract
This report evaluates the effects of blisibimod (A-623, AMG 623), a potent and selective inhibitor of B-cell activating factor (BAFF), on patient-reported fatigue and disease activity in the Phase 2b PEARL-SC clinical trial in patients with systemic lupus erythematosus (SLE). A total of 547 individuals who met the American College of Rheumatology (ACR) classification criteria for SLE, were positive for anti-double-stranded DNA or antinuclear antibodies, and had a Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score ≥6 at baseline, were randomized to receive placebo or blisibimod for at least 24 weeks. Patient self-reported fatigue was evaluated using the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale, and disease activity was evaluated using Physician's Global Assessment, SELENA-SLEDAI, and British Isles Lupus Assessment Group Score. Statistically significant improvements in FACIT-Fatigue score were observed among individuals randomized to blisibimod, especially in the 200 mg QW group where favorable effects on disease activity with blisibimod compared to placebo were observed as early as Week 8. The mean improvement from baseline of 6.9 points at Week 24, compared with 4.4 points with placebo, met the criteria for minimal clinically important improvement difference defined for patients with SLE. Despite concomitant improvements in FACIT-Fatigue, SLE Responder Index (SRI) and SLE biomarkers (reported previously), FACIT-Fatigue score correlated only weakly with disease activity. While poor correlation between fatigue and disease activity is not new, the observation that correlation remains poor despite concurrent population improvements in disease and fatigue brings a new facet to our understanding of SLE.
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Affiliation(s)
- M A Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R S Martin
- Medical Sciences, Anthera Pharmaceuticals Inc, Hayward, CA, USA
| | - M A Scheinberg
- Clinical Research Center, Hospital Abreu Sodré-AACD, São Paulo, Brazil
| | - R A Furie
- Division of Rheumatology and Allergy-Clinical Immunology, North Shore-Long Island Jewish Health System, Great Neck, NY, USA
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Stitzel JD, Weaver AA, Talton JW, Barnard RT, Schoell SL, Doud AN, Martin RS, Meredith JW. An Injury Severity-, Time Sensitivity-, and Predictability-Based Advanced Automatic Crash Notification Algorithm Improves Motor Vehicle Crash Occupant Triage. J Am Coll Surg 2016; 222:1211-1219.e6. [PMID: 27178370 DOI: 10.1016/j.jamcollsurg.2016.03.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/26/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Advanced Automatic Crash Notification algorithms use vehicle telemetry measurements to predict risk of serious motor vehicle crash injury. The objective of the study was to develop an Advanced Automatic Crash Notification algorithm to reduce response time, increase triage efficiency, and improve patient outcomes by minimizing undertriage (<5%) and overtriage (<50%), as recommended by the American College of Surgeons. STUDY DESIGN A list of injuries associated with a patient's need for Level I/II trauma center treatment known as the Target Injury List was determined using an approach based on 3 facets of injury: severity, time sensitivity, and predictability. Multivariable logistic regression was used to predict an occupant's risk of sustaining an injury on the Target Injury List based on crash severity and restraint factors for occupants in the National Automotive Sampling System - Crashworthiness Data System 2000-2011. The Advanced Automatic Crash Notification algorithm was optimized and evaluated to minimize triage rates, per American College of Surgeons recommendations. RESULTS The following rates were achieved: <50% overtriage and <5% undertriage in side impacts and 6% to 16% undertriage in other crash modes. Nationwide implementation of our algorithm is estimated to improve triage decisions for 44% of undertriaged and 38% of overtriaged occupants. Annually, this translates to more appropriate care for >2,700 seriously injured occupants and reduces unnecessary use of trauma center resources for >162,000 minimally injured occupants. CONCLUSIONS The algorithm could be incorporated into vehicles to inform emergency personnel of recommended motor vehicle crash triage decisions. Lower under- and overtriage was achieved, and nationwide implementation of the algorithm would yield improved triage decision making for an estimated 165,000 occupants annually.
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Affiliation(s)
- Joel D Stitzel
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC.
| | - Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Jennifer W Talton
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ryan T Barnard
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Samantha L Schoell
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Andrea N Doud
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - R Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - J Wayne Meredith
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
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Schoell SL, Doud AN, Weaver AA, Barnard RT, Meredith JW, Stitzel JD, Martin RS. Predicting patients that require care at a trauma center: analysis of injuries and other factors. Injury 2015; 46:558-63. [PMID: 25541419 DOI: 10.1016/j.injury.2014.11.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [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: 09/04/2014] [Revised: 11/21/2014] [Accepted: 11/29/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The detection of occult or unpredictable injuries in motor vehicle crashes (MVCs) is crucial in correctly triaging patients and thus reducing fatalities. The purpose of the study was to develop a metric that indicates the likelihood that an injury sustained in a MVC would require management at a Level I/II trauma centre (TC) versus a non-trauma centre (non-TC). METHODS Transfer Scores (TSs) were computed for 240 injuries that comprise the top 95% most frequently occurring injuries in the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) with an Abbreviated Injury Scale (AIS) severity of 2 or greater. A TS for each injury was computed using the proportions of patients involved in a MVC from the National Inpatient Sample (NIS) that were transferred to a TC or managed at a non-TC. Similarly, a TSMAIS that excludes patients with higher severity co-injuries was calculated using the proportion of patients with a maximum AIS (MAIS) equal to the AIS severity of a given injury. RESULTS The results indicated for injuries of a given AIS severity, body region, and injury type, there were large variations in the TSMAIS. Overall results demonstrated higher TSMAIS values when injuries were internal, haemorrhagic, intracranial or of moderate severity (AIS 3-5). Specifically, injuries to the head possessed a TSMAIS that ranged from 0.000 to 0.889, with head injuries of AIS 3-5 severities being the most likely to be transferred. DISCUSSION AND CONCLUSIONS The analysis indicated that the TSMAIS is not solely correlated with AIS severity and therefore it captures other important aspects of injury such as predictability and trauma system capabilities. The TS and TSMAIS can be useful in advanced automatic crash notification (AACN) research for the detection of highly unpredictable injuries in MVCs that require direct transport to a TC.
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Affiliation(s)
- Samantha L Schoell
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA; Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Andrea N Doud
- Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Ashley A Weaver
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA; Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Ryan T Barnard
- Wake Forest University, Health Sciences, Medical Center Boulevard, Winston-Salem, NC, USA.
| | - J Wayne Meredith
- Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Joel D Stitzel
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA; Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - R Shayn Martin
- Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Schoell SL, Doud AN, Weaver AA, Talton JW, Barnard RT, Martin RS, Meredith JW, Stitzel JD. Development of a Time Sensitivity Score for Frequently Occurring Motor Vehicle Crash Injuries. J Am Coll Surg 2015; 220:305-312.e3. [DOI: 10.1016/j.jamcollsurg.2014.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/13/2014] [Indexed: 10/24/2022]
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Calabrese S, D'Alessandro W, Bellomo S, Brusca L, Martin RS, Saiano F, Parello F. Characterization of the Etna volcanic emissions through an active biomonitoring technique (moss-bags): part 1--major and trace element composition. Chemosphere 2015; 119:1447-1455. [PMID: 25262949 DOI: 10.1016/j.chemosphere.2014.08.086] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 10/11/2013] [Revised: 08/22/2014] [Accepted: 08/31/2014] [Indexed: 06/03/2023]
Abstract
Active biomonitoring using moss-bags was applied to an active volcanic environment for the first time. Bioaccumulation originating from atmospheric deposition was evaluated by exposing mixtures of washed and air-dried mosses (Sphagnum species) at 24 sites on Mt. Etna volcano (Italy). Concentrations of major and a large suite of trace elements were analysed by inductively coupled mass and optical spectrometry (ICP-MS and ICP-OES) after total acid digestion. Of the 49 elements analysed those which closely reflect summit volcanic emissions were S, Tl, Bi, Se, Cd, As, Cu, B, Na, Fe, Al. Enrichment factors and cluster analysis allowed clear distinction between volcanogenic, geogenic and anthropogenic inputs that affect the local atmospheric deposition. This study demonstrates that active biomonitoring with moss-bags is a suitable and robust technique for implementing inexpensive monitoring in scarcely accessible and harsh volcanic environments, giving time-averaged quantitative results of the local exposure to volcanic emissions. This task is especially important in the study area because the summit area of Mt. Etna is visited by nearly one hundred thousand tourists each year who are exposed to potentially harmful volcanic emissions.
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Affiliation(s)
- S Calabrese
- Dipartimento di Scienze della Terra e del Mare (DiSTeM), Università degli Studi di Palermo, via Archirafi 36, 90123 Palermo, Italy.
| | - W D'Alessandro
- Istituto Nazionale di Geofisica e Vulcanologia (INGV), Sezione di Palermo, via La Malfa 153, 90146 Palermo, Italy
| | - S Bellomo
- Istituto Nazionale di Geofisica e Vulcanologia (INGV), Sezione di Palermo, via La Malfa 153, 90146 Palermo, Italy
| | - L Brusca
- Istituto Nazionale di Geofisica e Vulcanologia (INGV), Sezione di Palermo, via La Malfa 153, 90146 Palermo, Italy
| | - R S Martin
- Department of Geography, University of Cambridge, CB2 3EN Cambridge, UK
| | - F Saiano
- Dipartimento Scienze Agrarie e Forestali (SAF), Università degli Studi di Palermo, viale delle scienze, 90128 Palermo, Italy
| | - F Parello
- Dipartimento di Scienze della Terra e del Mare (DiSTeM), Università degli Studi di Palermo, via Archirafi 36, 90123 Palermo, Italy
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Furie RA, Leon G, Thomas M, Petri MA, Chu AD, Hislop C, Martin RS, Scheinberg MA. A phase 2, randomised, placebo-controlled clinical trial of blisibimod, an inhibitor of B cell activating factor, in patients with moderate-to-severe systemic lupus erythematosus, the PEARL-SC study. Ann Rheum Dis 2014; 74:1667-75. [DOI: 10.1136/annrheumdis-2013-205144] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/23/2014] [Indexed: 11/04/2022]
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Miller PR, Chang MC, Hoth JJ, Mowery NT, Hildreth AN, Martin RS, Holmes JH, Meredith JW, Requarth JA. Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success Rate Is Significantly Improved. J Am Coll Surg 2014; 218:644-8. [DOI: 10.1016/j.jamcollsurg.2014.01.040] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/09/2014] [Indexed: 11/15/2022]
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Barnard RT, Loftis KL, Martin RS, Stitzel JD. Development of a robust mapping between AIS 2+ and ICD-9 injury codes. Accid Anal Prev 2013; 52:133-143. [PMID: 23333320 DOI: 10.1016/j.aap.2012.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/07/2012] [Accepted: 11/30/2012] [Indexed: 06/01/2023]
Abstract
Motor vehicle crashes result in millions of injuries and thousands of deaths each year in the United States. While most crash research datasets use Abbreviated Injury Scale (AIS) codes to identify injuries, most hospital datasets use the International Classification of Diseases, version 9 (ICD-9) codes. The objective of this research was to establish a one-to-one mapping between AIS and ICD-9 codes for use with motor vehicle crash injury research. This paper presents results from investigating different mapping approaches using the most common AIS 2+ injuries from the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS). The mapping approaches were generated from the National Trauma Data Bank (NTDB) (428,637 code pairs), ICDMAP (2500 code pairs), and the Crash Injury Research and Engineering Network (CIREN) (4125 code pairs). Each approach may pair given AIS code with more than one ICD-9 code (mean number of pairs per AIS code: NTDB=211, ICDMAP=7, CIREN=5), and some of the potential pairs are unrelated. The mappings were evaluated using two comparative metrics coupled with qualitative inspection by an expert physician. Based on the number of false mappings and correct pairs, the best mapping was derived from CIREN. AIS and ICD-9 codes in CIREN are both manually coded, leading to more proper mappings between the two. Using the mapping presented herein, data from crash and hospital datasets can be used together to better understand and prevent motor vehicle crash injuries in the future.
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Affiliation(s)
- Ryan T Barnard
- Health Sciences, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Bowton DL, Hite RD, Martin RS, Sherertz R. The impact of hospital-wide use of a tapered-cuff endotracheal tube on the incidence of ventilator-associated pneumonia. Respir Care 2013; 58:1582-7. [PMID: 23431308 DOI: 10.4187/respcare.02278] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aspiration of colonized oropharyngeal secretions is a major factor in the pathogenesis of ventilator-associated pneumonia (VAP). A tapered-cuff endotracheal tube (ETT) has been demonstrated to reduce aspiration around the cuff. Whether these properties are efficacious in reducing VAP is not known. METHODS This 2-period, investigator-initiated observational study was designed to assess the efficacy of a tapered-cuff ETT to reduce the VAP rate. All intubated, mechanically ventilated patients over the age of 18 were included. During the baseline period a standard, barrel-shaped-cuff ETT (Mallinckrodt Hi-Lo) was used. All ETTs throughout the hospital were then replaced with a tapered-cuff ETT (TaperGuard). The primary outcome variable was the incidence of VAP per 1,000 ventilator days. RESULTS We included 2,849 subjects, encompassing 15,250 ventilator days. The mean ± SD monthly VAP rate was 3.29 ± 1.79/1,000 ventilator days in the standard-cuff group and 2.77 ± 2.00/1,000 ventilator days in the tapered-cuff group (P = .65). While adherence to the VAP prevention bundle was high throughout the study, bundle adherence was significantly higher during the standard-cuff period (96.5 ± 2.7%) than in the tapered-cuff period (90.3 ± 3.5%, P = .01). CONCLUSIONS In the setting of a VAP rate very near the average of ICUs in the United States, and where there was high adherence to a VAP prevention bundle, the use of a tapered-cuff ETT was not associated with a reduction in the VAP rate.
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Weaver AA, Barnard RT, Kilgo PD, Martin RS, Stitzel JD. Mortality-based Quantification of Injury Severity for Frequently Occurring Motor Vehicle Crash Injuries. Ann Adv Automot Med 2013; 57:235-246. [PMID: 24406961 PMCID: PMC3861825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The study purpose was to develop mortality-based metrics of injury severity for frequent motor vehicle crash (MVC) injuries. Injury severity was quantified with mortality-based metrics for 240 injuries comprising the top 95% most frequently occurring AIS 2+ injuries in the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) 2000-2011. Mortality risk ratios (MRRs) were computed by dividing the number of deaths by occurrences for each of the 240 injuries using National Trauma Data Bank Research Data System (NTDB-RDS) MVC cases. MRRMAIS was computed using only patients with a maximum AIS (MAIS) equal to the AIS severity of a given injury. Each injury had an associated MRR and MRRMAIS which ranged from zero (0% mortality representing low severity) to one (100% or universal mortality representing high severity). Injuries with higher MRR and MRRMAIS values are considered more severe because they resulted in a greater proportion of deaths among injured patients. The results illustrated an overall positive trend between AIS severity and the MRR and MRRMAIS values as expected, but showed large variations in MRR and MRRMAIS for some injuries of the same AIS severity. Mortality differences up to 83% (MRR) and 54% (MRRMAIS) were observed for injuries of the same AIS severity. The MRR-based measures of injury severity indicate that some lower AIS severity injuries may result in as many deaths as higher AIS severity injuries. This data-driven determination of injury severity using MRR and MRRMAIS provides a supplement or an alternative to AIS severity classification.
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Affiliation(s)
- Ashley A. Weaver
- Wake Forest University School of Medicine, Winston-Salem, NC
- Virginia Tech – Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Ryan T. Barnard
- Wake Forest University Public Health Sciences, Winston-Salem, NC
| | | | - R. Shayn Martin
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Joel D. Stitzel
- Wake Forest University School of Medicine, Winston-Salem, NC
- Virginia Tech – Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
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Hayes AR, Gayzik FS, Moreno DP, Martin RS, Stitzel JD. Abdominal Organ Location, Morphology, and Rib Coverage for the 5(th), 50(th), and 95(th) Percentile Males and Females in the Supine and Seated Posture using Multi-Modality Imaging. Ann Adv Automot Med 2013; 57:111-122. [PMID: 24406951 PMCID: PMC3861817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The purpose of this study was to use data from a multi-modality image set of males and females representing the 5(th), 50(th), and 95(th) percentile (n=6) to examine abdominal organ location, morphology, and rib coverage variations between supine and seated postures. Medical images were acquired from volunteers in three image modalities including Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and upright MRI (uMRI). A manual and semi-automated segmentation method was used to acquire data and a registration technique was employed to conduct a comparative analysis between abdominal organs (liver, spleen, and kidneys) in both postures. Location of abdominal organs, defined by center of gravity movement, varied between postures and was found to be significant (p=0.002 to p=0.04) in multiple directions for each organ. In addition, morphology changes, including compression and expansion, were seen in each organ as a result of postural changes. Rib coverage, defined as the projected area of the ribs onto the abdominal organs, was measured in frontal, lateral, and posterior projections, and also varied between postures. A significant change in rib coverage between postures was measured for the spleen and right kidney (p=0.03 and p=0.02). The results indicate that posture affects the location, morphology and rib coverage area of abdominal organs and these implications should be noted in computational modeling efforts focused on a seated posture.
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Affiliation(s)
- Ashley R Hayes
- Wake Forest School of Medicine VT-WFU School of Biomedical Engineering and Sciences
| | - F Scott Gayzik
- Wake Forest School of Medicine VT-WFU School of Biomedical Engineering and Sciences
| | - Daniel P Moreno
- Wake Forest School of Medicine VT-WFU School of Biomedical Engineering and Sciences
| | | | - Joel D Stitzel
- Wake Forest School of Medicine VT-WFU School of Biomedical Engineering and Sciences
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Becher RD, Hoth JJ, Neff LP, Rebo JJ, Martin RS, Miller PR. Multidrug-resistant pathogens and pneumonia: comparing the trauma and surgical intensive care units. Surg Infect (Larchmt) 2011; 12:267-72. [PMID: 21524206 DOI: 10.1089/sur.2010.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND As acute care surgery evolves, more trauma surgeons are caring for critically ill general surgery as well as trauma patients. However, these two populations are unique, and infectious complications may need to be addressed differently, as the causative organisms may not be the same in the two groups. To study this, we evaluated ventilator-associated (VAP) and hospital-acquired (HAP) pneumonia in the trauma (TICU) and general surgical (SICU) intensive care units to investigate differences in the causative pathogens. Our hypothesis was that SICU patients would have a higher incidence of multi-drug-resistant (MDR) organisms causing VAP/HAP, possibly contributing to inadequate empiric antibiotic (IEA) coverage. METHODS Retrospective review of 116 patients admitted with VAP or HAP over a one-year period to the TICU (n = 72) or SICU (n = 44) at a tertiary medical center. Culture was followed by initiation of empiric antibiotics on the basis of an antibiotic algorithm derived from trauma patients. Demographics, illness, and pneumonia characteristics were assessed; MDR organisms were identified. RESULTS Multi-drug-resistant organisms caused 30.6% of first pneumonias in the TICU vs. 65.9% in the SICU (p = 0.0002). Subsequent pneumonias were seen in 31.8% of SICU patients and 16.7% of TICU patients (p = 0.0576). Inadequate empiric antibiotic coverage was documented in 38.6% of SICU pneumonias vs. 26.4% in the TICU (p = 0.12). CONCLUSIONS Multiply-resistant pathogens cause a significantly greater number of VAP/HAPs in the SICU than in the TICU. Associated with this, when using an antibiotic algorithm based on TICU bacterial pathogens, there is a trend toward a greater likelihood of subsequent pneumonias and toward more IEA coverage in the SICU population compared with TICU patients. Our results indicate that these distinct patient populations have different pathogens causing VAP/HAP and affirm the necessity for population-specific algorithms to tailor empiric coverage for presumed VAP/HAP.
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Affiliation(s)
- Robert D Becher
- Acute Care Surgery Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Loftis KL, Pranikoff T, Anthony EY, Meredith JW, Martin RS, Stitzel JD. Pediatric occupants, restraint use, and injuries in motor vehicle crashes - biomed 2011. Biomed Sci Instrum 2011; 47:94-99. [PMID: 21525603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pediatric occupants are vulnerable in motor vehicle crashes (MVCs), and alternative restraints have been developed for their protection. This study sought to characterize injuries in MVCs for pediatric occupants and to identify scenarios that may benefit from enhanced vehicle safety. Using the NASS-CDS database (2000-2008), pediatric occupants (< 19 yr old) were characterized by their age and injuries to look at national averages in MVCs. There were over 14 million pediatric injuries and non-injured occupants in weighted NASS-CDS (out of over 70 million total). Of these pediatric cases, 60% sustained injuries, which was comparable to the percentage of all occupants injured (65%). Six percent of NASS-CDS pediatric occupants had AIS 2+ injuries, which is the injury inclusion criteria for CIREN pediatric cases. CIREN was used to investigate pediatric occupants and injuries resulting from incorrect positioning and restraints according to NHTSA suggestions. Results indicated that many injured pediatric occupants were not properly restrained, with over 100 in the front row of the vehicle under 13 years of age. There were also over 200 CIREN pediatric occupants under 4 9 that were not seated in a child safety seat (CSS). The most frequently injured body region was the face, followed by the head and lower extremity. Eighty-six percent of head injuries and 82% of spinal injuries were AIS 2+. This study supports prior findings that demonstrate a need for enhanced public awareness for proper CSS use to reduce pediatric injuries in the future.
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Affiliation(s)
- Kathryn L Loftis
- Virginia-Tech - Wake Forest University School of Medicine, Winston Salem, North Carolina
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Stitzel JD, Kilgo PD, Weaver AA, Martin RS, Loftis KL, Meredith JW. Age thresholds for increased mortality of predominant crash induced thoracic injuries. Ann Adv Automot Med 2010; 54:41-50. [PMID: 21050590 PMCID: PMC3242540] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The growing elderly population in the United States presents medical, engineering, and legislative challenges in trauma management and prevention. Thoracic injury incidence, morbidity, and mortality increase with age. This study utilized receiver-operator characteristic analysis to identify the quantitative age thresholds associated with increased mortality in common isolated types of thoracic injuries from motor vehicle crashes (MVCs).The subject pool consisted of patients with a single AIS 3+ thorax injury and no injury greater than AIS 2 in any other body region. A logistic regression algorithm was performed for each injury to estimate an age threshold that maximally discriminates between survivors and fatalities. The c-index describing discrimination of the model and odds ratio describing the increased mortality risk associated with being older than the age threshold were computed.Twelve leading thoracic injuries were included in the study: unilateral and bilateral pulmonary contusion (AIS 3/4), hemo/pneumothorax, rib fractures with and without hemo/pneumothorax (AIS 3/4), bilateral flail chest, and thoracic penetrating injury with hemo/pneumothorax. Results are consistent with the traditional age threshold of 55, but were injury-specific. Pulmonary contusions had lower age thresholds compared to rib fractures. Higher severity pulmonary contusions and rib fractures had lower age thresholds compared to lower severity injuries.This study presents the first quantitatively estimated mortality age thresholds for common isolated thoracic injuries. This data provides information on the ideal 'threshold' beyond which age becomes an important factor to patient survival. Results of the current study and future work could lead to improvements in automotive safety design and regulation, automated crash notification, and hospital treatment for the elderly.
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Affiliation(s)
- Joel D Stitzel
- Wake Forest University School of Medicine, Winston-Salem, NC Virginia Tech - Wake Forest University Center for Injury Biomechanics, Blacksburg, VA, Winston-Salem, NC
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Danelson KA, Gayzik FS, Yu MM, Martin RS, Duma SM, Stitzel JD. Bilateral carotid artery injury response in side impact using a vessel model integrated with a human body model. Ann Adv Automot Med 2009; 53:271-279. [PMID: 20184850 PMCID: PMC3256791] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In a far-side crash configuration, the occupant can experience severe excursion from the seat space. Given this challenge, there are research efforts focused on alternate restraints, such as four-point belts. A potential implication of this geometry would be interaction of the belt with the occupant's neck. This study examines the response of the carotid arteries using a Finite Element Model (FEM) in a far-side crash configuration with a reversed three-point restraint. A FEM of the carotid artery and neck fascia was developed and integrated with the Total Human Model for Safety (THUMS) version 1.44. This model was subjected to four test conditions simulating far-side crashes. Load conditions included a low velocity impact of approximately 4 m/s and a higher velocity impact of approximately 10 m/s. For each velocity, the model was restrained with a belt placed low on the neck and a belt placed higher on the neck. Strain data in each element of the carotid arteries was analyzed. The overall response of the vessel was examined to determine locations of high strain values. Low belt placement resulted in more head excursion, stretching the carotid on the non-struck side. High belt placement resulted in compression of the artery on the struck side due to direct loading of the vessel from the belt. Strain values in the carotid artery elements increased with increasing speed of impact. The lower and higher speed tests with a low belt configuration resulted in a maximum principal strains, at maximal belt engagement, of 0.223 and 0.459, respectively. Corresponding values for the high belt configuration were 0.222 and 0.563. In both belt configurations, the non-struck side vessel stretched more than the struck side vessel; however, the non-struck side vessel experienced higher compressive forces. Strain values measured during the simulations can be compared to a value of 0.31 to intimal failure in previous experimental tests. These results quantitatively illustrate the two primary mechanisms of injury to the carotid artery: tension and intima-to-intima contact of the vessel. Based on the study, low belt placement and limiting head excursion is recommended to reduce both stretching and compression of the carotids in side impact.
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Affiliation(s)
- Kerry A Danelson
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Loftis K, Martin RS, Meredith JW, Stitzel J. Investigating methods for determining mismatch in near side vehicle impacts - biomed 2009. Biomed Sci Instrum 2009; 45:256-261. [PMID: 19369772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This study investigates vehicle mismatch in severe side-impact motor vehicle collisions. Research conducted by the Insurance Institute for Highway Safety has determined that vehicle mismatch often leads to very severe injuries for occupants in the struck vehicle, because the larger striking vehicle does not engage the lower sill upon impact, resulting in severe intrusions into the occupant compartment. Previous studies have analyzed mismatched collisions according to vehicle type, not by the difference in vehicle height and weight. It is hypothesized that the combination of a heavier striking vehicle at a taller height results in more intrusion for the struck vehicle and severe injury for the near side occupant. By analyzing Crash Injury Research and Engineering Network (CIREN) data and occupant injury severity, it is possible to study intrusion and injuries that occur due to vehicle mismatch. CIREN enrolls seriously injured occupants involved in motor vehicle crashes (MVC) across the United States. From the Toyota-Wake Forest University CIREN center, 23 near side impact cases involving two vehicles were recorded. Only 3 of these seriously injured occupant cases were not considered mismatched according to vehicle curb weight, and only 2 were not considered vehicle mismatched according to height differences. The mismatched CIREN cases had an average difference in vehicle curb weight of 737.0 kg (standard deviation of 646.8) and an average difference in vehicle height of 16.38 cm (standard deviation of 7.186). There were 13 occupants with rib fractures, 12 occupants with pelvic fractures, 9 occupants with pulmonary contusion, and 5 occupants with head injuries, among other multiple injuries. The average Injury Severity Score (ISS) for these occupants was 27, with a standard deviation of 16. The most serious injuries resulted in an Abbreviated Injury Scale (AIS) of 5, which included 3 occupants. Each of these AIS 5 injuries were to different body regions on different occupants. By analyzing the vehicle information and occupant injuries, it was found that the vehicle mismatch problem involves differences in vehicle weights and heights and also results in severe injuries to multiple body regions for the near side occupant involved. There was a low correlation of vehicle height difference to occupant ISS.
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Martin RS, Smith JS, Hoth JJ, Miller PR, Meredith JW, Chang MC. Increased insulin requirements are associated with pneumonia after severe injury. ACTA ACUST UNITED AC 2007; 63:358-64. [PMID: 17693836 DOI: 10.1097/ta.0b013e31809ed905] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Hyperglycemia after severe injury has been associated with an increased risk of infection and death. Strict glycemic control has been found to be valuable in select surgical populations. Varying amounts of insulin by infusion are required to maintain blood glucose levels within normal limits. Little is known about how insulin requirements are affected by the presence of infection, and therefore, the purpose of this study was to characterize this relationship. METHODS Medical records of all intubated, injured patients admitted to the intensive care unit during a 16-month period were reviewed. Patients were included if they were managed with an insulin infusion, and they had a single bronchoalveolar lavage (BAL) culture performed for presumed pneumonia between 48 hours and 8 days. Mean hourly and 24-hour insulin requirements were analyzed before BAL was performed and then compared with values after cultures were obtained. This difference was then compared between patients with and without pneumonia. RESULTS Eighty-two patients met inclusion criteria during the 16-month study period. The hourly and 24-hour insulin requirements significantly increased from before to after BAL was performed in patients with pneumonia (n = 54) and not in those without (n = 28) (p = 0.008). The 24-hour insulin requirement increased by 26.2 units from before to after BAL in the pneumonia group versus 7.6 units in the nonpneumonia group (p = 0.029). A mean hourly insulin requirement increase of 1.2 units more than the pre-BAL level demonstrated an 86% positive predictive value and 89% specificity for pneumonia. CONCLUSIONS An increase in insulin requirements at the time of obtaining pulmonary cultures is associated with the presence of pneumonia and may represent a valuable tool for earlier recognition.
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Affiliation(s)
- R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Helm CW, Toler CR, Martin RS, Gordinier ME, Parker LP, Metzinger DS, Edwards RP. Cytoreduction and intraperitoneal heated chemotherapy for the treatment of endometrial carcinoma recurrent within the peritoneal cavity. Int J Gynecol Cancer 2007; 17:204-9. [PMID: 17291254 DOI: 10.1111/j.1525-1438.2006.00751.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [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: 12/01/2022] Open
Abstract
Our experience with hyperthermic intraperitoneal chemotherapy (IPHC) in conjunction with surgical resection for endometrial cancer recurrent within the abdominal cavity was reviewed. Eligible patients underwent exploratory laparotomy with the aim of resecting disease to ≤5 mm maximum dimension followed immediately by intraperitoneal perfusion of cisplatin (100 mg/m2) heated to 41–43°C (105.8–109.4°F) for 1.5 h. Data for analysis was extracted from retrospective chart review. Five patients underwent surgery and IPHC between September 2002 and January 2005 for abdomino-pelvic recurrence. Original stage and histology were 1A papillary serous (1), 1C endometrioid with clear cell features (1), and 1B endometrioid (3). Mean age was 61 (41–75) years, mean prior laparotomies were 1.4 (1–2), and mean chemotherapy agent exposure was 1.6 (0–4). Mean time from initial treatment to surgery and IPHC was 47 (29–66) months. Mean length of surgery was 9.8 (7–11) h after which three patients had no residual disease and two had ≤5 mm disease. The mean duration of hospital stay was 12.6 (6–20) days. Postoperative surgical complications included wound infection with septicemia in one patient. Mean maximum postoperative serum creatinine was 1.02 (0.6–1.70) mg/dL. There was no ototoxicity or neuropathy and no perioperative mortality. No patients have been lost to follow-up. Two are living disease free at 28 and 32 m and two are living with disease at 12 and 36 m. One patient died at 3 m without evidence of cancer. Two patients who had no residual macroscopic disease at the end of surgery are alive at 32 and 36 m. The combination of IPHC with surgery for recurrent endometrial carcinoma is relatively well tolerated. The unexpectedly long survival seen in this cohort supports a phase II trial of IPHC with cisplatin for recurrent endometrial cancer.
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Affiliation(s)
- C W Helm
- Division of Gynecologic Oncology, James Graham Brown Cancer Center, University of Louisville, 529 South Jackson Street, Louisville, KY 40202, USA.
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Martin RS, Norris PR, Kilgo PD, Miller PR, Hoth JJ, Meredith JW, Chang MC, Morris JA. Validation of stroke work and ventricular arterial coupling as markers of cardiovascular performance during resuscitation. ACTA ACUST UNITED AC 2006; 60:930-4; discussion 934-5. [PMID: 16688052 DOI: 10.1097/01.ta.0000217943.72465.52] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [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: 11/25/2022]
Abstract
BACKGROUND Resuscitation regimens based on stroke work index (SWI) and ventricular-arterial coupling (VAC) are controversial. The Signal Interpretation and Monitoring (SIMON) system continuously collects and stores physiologic intensive care unit (ICU) bedside data at 3- to 5-second intervals. The purpose of this study was to demonstrate the capabilities of a completely automated data management system by further evaluating SWI-based resuscitation. METHODS This study was a retrospective review of all severely injured patients requiring a pulmonary artery catheter (PAC) for acute postinjury resuscitation. Patients with a severe head injury were excluded. Hemodynamic (HD) data (21 million datapoints) were densely acquired and archived by SIMON. Mean values of HD variables were compared between survivors and nonsurvivors. Receiver operator characteristic (ROC) curves were constructed for HD variables. Threshold values which maximized sensitivity and specificity were determined. RESULTS Eighty-eight patients over a 19-month time period met criteria and were included in the analysis. SWI was significantly greater in survivors versus nonsurvivors (4421 +/- 1278 versus 3163 +/- 1066 mm Hg . mL/m, p = 0.0008). VAC was quantified by the ratio (RATIO) of afterload (Ea) to contractility (Ees). RATIO (Ea/Ees) in survivors was significantly better than in nonsurvivors (1.9 +/- 1.1 vs. 2.9 +/- 1.0, p = 0.002). ROC curves identified threshold values of 3250 mm Hg x mL/m for SWI and 2.1 for RATIO (AUC = 0.78 and 0.82, respectively). CONCLUSION Previous work demonstrating the use of SWI and VAC as resuscitation guidelines was supported through the use of a powerful ICU data management system (SIMON). The emergence of these "new vital signs" may change the way injured patients are evaluated and resuscitated in the ICU.
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Affiliation(s)
- R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Abstract
Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures <35 degrees C, and 802 had temperatures <32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures <32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P < 0.001) and BD (7.8 vs. 3.7, P < 0.001) when compared with patients with temperatures >or=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures <35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P < 0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at <32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.
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Affiliation(s)
- R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Martin RS, Kincaid EH, Russell HM, Meredith JW, Chang MC. Selective management of cardiovascular dysfunction in posttraumatic SIRS and sepsis. Shock 2005; 23:202-8. [PMID: 15718916] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Cardiovascular dysfunction associated with the systemic inflammatory response syndrome (SIRS) is caused by a combination of decreased myocardial contractility and low vascular resistance. The contribution of each of these components can be determined at the bedside, and directed therapy can be appropriately initiated. Over an 8-month period of time, 23 consecutive patients who experienced posttraumatic SIRS while still being monitored with a volumetric pulmonary artery catheter (PAC) were prospectively evaluated. Ventricular pressure-volume diagrams were constructed to quantify myocardial contractility and afterload. In a resuscitation protocol, dobutamine was administered to patients with an isolated decrease in contractility, and dopamine or epinephrine was instituted for the combination of reduced contractility and afterload. Variables describing cardiovascular function were measured at the time of resolution of initial shock resuscitation (BASE), at the onset of SIRS (ONSET), and after administration of inotropic or vasoactive agents (TREAT). ONSET was associated with a significant decrease in left ventricular power (LVP) (362 +/- 96 to 235 +/- 55 mmHg.L/min/m(2), P < 0.00001) and stroke work index (SWI) (4670 +/- 1213 to 3060 +/- 848 mmHg.mL/m, P < 0.00001) from BASE. Sixteen patients (70%) demonstrated predominantly decreased contractility, which returned to near BASE values after the administration of dobutamine. The remaining seven patients (30%) had both decreased contractility and afterload, which was treated with dopamine or epinephrine. LVP and SWI significantly increased (235 +/- 55 to 328 +/- 77 mmHg.L/min/m(2), P < 0.00001, and 3060 +/- 848 to 4554 +/- 1423 mmHg.mL/m(2), P < 0.00001, respectively) on the initiation of directed therapy. Specific cardiovascular abnormalities can be identified at the bedside, and this information can guide pharmacologic management. Directed therapy improves cardiovascular function.
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Affiliation(s)
- R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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Chang MC, Martin RS, Scherer LA, Meredith JW. Improving ventricular-arterial coupling during resuscitation from shock: effects on cardiovascular function and systemic perfusion. J Trauma 2002; 53:679-85. [PMID: 12394866 DOI: 10.1097/00005373-200210000-00010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Efficacy of circulation depends on interactions between the heart and the vascular system. Ventricular-arterial coupling (VAC) has been described as an important determinant of cardiovascular function during resuscitation from shock. However, no prospective studies examining VAC and systemic perfusion have been performed. VAC is measured by the ratio of afterload (aortic input impedance [E ]) to contractility (end-systolic elastance [E ]). Lowering E /E is associated with better VAC and improved myocardial work efficiency. Our hypothesis was that optimizing VAC during resuscitation results in improved myocardial work efficiency while simultaneously improving systemic perfusion. METHODS This was a prospective study in a consecutive series of critically injured patients. Hemodynamic variables, including E, E, and myocardial work efficiency were evaluated by constructing ventricular pressure-volume loops at the bedside during resuscitation. After pulmonary artery catheterization and adequate fluid resuscitation, left ventricular power output and E /E were optimized with inotropic agents and/or afterload reduction. Efficiency was calculated as stroke work/total left ventricular energy expenditure. Tissue perfusion was estimated by calculating base deficit clearance per hour. RESULTS Twenty-three patients were studied over a 9-month period. Fifteen patients required inotropic support or afterload reduction. Improvements were seen in E /E (from 1.0 +/- 0.4 to 0.6 +/- 0.2 mm Hg/mL/m, p = 0.0004), and left ventricular power output (from 280 +/- 77 to 350 +/- 81 L/min/m. mm Hg, p = 0.003) with resuscitation. A concomitant improvement in myocardial efficiency (from 70% +/- 8.0% to 77% +/- 5.0%, p = 0.0001) and base deficit clearance (from 0.1 +/- 0.4 to -0.2 +/- 0.1 mEq/L/h, p = 0.006) was seen. CONCLUSION Improved ventricular-arterial coupling during resuscitation is associated with improved myocardial efficiency and systemic tissue perfusion. Perfusion can be improved at lower energy cost to the heart by focusing on thermodynamic principles during resuscitation.
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Affiliation(s)
- Michael C Chang
- Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Abstract
Microfabricated fluidic devices have generated considerable interest over the past ten years due to the fact that sample preparation, injection, separation, derivatization, and detection can be integrated into one miniaturized device. This review reports progress in the development of microfabricated analytical systems based on microchip capillary electrophoresis (CE) with electrochemical (EC) detection. Electrochemical detection has several advantages for use with microchip electrophoresis systems, for example, ease of miniaturization, sensitivity, and selectivity. In this review, the basic components necessary for microchip CEEC are described, including several examples of different detector configurations. Lastly, details of the application of this technique to the determination of catechols and phenols, amino acids, peptides, carbohydrates, nitroaromatics, polymerase chain reaction (PCR) products, organophosphates, and hydrazines are described.
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Affiliation(s)
- N A Lacher
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence 66047, USA
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Abstract
The application of microchip capillary electrophoresis (CE) systems to biomedical and pharmaceutical analysis is described and reviewed. Fabrication, instrumentation, and operation of the systems are discussed. An overview of applications is presented, covering four main areas: DNA sequencing, genetic analysis, immunoassays, and protein and peptide analysis. These systems have the potential to dramatically change the way that biochemical analyses are performed.
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Affiliation(s)
- A J Gawron
- Department of Pharmaceutical Chemistry and Center for Bioanalytical Research, University of Kansas, 2095 Constant Avenue, 66047, Lawrence, KS, USA
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Abstract
Microfabricated fluidic devices have generated considerable interest over the past ten years due to the fact that sample preparation, injection, separation, derivatization, and detection can be integrated into one miniaturized device. This review reports progress in the development of microfabricated analytical systems based on microchip capillary electrophoresis (CE) with electrochemical (EC) detection. Electrochemical detection has several advantages for use with microchip electrophoresis systems, for example, ease of miniaturization, sensitivity, and selectivity. In this review, the basic components necessary for microchip CEEC are described, including several examples of different detector configurations. Lastly, details of the application of this technique to the determination of catechols and phenols, amino acids, peptides, carbohydrates, nitroaromatics, polymerase chain reaction (PCR) products, organophosphates, and hydrazines are described.
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Affiliation(s)
- N A Lacher
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence 66047, USA
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Martin RS, Gawron AJ, Fogarty BA, Regan FB, Dempsey E, Lunte SM. Carbon paste-based electrochemical detectors for microchip capillary electrophoresis/electrochemistry. Analyst 2001; 126:277-80. [PMID: 11284324 DOI: 10.1039/b009827m] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [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: 11/21/2022]
Abstract
The first reported use of a carbon paste electrochemical detector for microchip capillary electrophoresis (CE) is described. Poly(dimethylsiloxane) (PDMS)-based microchip CE devices were constructed by reversibly sealing a PDMS layer containing separation and injection channels to a separate PDMS layer that contained carbon paste working electrodes. End-channel amperometric detection with a single electrode was used to detect amino acids derivatized with naphthalene dicarboxaldehyde. Two electrodes were placed in series for dual electrode detection. This approach was demonstrated for the detection of copper(II) peptide complexes. A major advantage of carbon paste is that catalysts can be easily incorporated into the electrode. Carbon paste that was chemically modified with cobalt phthalocyanine was used for the detection of thiols following a CE separation. These devices illustrate the potential for an easily constructed microchip CE system with a carbon-based detector that exhibits adjustable selectivity.
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Affiliation(s)
- R S Martin
- Department of Pharmaceutical Chemistry, University of Kansas, 2095 Constant Avenue, Lawrence, Kansas 66047, USA.
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Abstract
BACKGROUND Increased intra-abdominal pressure (IAP) is an adverse complication seen in critically ill, injured, and postoperative patients. IAP is estimated via the measurement of bladder pressure. Few studies have been performed to establish the actual relationship between IAP and bladder pressure. The purpose of this study was to confirm the association between intravesicular pressure and IAP and to determine the bladder volume that best approximates IAP. METHODS Thirty-seven patients undergoing laparoscopy had intravesicular pressures measured with bladder volumes of 0, 50, 100, 150, and 200 mL at directly measured intra-abdominal pressures of 0, 5, 10, 15, 20, and 25 mm Hg. Correlation coefficients and differences were then determined. RESULTS Across the IAP range of 0 to 25 mm Hg using all of the tested bladder volumes, the difference between IAP and intravesicular pressures (bias) was -3.8 +/- 0.29 mm Hg (95% confidence interval) and measurements were well correlated (R2 = 0.68). Assessing all IAPs tested, a bladder volume of 0 mL demonstrated the lowest bias (-0.79 +/- 0.73 mm Hg). When considering only elevated IAPs (25 mm Hg), a bladder volume of 50 mL revealed the lowest bias (-1.5 +/- 1.36 mm Hg). A bladder volume of 50 mL in patients with elevated IAP resulted in an intravesicular pressure 1 to 3 mm Hg higher than IAP (95% confidence interval). CONCLUSION Intravesicular pressure closely approximates IAP. Instillation of 50 mL of liquid into the bladder improves the accuracy of the intravesicular pressure in measuring elevated IAPs.
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Affiliation(s)
- M A Fusco
- Melbourne Internal Medicine Associates, Melbourne, Florida, USA
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Martin RS, Martin GR. Investigations into migraine pathogenesis: time course for effects of m-CPP, BW723C86 or glyceryl trinitrate on appearance of Fos-like immunoreactivity in rat trigeminal nucleus caudalis (TNC). Cephalalgia 2001; 21:46-52. [PMID: 11298663 DOI: 10.1046/j.1468-2982.2001.00157.x] [Citation(s) in RCA: 24] [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: 11/20/2022]
Abstract
Clinical and preclinical studies suggest that 5-HT and nitric oxide (NO) mobilization within the trigeminovascular system is fundamental to the initiation of migraine attacks., e.g. m-chlorophenylpiperazine (m-CPP) and glyceryl trinitrate (GTN) induce headache in humans. 5-HT2B receptors are known to mediate NO-dependent vasorelaxation in peripheral blood vessels, raising the possibility that this receptor is implicated in the pathogenesis of the disease. Therefore, we measured the effects of 5-HT2B agonists (m-CPP or BW723C86) or GTN on trigeminal nerves by quantifying Fos expression in the rat TNC. m-CPP (0.1 mg/kg, i.v.) induced time-dependent elevations in Fos-LI in the rat TNC 2 h and 8 h after injection. In contrast, neither intravenous GTN (0.5 microg/kg per min, infused 20 min) nor BW723C86 (0.1 mg/kg, i.v.) increased Fos-LI at 2 h or 8 h after administration. These data are not consistent with the involvement of the 5-HT2B/2C receptors or NO in trigeminovascular activation, and by inference migraine, and suggest the contribution of some other unidentified pathway.
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Affiliation(s)
- R S Martin
- Neurobiology Unit, Roche Bioscience, Palo Alto, CA 94304, USA.
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