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Warren JA, Lucas C, Beffa LR, Petro CC, Prabhu AS, Krpata DM, Rosen MJ, Orenstein SB, Nikolian VC, Pauli EM, Horne CM, LaBelle M, Phillips S, Poulose BK, Carbonell AM. Reducing the incidence of surgical site infection after ventral hernia repair: Outcomes from the RINSE randomized control trial. Am J Surg 2024; 232:68-74. [PMID: 38199871 DOI: 10.1016/j.amjsurg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND The clinical and financial impact of surgical site infection after ventral hernia repair is significant. Here we investigate the impact of dual antibiotic irrigation on SSI after VHR. METHODS This was a multicenter, prospective randomized control trial of open retromuscular VHR with mesh. Patients were randomized to gentamicin + clindamycin (G + C) (n = 125) vs saline (n = 125) irrigation at time of mesh placement. Primary outcome was 30-day SSI. RESULTS No significant difference was seen in SSI between control and antibiotic irrigation (9.91 vs 9.09 %; p = 0.836). No differences were seen in secondary outcomes: SSO (11.71 vs 13.64 %; p = 0.667); 90-day SSO (11.1 vs 13.9 %; p = 0.603); 90-day SSI (6.9 vs 3.8 %; p = 0.389); SSIPI (7.21 vs 7.27 %, p = 0.985); SSOPI (3.6 vs 3.64 %; p = 0.990); 30-day readmission (9.91 vs 6.36 %; p = 0.335); reoperation (5.41 vs 0.91 %; p = 0.056). CONCLUSION Dual antibiotic irrigation with G + C did not reduce the risk of surgical site infection during open retromuscular ventral hernia repair.
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Affiliation(s)
- Jeremy A Warren
- University of South Carolina School of Medicine Greenville and Prisma Health Upstate Department of Surgery, Greenville, SC, USA.
| | - Claiborne Lucas
- Prisma Health Upstate Department of Surgery, Greenville, SC, USA
| | | | | | | | | | | | | | | | - Eric M Pauli
- Penn State Health Milton S Hershey Medical Center Department of Surgery, Hershey, PA, USA
| | - Charlotte M Horne
- Penn State Health Milton S Hershey Medical Center Department of Surgery, Hershey, PA, USA
| | - Molly LaBelle
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | | | - Benjamin K Poulose
- The Ohio State University Wexner Department of Surgery and Center for Abdominal Core Health, Columbus, OH, USA
| | - Alfredo M Carbonell
- University of South Carolina School of Medicine Greenville and Prisma Health Upstate Department of Surgery, Greenville, SC, USA
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2
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Nikolian VC, Pereira X, Arias-Espinosa L, Bazarian AN, Porter CG, Henning JR, Malcher F. Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes. Hernia 2024:10.1007/s10029-024-03009-9. [PMID: 38502368 DOI: 10.1007/s10029-024-03009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias. METHODS A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried. RESULTS Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45-65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date. CONCLUSION We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.
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Affiliation(s)
- V C Nikolian
- Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - X Pereira
- New York University Langone Health, New York, NY, USA
| | | | - A N Bazarian
- Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - C G Porter
- Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - J R Henning
- New York University Langone Health, New York, NY, USA
| | - F Malcher
- New York University Langone Health, New York, NY, USA
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Nikolian VC, Camacho D, Earle D, Lehmann R, Nau P, Ramshaw B, Stulberg J. Development and preliminary validation of a new task-based objective procedure-specific assessment of inguinal hernia repair procedural safety. Surg Endosc 2024; 38:1583-1591. [PMID: 38332173 DOI: 10.1007/s00464-024-10677-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/30/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Surgical videos coupled with structured assessments enable surgical training programs to provide independent competency evaluations and align with the American Board of Surgery's entrustable professional activities initiative. Existing assessment instruments for minimally invasive inguinal hernia repair (IHR) have limitations with regards to reliability, validity, and usability. A cross-sectional study of six surgeons using a novel objective, procedure-specific, 8-item competency assessment for minimally invasive inguinal hernia repair (IHR-OPSA) was performed to assess inter-rater reliability using a "safe" vs. "unsafe" scoring rubric. METHODS The IHR-OPSA was developed by three expert IHR surgeons, field tested with five IHR surgeons, and revised based upon feedback. The final instrument included: (1) incision/port placement; (2) dissection of peritoneal flap (TAPP) or dissection of peritoneal flap (TEP); (3) exposure; (4) reducing the sac; (5) full dissection of the myopectineal orifice; (6) mesh insertion; (7) mesh fixation; and (8) operation flow. The IHR-OPSA was applied by six expert IHR surgeons to 20 IHR surgical videos selected to include a spectrum of hernia procedures (15 laparoscopic, 5 robotic), anatomy (14 indirect, 5 direct, 1 femoral), and Global Case Difficulty (easy, average, hard). Inter-rater reliability was assessed against Gwet's AC2. RESULTS The IHR-OPSA inter-rater reliability was good to excellent, ranging from 0.65 to 0.97 across the eight items. Assessments of robotic procedures had higher reliability with near perfect agreement for 7 of 8 items. In general, assessments of easier cases had higher levels of agreement than harder cases. CONCLUSIONS A novel 8-item minimally invasive IHR assessment tool was developed and tested for inter-rater reliability using a "safe" vs. "unsafe" rating system with promising results. To promote instrument validity the IHR-OPSA was designed and evaluated within the context of intended use with iterative engagement with experts and testing of constructs against real-world operative videos.
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Affiliation(s)
- Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA.
| | - Diego Camacho
- Minimally Invasive and Endoscopic Surgery at Montefiore Medical Center, New York, NY, USA
| | - David Earle
- New England Hernia Center, Lowell, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Ryan Lehmann
- Department of Surgery, Section of Bariatric Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Peter Nau
- Department of Surgery, Section of Bariatric Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Bruce Ramshaw
- CQInsights PBC, Knoxville, TN, USA
- Caresyntax Corporation, Boston, MA, USA
| | - Jonah Stulberg
- Department of Surgery, McGovern Medical School University of Texas Health Science Center at Houston, Houston, TX, USA
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O'Connor AL, Shmelev A, Shettig A, Santucci NM, Bray J, Bazarian A, Orenstein SB, Nikolian VC. Assessing Patient-Reported Experiences for In-Person and Telemedicine-Based Preoperative Evaluations. Telemed J E Health 2024; 30:472-479. [PMID: 37624627 DOI: 10.1089/tmj.2023.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Abstract
Background: The COVID-19 pandemic has transformed health care delivery through the rise of telehealth solutions. Though telemedicine-based care has been identified as safe and feasible in postoperative care, data on initial surgical consultations in the preoperative setting are lacking. We sought to compare patient characteristics, anticipated downstream care utilization, and patient-reported experiences (PREs) for in-person versus telemedicine-based care conducted for initial consultation encounters at a hernia and abdominal wall center. Methods: Patients evaluated at an abdominal wall reconstruction center from August 2021 to August 2022 were prospectively surveyed. Patient characteristics, anticipated downstream care utilization, and PREs were compared. Results: Of the 176 respondents, 50.6% (n = 89) utilized telemedicine-based care and had similar demographic and disease characteristics to those receiving in-person care. Telemedicine-based care saved a median of 47 min [interquartile range 20-112.5 min] of round-trip travel time per patient, with 10.1% of encounters resulting in supplemental in-person evaluation. A large proportion of telemedicine-based and in-person encounters resulted in recommendations for operative intervention, 38.2% versus 55.2%, respectively. Indirect costs of care were significantly lower for patients utilizing telemedicine-based services. Patient satisfaction related to encounters was non-inferior to in-person care. Overall, the majority of patients responded that they preferred future care to be delivered via telemedicine-based services, if offered. Conclusions: Preoperative telemedicine-based care was associated with significant cost-savings over in-person care related with comparable patient satisfaction. Health systems should continue to dedicate resources to optimizing and expanding perioperative telemedicine capabilities.
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Affiliation(s)
- Amber L O'Connor
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Artem Shmelev
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Abigale Shettig
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Nicole M Santucci
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Jordan Bray
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Alina Bazarian
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Sean B Orenstein
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Vahagn C Nikolian
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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5
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Shmelev A, Olsen MA, Bray JO, Nikolian VC. Surgeon volumes: preserving appropriate surgical outcomes in higher-risk patient populations undergoing abdominal wall reconstruction. Surg Endosc 2023; 37:7582-7590. [PMID: 37460820 DOI: 10.1007/s00464-023-10286-5] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/05/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND It is increasingly recognized that complex abdominal wall reconstruction (cAWR) necessitates specialized training. No studies have been conducted to assess whether a volume-outcomes relationship is present in cAWR. We sought to determine if outcomes for patients undergoing cAWR varied based on surgeon volume among participants in the Abdominal Core Health Quality Collaborative (ACHQC). METHODS All patients with ventral hernias undergoing elective cAWR with component separation (lateral component release) were selected from ACHQC database. Surgeons were ranked based on annual number of cAWR procedures performed and then grouped in tertiles. Patient characteristics, hernia risk factors, operative details, and 30-days outcomes were evaluated. RESULTS A total of 9206 patients were identified, of which 310 (3.4%), 723 (7.9%) and 8173 (88.7%) cAWRs were performed by low (105 surgeons), medium (49) and high-volume (66) surgeons, respectively. Patients operated upon by high-volume surgeons tended to have more comorbidities and higher ASA class (72.5% of class ≥ III, vs 53.5%). Hernia characteristics demonstrated that high-volume surgeons more commonly operated on patients presenting with recurrent hernias (50.2% vs 42%), wider hernias (13.5 cm vs 10.5 cm), associated ostomies (13% vs 3.6%), and prior of surgical site infections (32% vs 26%, P = 0.035). High-volume surgeons more commonly performed posterior component separation procedures (92% vs 84%), utilized permanent mesh (92% vs 88%), and placed mesh in sublay position. In spite of operating on more advanced hernias, high-volume surgeons achieved comparable rates (all P > 0.4) of 30-day surgical site infections (SSI: 6.9% vs 7.1%) and surgical site occurrences requiring procedural intervention (SSO-PI: 8.9% vs 10%). CONCLUSIONS High-volume surgeons maintain comparable outcomes following cAWR despite performing operations on patients with more comorbidities and advanced hernia disease. These findings should be integrated into the debates related to regionalizing abdominal wall reconstruction procedures among high-volume surgeons.
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Affiliation(s)
- Artem Shmelev
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Molly A Olsen
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Jordan O Bray
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L 233A, Portland, OR, 97239, USA
| | - Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L 233A, Portland, OR, 97239, USA.
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Cochrun SL, Herbey I, Ivankova N, Nikolian VC, Jansen JO, Parmar AD. Surgeon perspectives on the STITCH trial: a mixed methods study. Surg Endosc 2023:10.1007/s00464-023-10086-x. [PMID: 37129637 DOI: 10.1007/s00464-023-10086-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Incisional hernia prevention strategies related to fascial closure technique during laparotomy are well described yet poorly implemented in practice. The factors hindering the surgeon's adoption of evidence-based techniques for fascial closure are poorly understood and characterized. METHODS Using an exploratory sequential mixed methods design, we first collected 139 responses to a validated quantitative survey based on a Theoretical Domain Framework for adoption of healthcare practices. Mean scores from survey responses were tabulated, and the findings were used to develop an interview guide for subsequent qualitative individual semi-structured phone interviews. Fourteen practicing surgeons were purposively sampled from social media outlets and our institution. The interviews were recorded and transcribed verbatim for coding and thematic analysis using NVivo 12 Plus. Data from the surveys and interviews were integrated using joint displays. RESULTS Quantitative and qualitative analyses from surveys and semi-structured interviews revealed various themes related to surgeon decision-making related to fascial closure technique. Surgeons cited limitations of prior studies, applicability of findings, anecdotal experiences, and situation-specific environments that influence their decision-making. Peer influence and lack of training also affected surgeons' perspectives on integrating small bite technique into practice. CONCLUSION Trial design limitations, peer influence, and patient-specific factors impacted surgeon decision-making in the choice of fascial closure technique. Future clinical trials in diverse patient populations may improve surgeons' confidence in implementing technique for fascial closure.
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Affiliation(s)
- Steven L Cochrun
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 8Th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA.
| | - Ivan Herbey
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 8Th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
| | - Nataliya Ivankova
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Jan O Jansen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Abhishek D Parmar
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 8Th Avenue South, Boshell Diabetes Building #525, Birmingham, AL, 35294, USA
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O'Connor AL, Shettig A, Santucci NM, Sutton TL, Bray JO, Borzy C, Orenstein SB, Nikolian VC. Bedside vs webside: Assessing patient-reported experiences for in-person and telemedicine-based perioperative evaluations. Am J Surg 2023; 225:847-851. [PMID: 36870791 DOI: 10.1016/j.amjsurg.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/24/2023] [Accepted: 02/26/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Though telemedicine has been identified as safe and feasible, data on patient reported experiences (PREs) are lacking. We sought to compare PREs between in-person and telemedicine-based perioperative care. METHODS Patients evaluated from August-November 2021 were prospectively surveyed to assess experiences and satisfaction with care rendered during in-person and telemedicine-based encounters. Patient and hernia characteristics, encounter related plans, and PREs were compared between in-person and telemedicine-based care. RESULTS Of 109 respondents (86% response rate), 55% (n = 60) utilized telemedicine-based perioperative care. Indirect costs were lower for patients using telemedicine-based services, including work absence (3% vs. 33%, P < 0.001), lost wages (0% vs. 14%, P = 0.003), and requirements for hotel accommodations (0% vs. 12%, P = 0.007). PREs related to telemedicine-based care were non-inferior to in-person care across all measured domains (P > 0.4). CONCLUSIONS Telemedicine-based care yields significant cost-savings over in-person care with similar patient satisfaction. These findings suggest that systems should focus on optimization of perioperative telemedicine services.
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Affiliation(s)
| | | | | | | | - Jordan O Bray
- Oregon Health & Science University, Portland, OR, USA
| | - Charlie Borzy
- Oregon Health & Science University, Portland, OR, USA
| | | | - Vahagn C Nikolian
- Oregon Health & Science University, Portland, OR, USA. https://twitter.com/VNikolian
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8
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Bray JO, O'Connor S, Sutton TL, Santucci NM, Elsheikh M, Bazarian AN, Orenstein SB, Nikolian VC. Patient-performed at-home surgical drain removal is safe and feasible following hernia repair and abdominal wall reconstruction. Am J Surg 2023; 225:388-393. [PMID: 36167625 DOI: 10.1016/j.amjsurg.2022.09.022] [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] [Received: 08/13/2022] [Revised: 09/11/2022] [Accepted: 09/18/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Traditionally, surgical drains are considered a relative contraindication to telemedicine-based postoperative care. We sought to assess the safety, feasibility, and outcomes of an at-home patient-performed surgical drain removal pilot program. METHODS A prospective cohort study among patients who were discharged with surgical drains was performed. Patients discharged with drains were given the option for in-clinic, provider-performed removal, or at-home, patient-performed drain removal. Patient demographics, health characteristics, perioperative metrics, and operative outcomes were compared and analyzed. RESULTS A total of 68 encounters with drain removal were included (at-home: 28%, n = 19; in-clinic: 72%, n = 49), with both groups having similar demographics, except for age (median age of telemedicine-based at-home: 50 vs in-clinic: 62 years, p = 0.03). Patients who opted into at-home, patient-performed drain removal were more likely to have drain removal occur earlier (9 vs 13 days for in-clinic, p < 0.001). In-clinic removal resulted in increased encounters with surgical nursing staff and increased travel time, with no significant difference in complication burden. CONCLUSIONS Patient-performed at-home drain removal is safe and allows for more timely drain removal.
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Affiliation(s)
- Jordan O Bray
- Oregon Health & Science University, Portland, OR, USA
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Iqbal E, Bray JO, Sutton T, Akhter M, Orenstein SB, Nikolian VC. Perioperative Telemedicine Utilization Among Geriatric Patients Being Evaluated for Abdominal Wall Reconstruction and Hernia Repair. Telemed J E Health 2022. [PMID: 36255440 DOI: 10.1089/tmj.2022.0223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Perioperative telemedicine services have increasingly been utilized for ambulatory care, although concerns exist regarding the feasibility of virtual consultations for older patients. We sought to review telemedicine encounters for geriatric patients evaluated at a hernia repair and abdominal wall reconstruction center. Methods: A retrospective review of telemedicine encounters between May 2020 and May 2021 was performed. Patient characteristics and encounter-specific outcomes were compared among geriatric (older than65 years old) and nongeriatric patients. Clinical care plans for encounters were reviewed to determine potential downstream care utilization. Patient-derived benefits related to time saved in travel time was calculated using geo-mapping. Outcomes for postoperative encounters were assessed to determine if complication rates differed between geriatric and nongeriatric populations. Results: A total of 313 telemedicine encounters (geriatric: 41.9%) were conducted among 251 patients. Reviewing preoperative factors for hernia care, geriatric patients presented with higher rates of recurrent or incisional hernias (87.9% vs. 70.7%, p < 0.01). Potential travel time was longer for geriatric patients (104 min vs. 42 min, p = 0.03) in the preoperative setting. No differences in clinical care plans were found. Only 8.6% of preoperative encounters resulted in recommendations for supplemental in-person evaluation. Operative plans were coordinated for 42.5% of all preoperative telemedicine encounters. There was no difference in complication rate between geriatric and nongeriatric patients (p > 0.05) in the postoperative setting, with no complications directly attributable to telemedicine-based care. Conclusions: Telemedicine-based evaluations appear to function well among geriatric patients seeking hernia repair and abdominal wall reconstruction. Clinical care plans rendered following telemedicine-based encounters are appropriate with a low rate of supplemental in-person evaluations. Telemedicine use resulted in significantly more time saved in commuting to and from clinic for geriatric patients.
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Affiliation(s)
- Emaad Iqbal
- Columbia University Irving Medical Center, New York, New York, USA
| | - Jordan O Bray
- Oregon Health and Science University, Portland, Oregon, USA
| | - Thomas Sutton
- Oregon Health and Science University, Portland, Oregon, USA
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10
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Bray JO, Sutton TL, Akhter MS, Iqbal E, Orenstein SB, Nikolian VC. Outcomes of Telemedicine-Based Consultation among Rural Patients Referred for Abdominal Wall Reconstruction and Hernia Repair. J Am Coll Surg 2022; 235:128-137. [PMID: 35703970 DOI: 10.1097/xcs.0000000000000213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perioperative telemedicine use has increased as a result of the COVID-19 pandemic and may improve access to surgical care. However, studies assessing outcomes in populations at risk for digital-health disparities are lacking. We sought to characterize the pre- and postoperative outcomes for rural patient populations being assessed for hernia repair and abdominal wall reconstruction with telehealth. METHODS Patients undergoing telehealth evaluation from March 2020 through May 2021 were identified. Rurality was identified by zip code of residence. Rural and urban patients were compared based on demographics, diagnosis, treatment plan, and visit characteristics and outcomes. Downstream care use related to supplementary in-person referral, and diagnostic testing was assessed. RESULTS Three hundred-seventy-three (196 preoperative, 177 postoperative) telehealth encounters occurred during the study period (rural: 28% of all encounters). Rural patients were more likely to present with recurrent or incisional hernias (90.0 vs 72.7%, p = 0.02) and advanced comorbidities (American Society of Anesthesiologists status score > 2: 73.1 vs 52.1%, p = 0.009). Rural patients derived significant benefits related to time saved commuting, with median distances of 299 and 293 km for pre- and postoperative encounters, respectively. Downstream care use was 6.1% (N = 23) for additional in-person evaluations and 3.4% (N = 13) for further diagnostic testing, with no difference by rurality. CONCLUSIONS Perioperative telehealth can safely be implemented for rural populations seeking hernia repair and may be an effective method for reducing disparities. Downstream care use related to additional in-person referral or diagnostic testing was minimally impacted in both the preoperative and postoperative settings. These findings suggest that rurality should not deter surgeons from providing telemedicine-based surgical consultation for hernia repair.
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Affiliation(s)
- Jordan O Bray
- From the Department of Surgery, Oregon Health and Science University, Portland, OR (Bray, Sutton, Akhter, Orenstein, Nikolian)
| | - Thomas L Sutton
- From the Department of Surgery, Oregon Health and Science University, Portland, OR (Bray, Sutton, Akhter, Orenstein, Nikolian)
| | - Mudassir S Akhter
- From the Department of Surgery, Oregon Health and Science University, Portland, OR (Bray, Sutton, Akhter, Orenstein, Nikolian)
| | - Emaad Iqbal
- Department of Surgery, Columbia University Medical Center, New York, NY (Iqbal)
| | - Sean B Orenstein
- From the Department of Surgery, Oregon Health and Science University, Portland, OR (Bray, Sutton, Akhter, Orenstein, Nikolian)
| | - Vahagn C Nikolian
- From the Department of Surgery, Oregon Health and Science University, Portland, OR (Bray, Sutton, Akhter, Orenstein, Nikolian)
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11
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Nikolian VC, Stowers J, Brasel KJ. Technology and Surgical Training-Friend or Foe? JAMA Surg 2022; 157:561-562. [PMID: 35583865 DOI: 10.1001/jamasurg.2022.0640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - John Stowers
- Department of Surgery, Oregon Health & Science University, Portland.,Portland Veterans Affairs Medical Center, Portland, Oregon
| | - Karen J Brasel
- Department of Surgery, Oregon Health & Science University, Portland
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12
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Iqbal EJ, Sutton T, Akther MS, Samhan A, MacDonald S, Coleman JR, Turner PL, Nikolian VC. Current Surgical Trainee Perceptions and Experiences in Telehealth. Telemed J E Health 2021; 28:789-797. [PMID: 34637650 DOI: 10.1089/tmj.2021.0237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Broad expansion of telehealth technologies has been implemented during the coronavirus disease 2019 (COVID-19) pandemic to allow for physical distancing and limitation of viral transmission within health care facilities. Although telehealth has been studied for its impact on patients, payors, and practitioners, its educational impact is largely unstudied. To better understand the trainee experience and perception of telehealth during the COVID-19 pandemic, we conducted a survey of the membership of the American College of Surgeons Resident and Associate Society (RAS). Methods: An anonymous survey was sent to members of RAS. Descriptive analysis was used to report experiences and perceptions. Chi-square analysis was used to compare cohorts with and without exposure to telehealth. Results: Of the 465 RAS respondents, 292 (62.8%) reported knowledge of telehealth technologies at their institutions. The majority of these respondents experienced a decrease in in-person clinic volume (94.4%) and an associated increase in virtual clinic volume (95.7%) related to the COVID-19 pandemic. Trainee integration into telehealth workflows increased drastically from prepandemic levels (11% vs. 54.5%, p < 0.001). Likelihood of trainee exposure to telehealth was associated with university-based training programs or larger program size. Trainees demonstrated a desire for more integration and development of curricula. Conclusions: These data serve as the first description of surgical trainee experience with, and opinion of, telehealth. Trainees recognize the importance of their integration and training in telehealth. These results should be used to guide the development of workflows and curricula that integrate trainees into telemedicine clinics.
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Affiliation(s)
- Emaad J Iqbal
- Department of Surgery, Columbia University, New York City, New York, USA
| | - Thomas Sutton
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mudassir S Akther
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ashraf Samhan
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Stephanie MacDonald
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Julia R Coleman
- Department of Surgery, University of Colorado, Denver, Colorado, USA
| | - Patricia L Turner
- American College of Surgeons, Chicago, Illinois, USA.,Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Vahagn C Nikolian
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
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13
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Nikolian VC, Akhter M, Iqbal EJ, Sutton T, Samhan A, Orenstein SB, Rosen MJ, Poulose BK. A National Evaluation of Surgeon Experiences in Telemedicine for the Care of Hernia and Abdominal Core Health Patients. World J Surg 2021; 46:76-83. [PMID: 34604922 PMCID: PMC8487675 DOI: 10.1007/s00268-021-06332-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 12/11/2022]
Abstract
Background Surgeons are increasingly utilizing telemedicine to provide perioperative services to patients. Safety, satisfaction, and feasibility of these programs in general populations have been established, but it is unclear how telemedicine can be integrated into subspecialty care. We report results of a national survey related to telehealth practices among members of the Abdominal Core Health Quality Collaborative (ACHQC).
Methods Survey responses were analyzed to determine current strategies in telemedicine utilization. Surgeon preferences, perceptions of validity, and identified barriers to implementation of telemedicine were assessed. Results Forty surgeons within the ACHQC responded, with 90% of respondents reporting use of telemedicine to deliver perioperative care to patients with hernias and abdominal core health concerns. Surgeons appeared to be more comfortable managing preoperative patients with image-confirmed diagnoses of hernias. Surgeons were universally more comfortable delivering postoperative care via telemedicine. Connectivity, patient engagement, and reimbursement were identified as potential barriers to expansion of telemedicine. Seventy-eight percent of respondents reported that they would increase telemedicine utilization if current regulations were maintained in the future. Conclusions This study found that hernia specialists are utilizing telemedicine at a higher rate than before the COVID-19 pandemic, with surgeons reporting interest in continued use of this modality beyond the pandemic. These findings suggest that future work in telemedicine optimization may improve the quality of care that can be delivered to patients with abdominal core health concerns. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06332-9.
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Affiliation(s)
- Vahagn C Nikolian
- Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Mail Code L 233A, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Mudassir Akhter
- Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Mail Code L 233A, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Emaad J Iqbal
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Thomas Sutton
- Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Mail Code L 233A, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Ashraf Samhan
- Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Mail Code L 233A, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Sean B Orenstein
- Department of Surgery, Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Mail Code L 233A, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Michael J Rosen
- Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin K Poulose
- Center for Abdominal Core Health, Ohio State University, Columbus, OH, USA
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14
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LaPlaca MC, Huie JR, Alam HB, Bachstetter AD, Bayir H, Bellgowan PF, Cummings D, Dixon CE, Ferguson AR, Ferland-Beckham C, Floyd CL, Friess SH, Galanopoulou AS, Hall ED, Harris NG, Hawkins BE, Hicks RR, Hulbert LE, Johnson VE, Kabitzke PA, Lafrenaye AD, Lemmon VP, Lifshitz CW, Lifshitz J, Loane DJ, Misquitta L, Nikolian VC, Noble-Haeusslein LJ, Smith DH, Taylor-Burds C, Umoh N, Vovk O, Williams AM, Young M, Zai LJ. Pre-Clinical Common Data Elements for Traumatic Brain Injury Research: Progress and Use Cases. J Neurotrauma 2021; 38:1399-1410. [PMID: 33297844 PMCID: PMC8082734 DOI: 10.1089/neu.2020.7328] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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] [Indexed: 02/07/2023] Open
Abstract
Traumatic brain injury (TBI) is an extremely complex condition due to heterogeneity in injury mechanism, underlying conditions, and secondary injury. Pre-clinical and clinical researchers face challenges with reproducibility that negatively impact translation and therapeutic development for improved TBI patient outcomes. To address this challenge, TBI Pre-clinical Working Groups expanded upon previous efforts and developed common data elements (CDEs) to describe the most frequently used experimental parameters. The working groups created 913 CDEs to describe study metadata, animal characteristics, animal history, injury models, and behavioral tests. Use cases applied a set of commonly used CDEs to address and evaluate the degree of missing data resulting from combining legacy data from different laboratories for two different outcome measures (Morris water maze [MWM]; RotorRod/Rotarod). Data were cleaned and harmonized to Form Structures containing the relevant CDEs and subjected to missing value analysis. For the MWM dataset (358 animals from five studies, 44 CDEs), 50% of the CDEs contained at least one missing value, while for the Rotarod dataset (97 animals from three studies, 48 CDEs), over 60% of CDEs contained at least one missing value. Overall, 35% of values were missing across the MWM dataset, and 33% of values were missing for the Rotarod dataset, demonstrating both the feasibility and the challenge of combining legacy datasets using CDEs. The CDEs and the associated forms created here are available to the broader pre-clinical research community to promote consistent and comprehensive data acquisition, as well as to facilitate data sharing and formation of data repositories. In addition to addressing the challenge of standardization in TBI pre-clinical studies, this effort is intended to bring attention to the discrepancies in assessment and outcome metrics among pre-clinical laboratories and ultimately accelerate translation to clinical research.
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Affiliation(s)
- Michelle C. LaPlaca
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, Georgia, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - J. Russell Huie
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Hasan B. Alam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam D. Bachstetter
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Hűlya Bayir
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - C. Edward Dixon
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam R. Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | | | - Candace L. Floyd
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Stuart H. Friess
- Division of Critical Care Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Edward D. Hall
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Neil G. Harris
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Bridget E. Hawkins
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Lindsey E. Hulbert
- Department of Animal Sciences and Industry, Kansas State University, Manhattan, Kansas, USA
| | - Victoria E. Johnson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Audrey D. Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Vance P. Lemmon
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Carrie W. Lifshitz
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Jonathan Lifshitz
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - David J. Loane
- School of Biochemistry and Immunology, Trinity College Dublin, Dublin, Ireland
| | | | | | | | - Douglas H. Smith
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Nsini Umoh
- Department of Defense, U.S. Army Medical Research and Materiel Command, Fort Detrick, Frederick, Maryland, USA
| | - Olga Vovk
- National Institutes of Health, Bethesda, Maryland, USA
| | - Aaron M. Williams
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Margaret Young
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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15
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Bhatti UF, Karnovsky A, Dennahy IS, Kachman M, Williams AM, Nikolian VC, Biesterveld BE, Siddiqui A, O'Connell RL, Liu B, Li Y, Alam HB. Pharmacologic modulation of brain metabolism by valproic acid can induce a neuroprotective environment. J Trauma Acute Care Surg 2021; 90:507-514. [PMID: 33196629 DOI: 10.1097/ta.0000000000003026] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of trauma-related morbidity and mortality. Valproic acid (VPA) has been shown to attenuate brain lesion size and swelling within the first few hours following TBI. Because injured neurons are sensitive to metabolic changes, we hypothesized that VPA treatment would alter the metabolic profile in the perilesional brain tissues to create a neuroprotective environment. METHODS We subjected swine to combined TBI (12-mm cortical impact) and hemorrhagic shock (40% blood volume loss and 2 hours of hypotension) and randomized them to two groups (n = 5/group): (1) normal saline (NS; 3× hemorrhage volume) and (2) NS-VPA (NS, 3× hemorrhage volume; VPA, 150 mg/kg). After 6 hours, brains were harvested, and 100 mg of the perilesional tissue was used for metabolite extraction. Samples were analyzed using reversed-phase liquid chromatography-mass spectrometry in positive and negative ion modes, and data were analyzed using MetaboAnalyst software (McGill University, Quebec, Canada). RESULTS In untargeted reversed-phase liquid chromatography-mass spectrometry analysis, we detected 3,750 and 1,955 metabolites in positive and negative ion modes, respectively. There were no significantly different metabolites in positive ion mode; however, 167 metabolite features were significantly different (p < 0.05) in the negative ion mode, which included VPA derivates. Pathway analysis showed that several pathways were affected in the treatment group, including the biosynthesis of unsaturated fatty acids (p = 0.001). Targeted amino acid analysis on glycolysis/tricarboxylic acid (TCA) cycle revealed that VPA treatment significantly decreased the levels of the excitotoxic amino acid serine (p = 0.001). CONCLUSION Valproic acid can be detected in perilesional tissues in its metabolized form. It also induces metabolic changes in the brains within the first few hours following TBI to create a neuroprotective environment.
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Affiliation(s)
- Umar F Bhatti
- From the Department of Surgery (U.F.B., I.S.D., A.M.W., V.C.N., B.E.B., A.S., R.L.O., B.L., Y.L., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (U.F.B.), Washington University, St. Louis, Missouri; Department of Surgery (H.B.A.), Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Computational Medicine and Bioinformatics (A.K.), and Michigan Regional Comprehensive Metabolomics Resource Core (M.K.), University of Michigan Health System, Ann Arbor, Michigan
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16
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Nikolian VC, Coleman NL, Podolsky D, Novitsky YW. Robotic-Assisted Transabdominal Preperitoneal Ventral Hernia Repair. Surg Technol Int 2020; 36:95-97. [PMID: 32196564] [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: 06/10/2023]
Abstract
Ventral hernia repair is one of the most common operations performed by surgeons worldwide. The widespread adoption of laparoscopic surgery has significantly reduced complications related to traditional open approaches. The most common approach in laparoscopic ventral hernia repair is the intraperitoneal onlay mesh (IPOM) approach. This technique, though simple to perform, has limitations, including bridging mesh, intraperitoneal positioning of mesh, transfascial fixation, circumferential mesh fixation, and the use of more expensive composite mesh materials. These limitations are magnified when hernias occur in anatomically difficult sites such as the subxiphoid, suprapubic, and flank regions. Robotic-assisted hernia repair using a transabdominal preperitoneal (TAPP) approach has emerged as a viable alternative to traditional IPOM by potentially addressing these limitations. We review the operative considerations, intraoperative approach, and current body of literature related to robotic-assisted TAPP ventral hernia repair and conclude that it is feasible and may result in improved outcomes related to the restoration of abdominal wall anatomy and reduced operative costs. Further studies are needed to assess if robotic-assisted TAPP should become the standard approach for repair of ventral hernia defects.
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Affiliation(s)
- Vahagn C Nikolian
- Comprehensive Hernia Center, Columbia University Medical Center, New York, NY
| | - Natasha L Coleman
- Comprehensive Hernia Center, Columbia University Medical Center, New York, NY
| | - Dina Podolsky
- Comprehensive Hernia Center, Columbia University Medical Center, New York, NY
| | - Yuri W Novitsky
- Comprehensive Hernia Center, Columbia University Medical Center, New York, NY
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17
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Sandhu G, Thompson J, Matusko N, Sutzko DC, Nikolian VC, Boniakowski AE, Georgoff PE, Prabhu KA, Minter RM. Greater faculty familiarity with residents improves intraoperative entrustment. Am J Surg 2020; 219:608-612. [DOI: 10.1016/j.amjsurg.2019.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/31/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
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18
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Williams AM, He W, Li Y, Bhatti UF, Nikolian VC, Chang P, Chang Z, Halaweish I, Liu B, Cheng X, Alam HB. Histone Deacetylase Inhibition Attenuates Cardiomyocyte Hypoxia-Reoxygenation Injury. Curr Mol Med 2019; 18:711-718. [PMID: 30734677 DOI: 10.2174/1566524019666190208102729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/28/2018] [Accepted: 01/24/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiac reperfusion injury can have devastating consequences. Histone deacetylase (HDAC) inhibitors are potent cytoprotective agents, but their role in the prevention of cardiac injury remains ill-defined. OBJECTIVE We sought to determine the therapeutic potential of HDAC inhibitors in an in vitro model of cardiomyocyte hypoxia-reoxygenation (H/R). METHOD H9c2 cardiomyocytes were subjected to H/R and treated with various classspecific and pan-HDAC inhibitors in equal concentrations (5µM). Biological activity of inhibitors was determined, as a proxy for concentration adequacy, by Western blot for acetylated histone H3 and α-tubulin. Cell viability and cytotoxicity were measured by methyl thiazolyl tetrazolium and lactate dehydrogenase assays, respectively. Mechanistic studies were performed to better define the effects of the most effective agent, Tubastatin-A (Tub-A), on the phosphoinositide 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) pathway effectors, and on the degree of autophagy. RESULTS All inhibitors acetylated well-known target proteins (histone H3 and α-tubulin), suggesting that concentrations were adequate to induce a biological effect. Improved cell viability and decreased cell cytotoxicity were noted in cardiomyocytes exposed to Tub-A, whereas the cytoprotective effects of other HDAC inhibitors were inconsistent. Pro-survival mediators in the PI3K/mTOR pathway were up-regulated and the degree of autophagy was significantly attenuated in cells that were treated with Tub-A. CONCLUSION HDAC inhibitors improve cell viability in a model of cardiomyocyte H/R, with Class IIb inhibition (Tub-A) demonstrating superior cellular-level potency and effectiveness. This effect is, at least in part, related to an increased expression of prosurvival mediators and a decreased degree of autophagy.
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Affiliation(s)
- Aaron M Williams
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Wei He
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States.,Department of Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yongqing Li
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Umar F Bhatti
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Vahagn C Nikolian
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Panpan Chang
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Zhigang Chang
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States.,Department of Surgical Intensive Care, Beijing Hospital Ministry of Health, Beijing, China
| | - Ihab Halaweish
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Baoling Liu
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Xin Cheng
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Hasan B Alam
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
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19
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Bhatti UF, Williams AM, Nikolian VC, Dennahy IS, Weykamp M, Georgoff PE, Biesterveld BE, Tagett R, Li Y, Alam HB. Valproic Acid Treatment Modulates the Inflammatory and Coagulation Proteome Following Traumatic Brain Injury and Hemorrhagic Shock. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Sandhu G, Thompson-Burdine J, Nikolian VC, Sutzko DC, Prabhu KA, Matusko N, Minter RM. Association of Faculty Entrustment With Resident Autonomy in the Operating Room. JAMA Surg 2019; 153:518-524. [PMID: 29466559 DOI: 10.1001/jamasurg.2017.6117] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A critical balance is sought between faculty supervision, appropriate resident autonomy, and patient safety in the operating room. Variability in the release of supervision during surgery represents a potential safety hazard to patients. A better understanding of intraoperative faculty-resident interactions is needed to determine what factors influence entrustment. Objective To assess faculty and resident intraoperative entrustment behaviors and to determine whether faculty behaviors drive resident entrustability in the operating room. Design, Setting, and Participants This observational study was conducted from September 1, 2015, to August 31, 2016, at Michigan Medicine, the University of Michigan's health care system. Two surgical residents, 1 medical student, 2 behavioral research scientists, and 1 surgical faculty member observed surgical intraoperative interactions between faculty and residents in 117 cases involving 28 faculty and 35 residents and rated entrustment behaviors. Without intervening in the interaction, 1 or 2 researchers observed each case and noted behaviors, verbal and nonverbal communication, and interaction processes. Immediately after the case, observers completed an assessment using OpTrust, a validated tool designed to assess progressive entrustment in the operating room. Purposeful sampling was used to generate variation in type of operation, case difficulty, faculty-resident pairings, faculty experience, and resident training level. Main Outcomes and Measures Observer results in the form of entrustability scores (range, 1-4, with 4 indicating full entrustability) were compared with resident- and faculty-reported measures. Difficulty of operation was rated on a scale of 1 to 3 (higher scores indicate greater difficulty). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and observation duration, observation month, and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients. Results Twenty-eight faculty and 35 residents were observed across 117 surgical cases from 4 surgical specialties. Cases observed by postgraduate year (PGY) of residents were distributed as follows: PGY-1, 21 (18%); 2, 15 (13%); 3, 17 (15%); 4, 27 (23%); 5, 28 (24%); and 6, 9 (8%). Case difficulty was evenly distributed: 36 (33%) were rated easy/straightforward; 43 (40%), moderately difficult; and 29 (27%), very difficult by attending physicians. Path analysis showed that the association of PGY with resident entrustability was mediated by faculty entrustment (0.23 [.03]; P < .001). At the univariate level, case difficulty (mean [SD] resident entrustability score range, 1.97 [0.75] for easy/straightforward cases to 2.59 [0.82] for very difficult cases; F = 6.69; P = .01), PGY (range, 1.31 [0.28] for PGY-1 to 3.16 [0.54] for PGY-6; F = 22.85; P < .001), and faculty entrustment (2.27 [0.79]; R2 = 0.91; P < .001) were significantly associated with resident entrustability. Mean (SD) resident entrustability scores were highest for very difficult cases (2.59 [0.82]) and PGY-6 (3.16 [0.54]). Conclusions and Relevance Faculty entrustment behaviors may be the primary drivers of resident entrustability. Faculty entrustment is a feature of faculty surgeons' teaching style and could be amenable to faculty development efforts.
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Affiliation(s)
- Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor
| | | | | | | | | | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor
| | - Rebecca M Minter
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas.,Currently with Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
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21
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Williams AM, Bhatti UF, Dennahy IS, Graham NJ, Nikolian VC, Chtraklin K, Chang P, Zhou J, Biesterveld BE, Eliason J, Alam HB. Traumatic brain injury may worsen clinical outcomes after prolonged partial resuscitative endovascular balloon occlusion of the aorta in severe hemorrhagic shock model. J Trauma Acute Care Surg 2019; 86:415-423. [PMID: 30605139 PMCID: PMC6715315 DOI: 10.1097/ta.0000000000002149] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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] [Indexed: 12/25/2022]
Abstract
BACKGROUND The use of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) in combined hemorrhagic shock (HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that the use of pREBOA in the setting of TBI would be associated with worse clinical outcomes. METHODS Female Yorkshire swine were randomized to the following groups: HS-TBI, HS-TBI-pREBOA, and HS-pREBOA (n = 5/cohort). Animals in the HS-TBI group were left in shock for a total of 2 hours, whereas animals assigned to pREBOA groups were treated with supraceliac pREBOA deployment (60 minutes) 1 hour into the shock period. All animals were then resuscitated, and physiologic parameters were monitored for 6 hours. Further fluid resuscitation and vasopressors were administered as needed. At the end of the observation period, brain hemispheric swelling (%) and lesion size (mm) were assessed. RESULTS Mortality was highest in the HS-TBI-pREBOA group (40% [2/5] vs. 0% [0/5] in the other groups, p = 0.1). Severity of shock was greatest in the HS-TBI-pREBOA group, as defined by peak lactate levels and pH nadir (p < 0.05). Fluid resuscitation and norepinephrine requirements were significantly higher in the HS-TBI-pREBOA group (p < 0.05). No significant differences were noted in brain hemispheric swelling and lesion size between the groups. CONCLUSION Prolonged application of pREBOA in the setting of TBI does not contribute to early worsening of brain lesion size and edema. However, the addition of TBI to HS-pREBOA may worsen the severity of shock. Providers should be aware of the potential physiologic sequelae induced by TBI.
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Affiliation(s)
| | - Umar F. Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Nathan J. Graham
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Kiril Chtraklin
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Panpan Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jing Zhou
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Jonathan Eliason
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hasan B. Alam
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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22
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Abstract
Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.
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23
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Kandagatla P, Nikolian VC, Matusko N, Mason S, Regenbogen SE, Hardiman KM. Patient-Reported Outcomes and Readmission after Ileostomy Creation in Older Adults. Am Surg 2018. [DOI: 10.1177/000313481808401141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Because of the concern about risk of poor outcome, ileostomy creation is sometimes avoided in older adults. We sought to evaluate the effect of a rigorous postoperative pathway and checklist on readmission and self-efficiacy in older surgical patients. After implementing a self-care checklist and standardized care pathway at our institution, we performed a retrospective review of patients between June 2013 and June 2016 and compared characteristics and outcomes for patients aged <65 and ≥65 years. Using logistic regression, we identified independent predictors of readmission. We also conducted a survey of patient self-efficacy after discharge to assess independence. There were 288 younger patients and 72 older patients. The older group had more patients with an American Society of Anesthesiologists >2 (53.0% vs 81.4%, P < 0.01) and were more likely to have had surgery for cancer (22.9% vs 48.5%, P < 0.01). In the multivariable analyses, age was not a predictor of readmission but American Society of Anesthesiologist and length of stay were. In the 57 patients surveyed after discharge, we found that older and younger patients reported similar self-efficacy scores. In our study, older and younger patients have similar rates of readmission and similar ability to independently care for their themselves after ileostomy creation.
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Affiliation(s)
- Pridvi Kandagatla
- Department of Surgery, Henry Ford Health System/Wayne State University, Detroit, Michigan and
| | - Vahagn C. Nikolian
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Shayna Mason
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Scott E. Regenbogen
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Karin M. Hardiman
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Kandagatla P, Nikolian VC, Matusko N, Mason S, Regenbogen SE, Hardiman KM. Patient-Reported Outcomes and Readmission after Ileostomy Creation in Older Adults. Am Surg 2018; 84:1814-1818. [PMID: 30747639 PMCID: PMC6613972] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Because of the concern about risk of poor outcome, ileostomy creation is sometimes avoided in older adults. We sought to evaluate the effect of a rigorous postoperative pathway and checklist on readmission and self-efficiacy in older surgical patients. After implementing a self-care checklist and standardized care pathway at our institution, we performed a retrospective review of patients between June 2013 and June 2016 and compared characteristics and outcomes for patients aged <65 and ≥65 years. Using logistic regression, we identified independent predictors of readmission. We also conducted a survey of patient self-efficacy after discharge to assess independence. There were 288 younger patients and 72 older patients. The older group had more patients with an American Society of Anesthesiologists >2 (53.0% vs 81.4%, P < 0.01) and were more likely to have had surgery for cancer (22.9% vs 48.5%, P < 0.01). In the multivariable analyses, age was not a predictor of readmission but American Society of Anesthesiologist and length of stay were. In the 57 patients surveyed after discharge, we found that older and younger patients reported similar self-efficacy scores. In our study, older and younger patients have similar rates of readmission and similar ability to independently care for their themselves after ileostomy creation.
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Affiliation(s)
- Pridvi Kandagatla
- Department of Surgery, Henry Ford Health System/Wayne State University, Detroit, MI 48201
| | - Vahagn C Nikolian
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Shayna Mason
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Scott E Regenbogen
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Karin M Hardiman
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
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Sandhu G, Sutzko DC, Nikolian VC, Matusko N, Thompson-Burdine JA, Prabhu K, Minter R. Effective Faculty Development Strategy for Enhancing Intraoperative Entrustment of Residents. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chang P, Williams AM, Dennahy IS, Bhatti UF, Liu B, Nikolian VC, Li Y, Alam HB. Valproic Acid Treatment Attenuates Degenerative Brain Lesions, Neuroinflammation, and Apoptosis in Long-Term Survival Model of Traumatic Brain Injury, Hemorrhagic Shock, and Polytrauma in Swine. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Williams AM, Bhatti UF, Barrett M, Nikolian VC, Han B, Matusko N, Sung RS, Reddy RM, Newman EA, Woodside KJ, Sandhu G. Resident perceptions and evaluations of fellow-led and resident-led surgical services. Am J Surg 2018; 217:373-381. [PMID: 30224072 DOI: 10.1016/j.amjsurg.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/06/2018] [Accepted: 09/01/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The impact of fellowship training on general surgery residency has remained challenging to assess. Surgical resident perceptions of fellow-led and resident-led surgical services have not been well described. METHODS Retrospective cross-sectional data were collected from residents' service evaluations from 7/2014 through 7/2017. Surgical services were categorized as resident-led or fellow-led. 31 variables were evaluated and collapsed into 7 factors including clinical experience, educational experiences, clinical staff, workload, feedback, treatment of residents, and overall rotation. RESULTS Among all PGY levels, fellow-led surgical services were rated significantly higher (p < 0.05) regarding clinical experience, clinical staff, treatment of residents, and overall rotation. PGY1-2 residents rated resident-led services significantly higher in the area of educational experiences, while PGY 3 residents rated resident-led services higher in the area of workload. However, PGY4-5 residents rated fellow-led services significantly higher in all 7 categories. Individual fellow-led services were rated significantly higher for various categories at different PGY levels. CONCLUSIONS Surgical residents appear to value the educational experiences of fellow-led services. Each fellow-led service may ultimately provide unique educational opportunities and resources for different PGY levels.
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Affiliation(s)
- Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Umar F Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Meredith Barrett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Britta Han
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Randall S Sung
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Erika A Newman
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Sandhu G, Thompson-Burdine J, Matusko N, Sutzko DC, Nikolian VC, Boniakowski A, Georgoff PE, Prabhu KA, Minter RM. Bridging the gap: The intersection of entrustability and perceived autonomy for surgical residents in the OR. Am J Surg 2018; 217:276-280. [PMID: 30177241 DOI: 10.1016/j.amjsurg.2018.07.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 04/16/2018] [Revised: 06/27/2018] [Accepted: 07/23/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Faculty entrustment decisions affect resident entrustability behaviors and surgical autonomy. The relationship between entrustability and autonomy is not well understood. This pilot study explores that relationship. METHODS 108 case observations were completed. Entrustment behaviors were rated using OpTrust. Residents completed a Zwisch self-assessment to measure surgical autonomy. Resident perceived autonomy was collected for 67 cases used for this pilot study. RESULTS Full entrustability was observed in 5 of the 108 observed cases. Residents in our study did not report full autonomy. Spearman's rank correlation coefficient identified that resident entrustability was positively correlated with perceived resident autonomy (ρ = 0.66, p < 0.05). Ordinal logistic regression assessed the relationship between resident entrustability and autonomy. The relationship persisted while controlling for PGY level, gender, and case complexity (OR = 8.42, SEM = 4.54, p < 0.000). CONCLUSIONS Resident entrustability is positively associated with perceived autonomy, yet full entrustability is not translating to the perception of full autonomy for residents.
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Affiliation(s)
- Gurjit Sandhu
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Julie Thompson-Burdine
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Niki Matusko
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Danielle C Sutzko
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Vahagn C Nikolian
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Anna Boniakowski
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Patrick E Georgoff
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Kaustubh A Prabhu
- Department of Surgery, University of Michigan Health System, 2207 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, USA.
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, H4/710D Clinical Science Center, 600 Highland Avenue, Madison, WI, USA.
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Williams AM, Bhatti UF, Dennahy IS, Chtraklin K, Chang P, Graham NJ, Baccouche BM, Roy S, Harajli M, Zhou J, Nikolian VC, Deng Q, Tian Y, Liu B, Li Y, Hays GL, Hays JL, Alam HB. Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine. J Vis Exp 2018:58284. [PMID: 30199035 PMCID: PMC6231876 DOI: 10.3791/58284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the forefront of trauma care in recent years. Since complete aortic occlusion presents serious concerns, the concept of partial aortic occlusion has gained a growing attention. Here, we present a large animal model of hemorrhagic shock to investigate the effects of a novel partial aortic balloon occlusion catheter and compare it with a catheter that works on the principles of complete aortic occlusion. Swine are anesthetized and instrumented in order to conduct controlled fixed-volume hemorrhage, and hemodynamic and physiological parameters are monitored. Following hemorrhage, aortic balloon occlusion catheters are inserted and inflated in the supraceliac aorta for 60 min, during which the animals receive whole-blood resuscitation as 20% of the total blood volume (TBV). Following balloon deflation, the animals are monitored in a critical care setting for 4 h, during which they receive fluid resuscitation and vasopressors as needed. The partial aortic balloon occlusion demonstrated improved distal mean arterial pressures (MAPs) during the balloon inflation, decreased markers of ischemia, and decreased fluid resuscitation and vasopressor use. As swine physiology and homeostatic responses following hemorrhage have been well-documented and are like those in humans, a swine hemorrhagic shock model can be used to test various treatment strategies. In addition to treating hemorrhage, aortic balloon occlusion catheters have become popular for their role in cardiac arrest, cardiac and vascular surgery, and other high-risk elective surgical procedures.
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Affiliation(s)
| | | | | | | | | | | | | | - Shalini Roy
- Department of Surgery, University of Michigan
| | | | - Jing Zhou
- Department of Surgery, University of Michigan
| | | | | | - Yuzi Tian
- Department of Surgery, University of Michigan
| | - Baoling Liu
- Department of Surgery, University of Michigan
| | - Yongqing Li
- Department of Surgery, University of Michigan
| | - Gregory L Hays
- Department of Surgery, University of Michigan; Hays Innovations
| | - Julia L Hays
- Department of Surgery, University of Michigan; Hays Innovations
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Williams AM, Dennahy IS, Bhatti UF, Halaweish I, Xiong Y, Chang P, Nikolian VC, Chtraklin K, Brown J, Zhang Y, Zhang ZG, Chopp M, Buller B, Alam HB. Mesenchymal Stem Cell-Derived Exosomes Provide Neuroprotection and Improve Long-Term Neurologic Outcomes in a Swine Model of Traumatic Brain Injury and Hemorrhagic Shock. J Neurotrauma 2018; 36:54-60. [PMID: 29690826 DOI: 10.1089/neu.2018.5711] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Combined traumatic brain injury (TBI) and hemorrhagic shock (HS) remains a leading cause of preventable death worldwide. Mesenchymal stem cell-derived exosomes have demonstrated promise in small animal models of neurologic injury. To investigate the effects of exosome treatment in a clinically realistic large animal model, Yorkshire swine underwent TBI and HS. Animals were maintained in shock for 2 h before resuscitation with normal saline (NS). Animals were then resuscitated either with NS (3 × volume of shed blood) or with the same volume of NS with delayed exosome administration (1 × 1013 particles/4 mL) (n = 5/cohort). Exosomes were administered 9 h post-injury, and on post-injury days (PID) 1, 5, 9, and 13. Neurologic severity scores (NSS) were assessed for 30 days, and neurocognitive functions were objectively measured. Exosome-treated animals had significantly lower NSS (p < 0.05) during the first five days of recovery. Exosome-treated animals also had a significantly shorter time to complete neurologic recovery (NSS = 0) compared with animals given NS alone (days to recovery: NS = 16.8 ± 10.6; NS + exosomes = 5.6 ± 2.8; p = 0.03). Animals treated with exosomes initiated neurocognitive testing earlier (days to initiation: NS = 9.6 ± 0.5 vs. NS + exosomes = 4.2 ± 0.8; p = 0.008); however, no difference was seen in time to mastery of tasks. In conclusion, treatment with exosomes attenuates the severity of neurologic injury and allows for faster neurologic recovery in a clinically realistic large animal model of TBI and HS.
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Affiliation(s)
- Aaron M Williams
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Isabel S Dennahy
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Umar F Bhatti
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ihab Halaweish
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ye Xiong
- 2 Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Panpan Chang
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Vahagn C Nikolian
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kiril Chtraklin
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jordana Brown
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Yanlu Zhang
- 2 Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan
| | - Zheng Gang Zhang
- 3 Department of Neurology, Henry Ford Hospital, Detroit, Michigan
| | - Michael Chopp
- 3 Department of Neurology, Henry Ford Hospital, Detroit, Michigan.,4 Department of Physics, Oakland University, Rochester, Michigan
| | - Benjamin Buller
- 3 Department of Neurology, Henry Ford Hospital, Detroit, Michigan
| | - Hasan B Alam
- 1 Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Thompson-Burdine J, Sutzko DC, Nikolian VC, Boniakowski A, Georgoff PE, Prabhu KA, Matusko N, Minter RM, Sandhu G. Impact of a resident's sex on intraoperative entrustment of surgery trainees. Surgery 2018; 164:583-588. [PMID: 30041964 DOI: 10.1016/j.surg.2018.05.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/04/2018] [Accepted: 05/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Optimizing intraoperative education is critical for development of autonomous residents. Faculty decisions concerning intraoperative entrustment determine the degree to which a resident gains intraoperative responsibility. Accordingly, residents exhibit entrustable behaviors that further faculty entrustment in the operating room. Little empiric evidence exists evaluating how the sex of a resident influences faculty-resident decisions of entrustment. Studies involving perception-based measurements of autonomy report inequities for women residents. We sought to assess faculty behaviors in entrustment in relation to resident sex using OpTrust, a third-party objective measurement tool. METHODS From September 2015 to June 2017 at the University of Michigan, surgical cases were observed and entrustment behaviors were rated using OpTrust. Critical case sampling was used to generate variation in operation type, case difficulty, faculty-resident pairings, faculty experience, and the level of the resident's training. Independent sample t-tests were conducted to compare faculty entrustment scores, as well as resident entrustability scores. RESULTS A total of 56 faculty and 73 residents were observed across 223 surgical cases from 4 surgical specialties: general, plastic, thoracic, and vascular. There was no difference in faculty entrustment or entrustability scores between women and men (2.54 vs 2.35, P = .117 and 2.32 vs 2.22, P = .393, respectively). CONCLUSION Using OpTrust scores, we found that a resident's sex does not appear to influence faculty entrustment in the OR. Faculty entrustment scores for women and men residents are similar across cases. This observation suggests that during the intraoperative interaction, faculty are not extending entrustment or opportunities for autonomy differently to women or men. Future research is needed to identify and measure perioperative elements that inform resident autonomy, which may contribute to inequities for women residents.
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Chang P, Weykamp M, Dennahy IS, Williams AM, Bhatti UF, Liu B, Nikolian VC, Li Y, Alam HB. Histone deacetylase inhibitors: Isoform selectivity improves survival in a hemorrhagic shock model. J Trauma Acute Care Surg 2018; 84:795-801. [PMID: 29401190 PMCID: PMC6318805 DOI: 10.1097/ta.0000000000001824] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hemorrhage is a leading preventable cause of death. Nonselective histone deacetylase inhibitors (HDACIs), such as valproic acid (VPA), have been shown to improve outcomes in hemorrhagic shock (HS). The HDACs can be divided into four functional classes (I, IIa/IIb, III, and IV). Classes I, IIa/IIb, and III have previously been implicated in the pathophysiology of HS. This study aimed to determine which HDAC class, or classes, are responsible for the survival benefit observed with nonselective HDACIs. METHODS Survival study: Sprague-Dawley rats were subjected to lethal HS (50% hemorrhage) and randomized to the following groups (n = 8): (1) no treatment, (2) normal saline vehicle, (3) cyclodextrin vehicle, (4) MS275 (class I HDACI), (5) VPA (class I/IIa HDACI), (6) MC1568 (class IIa HDACI), (7) ACY1083 (class IIb HDACI), and (8) EX527 (class III HDACI). Survival was monitored for 24 hours. Mechanistic study: Sprague-Dawley rats were subjected to sublethal HS (40% hemorrhage) and randomized to the same groups (n = 3), excluding EX527, based on results of the survival study. Tissues were harvested at 3 hours posttreatment, and expression of phosphorylated-AKT, β-catenin, acetylated histones H3 and H4, and acetylated α-tubulin were analyzed in myocardial tissue. RESULTS Survival rate was 12.5% in the untreated group, and did not improve with vehicle or MS275 treatment. EX527 improved survival to 50%, although this did not achieve statistical significance (p = 0.082). However, treatment with VPA, MC1568, and ACY1083 improved survival rates to 87.5%, 75%, and 75%, respectively (p < 0.05). The VPA-induced acetylation of both histones H3 and H4, while MC1568 and ACY1083 increased acetylation of histone H4. ACY1083 also induced acetylation of α-tubulin. All treatment groups, except MS275, increased phosphorylated-AKT, and β-catenin. CONCLUSION Inhibition of HDAC classes IIa or IIb, but not class I, activates prosurvival pathways, which may be responsible for the improved outcomes in rodent models of HS.
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Affiliation(s)
- Panpan Chang
- Department of Neurosurgery, the First Hospital of China Medical University, Shenyang, China
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Michael Weykamp
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Isabel S. Dennahy
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Aaron M. Williams
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Umar F. Bhatti
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Baoling Liu
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Vahagn C. Nikolian
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Yongqing Li
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Hasan B. Alam
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Weykamp M, Nikolian VC, Dennahy IS, Higgins GA, Georgoff PE, Remmer H, Ghandour MH, Alam HB. Rapid valproic acid-induced modulation of the traumatic proteome in a porcine model of traumatic brain injury and hemorrhagic shock. J Surg Res 2018; 228:84-92. [PMID: 29907235 DOI: 10.1016/j.jss.2018.02.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 09/19/2017] [Revised: 01/10/2018] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Histone deacetylase inhibitors such as valproic acid (VPA) improve survival in lethal models of hemorrhagic shock and polytrauma. Although VPA is known to modulate transcription, its ability to reduce mortality within minutes of administration suggests involvement of a rapid, posttranslational mechanism. We hypothesized that VPA treatment would cause proteomic changes within minutes of treatment including quantitative and/or posttranslational differences in structural and/or effector proteins. MATERIALS AND METHODS We used a porcine model of traumatic brain injury (computer-controlled cortical impact, 12 mm depth) and hemorrhagic shock (40% hemorrhage). Animals were kept in shock for 2 h and randomized to two groups (n = 3): normal saline (volume = 3:1 hemorrhage volume) or normal saline + VPA (150 mg/kg, single dose). Peripheral blood mononuclear cells were collected at baseline, postshock, and postresuscitation. Intracellular protein profiles were assessed using 1 dimensional gel electrophoresis, liquid chromatography, mass spectrometry, and analyzed with Ingenuity Pathway Analysis software. RESULTS Animals treated with VPA demonstrated significant proteomic changes. Quantitative differences were found in over 200 proteins including effector, regulatory, and structural proteins in critical cell signaling pathways. Posttranslational modification analysis demonstrated differential VPA-induced acetylation of lysine residues in histone and nonhistone proteins. Pathway analysis correlated these changes with significant increases in numerous prosurvival and cytoskeletal intracellular pathways, including Rho GTPase signaling (P = 1.66E-11), integrin signaling (P = 4.19E-21), and a decrease in Rho guanosine nucleotide dissociation inhibitor signaling (P = 4.83E-12). CONCLUSIONS In a porcine model of severe injuries, a single dose of VPA is associated with protective changes in the proteome that are measurable within minutes of treatment.
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Affiliation(s)
- Michael Weykamp
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Vahagn C Nikolian
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Isabel S Dennahy
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Gerald A Higgins
- Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Patrick E Georgoff
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Henriette Remmer
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mohamed H Ghandour
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Hasan B Alam
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
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Georgoff PE, Nikolian VC, Higgins G, Chtraklin K, Eidy H, Ghandour MH, Williams A, Athey B, Alam HB. Valproic acid induces prosurvival transcriptomic changes in swine subjected to traumatic injury and hemorrhagic shock. J Trauma Acute Care Surg 2018; 84:642-649. [PMID: 29251706 DOI: 10.1097/ta.0000000000001763] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Valproic acid (VPA) is a histone deacetylase inhibitor that improves outcomes in large animal models of trauma. However, its protective mechanism of action is not completely understood. We sought to characterize the genetic changes induced by VPA treatment following traumatic injuries. METHODS Six female Yorkshire swine were subjected to traumatic brain injury (controlled cortical impact), polytrauma (liver and splenic laceration, rib fracture, rectus crush), and hemorrhagic shock (HS, 40% total blood volume). Following 2 hours of HS, animals were randomized to resuscitation with normal saline (NS) or NS + 150 mg/kg of intravenous VPA (n = 3/cohort, 18 samples total). Blood samples were collected for isolation of peripheral blood mononuclear cells at three distinct time points: baseline, 6 hours following injuries, and on postinjury day 1. RNA was extracted from peripheral blood mononuclear cells and sequenced. Differential expression analysis (false discovery rate < 0.001 and p value <0.001) and gene set enrichment (Panther Gene Ontology and Ingenuity Pathway Analysis) was used to compare VPA to non-VPA-treated animals. RESULTS A total of 628 differentially expressed RNA transcripts were identified, 412 of which were used for analysis. There was no difference between treatment groups at baseline. The VPA-induced genetic changes were similar at 6 hours and on postinjury day 1. Upregulated genes were associated with gene expression (p 2.13E-34), cellular development (1.19E-33), cellular growth and proliferation (1.25E-30), and glucocorticoid receptor signaling (8.6E-21). Downregulated genes were associated with cell cycle checkpoint regulation (3.64E-22), apoptosis signaling (6.54E-21), acute phase response signaling (5.84E-23), and the inflammasome pathway (1.7E-19). CONCLUSION In injured swine, VPA increases the expression of genes associated with cell survival, proliferation, and differentiation and decreases those associated with cell death and inflammation. These genetic changes could explain the superior clinical outcomes in VPA-treated animals, including smaller brain lesion size and improved neurologic recovery.
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Affiliation(s)
- Patrick E Georgoff
- From the Department of Surgery (P.E.G., V.C.N., K.C., H.E., M.H.G., A.W., H.B.A.), and Department of Computational Medicine & Bioinformatics (G.H., B.A.), University of Michigan, Ann Arbor, Michigan
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Dekker SE, Nikolian VC, Sillesen M, Bambakidis T, Schober P, Alam HB. Different resuscitation strategies and novel pharmacologic treatment with valproic acid in traumatic brain injury. J Neurosci Res 2018; 96:711-719. [PMID: 28742231 PMCID: PMC5785554 DOI: 10.1002/jnr.24125] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 01/17/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 12/28/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of death in young adults, and effective treatment strategies have the potential to save many lives. TBI results in coagulopathy, endothelial dysfunction, inflammation, cell death, and impaired epigenetic homeostasis, ultimately leading to morbidity and/or mortality. Commonly used resuscitation fluids such as crystalloids or colloids have several disadvantages and might even be harmful when administered in large quantities. There is a need for next-generation treatment strategies (especially in the prehospital setting) that minimize cellular damage, improve survival, and enhance neurological recovery. Pharmacologic treatment with histone deacetylase inhibitors, such as valproic acid, has shown promising results in animal studies of TBI and may therefore be an excellent example of next-generation therapy. This review briefly describes traditional resuscitation strategies for TBI combined with hemorrhagic shock and describes preclinical studies on valproic acid as a new pharmacologic agent in the treatment of TBI. It finally discusses limitations and future directions on the use of histone deacetylase inhibitors for the treatment of TBI.
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Affiliation(s)
- Simone E. Dekker
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
- Department of Neurological Surgery, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Vahagn C. Nikolian
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Martin Sillesen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Institute for Inflammation Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ted Bambakidis
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Patrick Schober
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Hasan B. Alam
- Department of Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
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Nikolian VC, Pan B, Mesar T, Dennahy IS, Georgoff PE, Duan X, Liu B, Wu X, Duggan MJ, Alam HB, Li Y. Lung Protective Effects of Low-Volume Resuscitation and Pharmacologic Treatment of Swine Subjected to Polytrauma and Hemorrhagic Shock. Inflammation 2018; 40:1264-1274. [PMID: 28493077 DOI: 10.1007/s10753-017-0569-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hemorrhage is a common cause of death in the battlefield. Valproic acid (VPA) has been associated with improved outcomes in multiple models of trauma, when combined with isotonic fluid resuscitation. However, isotonic fluid administered in this setting is logistically impractical and may be associated with complications. In this study, we sought to evaluate the feasibility and immunologic impact of combining VPA treatment with low-volume hypertonic saline (HTS). In vivo: female Yorkshire swine were subjected to hemorrhage (40% total blood volume) and polytrauma (rib fracture and delayed liver injury). Animals were kept in shock for 30 minutes and resuscitated with (1) normal saline (NS, 3× hemorrhaged volume), (2) HTS (7.5% saline, 4 mL/kg), or (3) HTS + VPA (4 mg/kg; 150 mg/kg; n = 3/cohort). After 18 hours of observation, animals were euthanized and the lungs evaluated for acute injury and expression of myeloperoxidase (MPO) and caveolin-1 (Cav-1). In vitro: human umbilical vein endothelial cells (HUVECs) were exposed to anoxic conditions (5% CO2, 95% N2) for 16 hours in (1) normosmotic, (2) hyperosmotic (400 mOsm), or (3) hyperosmotic + VPA (4 mM) media. Immunohistochemistry and Western blots were performed to determine Cav-1 expression. Lungs from VPA-treated animals demonstrated decreased acute injury, MPO expression, and endothelial expression of Cav-1 when compared to lungs from animals resuscitated with NS or HTS alone. Similarly, HUVECs cultured in hyperosmotic media containing VPA demonstrated decreased expression of Cav-1. This study demonstrates that combined treatment with VPA and HTS is a viable strategy in hemorrhagic shock and polytrauma. Attenuation of lung injury following VPA treatment may be related to modulation of the inflammatory response.
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Affiliation(s)
- Vahagn C Nikolian
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Baihong Pan
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tomaz Mesar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Isabel S Dennahy
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Patrick E Georgoff
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Xiuzhen Duan
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Baoling Liu
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Xizi Wu
- Emergency Department, The First Hospital of China Medical University, Shenyang, China
| | - Michael J Duggan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Yongqing Li
- Department of Surgery, University of Michigan Health System, NCRC Building 26 Room 363N, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.
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Korley FK, Nikolian VC, Williams AM, Dennahy IS, Weykamp M, Alam HB. Valproic Acid Treatment Decreases Serum Glial Fibrillary Acidic Protein and Neurofilament Light Chain Levels in Swine Subjected to Traumatic Brain Injury. J Neurotrauma 2018; 35:1185-1191. [PMID: 29415612 DOI: 10.1089/neu.2017.5581] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 01/05/2023] Open
Abstract
The primary aim of this study was to examine the effects of valproic acid (VPA) treatment on serum glial fibrillary acidic protein (GFAP) and neurofilament light chain (NF-L) levels. To achieve this aim, we obtained serum samples from: 1) 10 Yorkshire swine subjected to controlled cortical impact traumatic brain injury (CCI TBI) + polytrauma and randomized to receive either normal saline (NS) + VPA (n = 5) or NS alone (n = 5) and 2) five additional swine subjected to CCI TBI without polytrauma and treated with VPA. GFAP and NF-L levels were measured in samples obtained from baseline until 10 days post-injury using a digital immunoassay from Quanterix Corporation. We found that elevated GFAP and NF-L levels were first detected at 2 h post-injury; and peaked at 24 h and 72 h respectively. GFAP levels returned to baseline levels by Day 10, while NF-L remained elevated at Day 10. In TBI + polytrauma swine, the magnitude and duration of biomarker elevation, quantified by the area under the biomarker-concentration-versus-time curve during the first 10 days (AUC0-10days), was higher in the NS group, compared with the VPA group. For GFAP, the AUC0-10days was 45,535 (IQR: 35,741-105,711) and 22,837 (IQR: 8,082-46,627) for the NS and NS+VPA groups, respectively. For NF-L, the AUC0-10days was 43,073 (IQR: 18,739-120,794) and 4,475 (2,868-11,157) for the NS and NS+VPA groups, respectively. Twenty-four hour GFAP and NF-L levels had the strongest correlation with lesion size and time to normalization of behavior. Accordingly, we conclude that treatment with VPA results in significantly lower serum GFAP and NF-L levels. The time-point at which GFAP and NF-L levels have the strongest correlation with outcome is 24 h post-injury.
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Affiliation(s)
- Frederick K Korley
- 1 Department of Emergency Medicine, University of Michigan Medical School , Ann Arbor, Michigan
| | - Vahagn C Nikolian
- 2 Department of Surgery, University of Michigan Medical School , Ann Arbor, Michigan
| | - Aaron M Williams
- 2 Department of Surgery, University of Michigan Medical School , Ann Arbor, Michigan
| | - Isabel S Dennahy
- 2 Department of Surgery, University of Michigan Medical School , Ann Arbor, Michigan
| | | | - Hasan B Alam
- 2 Department of Surgery, University of Michigan Medical School , Ann Arbor, Michigan
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Nikolian VC, Dennahy IS, Higgins GA, Williams AM, Weykamp M, Georgoff PE, Eidy H, Ghandour MH, Chang P, Alam HB. Transcriptomic changes following valproic acid treatment promote neurogenesis and minimize secondary brain injury. J Trauma Acute Care Surg 2018; 84:459-465. [PMID: 29251707 PMCID: PMC5905703 DOI: 10.1097/ta.0000000000001765] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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] [Indexed: 12/30/2022]
Abstract
BACKGROUND Early treatment with valproic acid (VPA) has demonstrated benefit in preclinical models of traumatic brain injury, including smaller brain lesion size, decreased edema, reduced neurologic disability, and faster recovery. Mechanisms underlying these favorable outcomes are not fully understood. We hypothesized that VPA treatment would upregulate genes involved in cell survival and proliferation and downregulate those associated with cell death and the inflammatory response. METHODS Ten female swine were subjected to a protocol of traumatic brain injury and hemorrhagic shock. They were assigned to two groups (n = 5): normal saline (NS; 3× volume of shed blood), or NS + VPA (150 mg/kg). Following 6 hours of observation, brain tissue was harvested to evaluate lesion size and edema. Brain tissue was processed for RNA sequencing. Gene set enrichment and pathway analysis was performed to determine the differential gene expression patterns following injury. RESULTS Animals treated with VPA were noted to have a 46% reduction in brain lesion size and a 57% reduction in ipsilateral brain edema. Valproic acid significantly upregulated genes involved in morphology of the nervous system, neuronal development and neuron quantity. The VPA treatment downregulated pathways related to apoptosis, glial cell proliferation, and neuroepithelial cell differentiation. Ingenuity Pathway Analysis identified VPA as the top upstream regulator of activated transcription, supporting it as a direct cause of these transcriptional changes. Master transcriptional regulator NEUROD1 was also significantly upregulated, suggesting that VPA may induce additional transcription factors. CONCLUSION Administration of VPA attenuated brain lesion size, reduced brain edema, and induced significant changes in the transcriptome of injured brain within 6 hours. Patterns of differential expression were consistent with the proposed neurogenic and prosurvival effects of VPA treatment.
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Affiliation(s)
| | | | - Gerald A. Higgins
- Department of Computational Medicine & Bioinformatics, University of Michigan, Ann Arbor, MI
| | | | - Michael Weykamp
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Hassan Eidy
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Panpan Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Hasan B. Alam
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Georgoff PE, Shaughness G, Leininger L, Nikolian VC, Sandhu G, Reddy R, Hughes DT. Evaluating the performance of the Minute Feedback System : A web-based feedback tool for medical students. Am J Surg 2018; 215:293-297. [DOI: 10.1016/j.amjsurg.2017.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/11/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
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Conner TM, Nikolian VC, Georgoff PE, Pai MP, Alam HB, Sun D, Reed RC, Zhang T. Physiologically based pharmacokinetic modeling of disposition and drug-drug interactions for valproic acid and divalproex. Eur J Pharm Sci 2018; 111:465-481. [DOI: 10.1016/j.ejps.2017.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/15/2017] [Accepted: 10/06/2017] [Indexed: 11/28/2022]
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Abstract
Telemedicine has become one of the most rapidly-expanding components of the health care system. Its adoption has afforded improved access to care, greater resource efficiency, and decreased costs associated with traditional office visits and has been well established in a wide array of fields. Telemedicine has been adopted in several domains of surgical care. In recent years, the role of telemedicine in postoperative care has caught attention as it has demonstrated excellent clinical outcomes, enhanced patient satisfaction, increased accessibility along with reduced wait times, and cost savings for patients and health care systems. In this narrative review, we describe the history of telemedicine, its adoption in the field of surgery and its various modalities, its use in the postoperative setting, and the potential benefits to both patients and healthcare systems. As telemedicine continues to emerge as a powerful tool for health care delivery, we also discuss several barriers to its widespread adoption as well as the future utility of telemedicine in postoperative care.
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Affiliation(s)
- Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Umar F Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Weykamp MB, Nikolian VC, Dennahy IS, Georgoff PE, Higgins GA, Chang P, Ghandour MH, Tafatia C, Eidy H, Alam HB. Valproic Acid Treatment Rapidly Modulates the Proteomic Profile in a Porcine Model of Hemorrhagic Shock and Traumatic Brain Injury. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shaughness G, Georgoff PE, Sandhu G, Leininger L, Nikolian VC, Reddy R, Hughes DT. Assessment of clinical feedback given to medical students via an electronic feedback system. J Surg Res 2017; 218:174-179. [DOI: 10.1016/j.jss.2017.05.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/31/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
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Nikolian VC, Ibrahim AM. What Does the Future Hold for Scientific Journals? Visual Abstracts and Other Tools for Communicating Research. Clin Colon Rectal Surg 2017; 30:252-258. [PMID: 28924398 DOI: 10.1055/s-0037-1604253] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 10/18/2022]
Abstract
Journals fill several important roles within academic medicine, including building knowledge, validating quality of methods, and communicating research. This section provides an overview of these roles and highlights innovative approaches journals have taken to enhance dissemination of research. As journals move away from print formats and embrace web-based content, design-centered thinking will allow for engagement of a larger audience. Examples of recent efforts in this realm are provided, as well as simplified strategies for developing visual abstracts to improve dissemination via social media. Finally, we hone in on principles of learning and education which have driven these advances in multimedia-based communication in scientific research.
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Affiliation(s)
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Georgoff PE, Nikolian VC, Halaweish I, Chtraklin K, Bruhn PJ, Eidy H, Rasmussen M, Li Y, Srinivasan A, Alam HB. Resuscitation with Lyophilized Plasma Is Safe and Improves Neurological Recovery in a Long-Term Survival Model of Swine Subjected to Traumatic Brain Injury, Hemorrhagic Shock, and Polytrauma. J Neurotrauma 2017; 34:2167-2175. [PMID: 28228060 DOI: 10.1089/neu.2016.4859] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We have shown previously that fresh frozen plasma (FFP) and lyophilized plasma (LP) decrease brain lesion size and improve neurological recovery in a swine model of traumatic brain injury (TBI) and hemorrhagic shock (HS). In this study, we examine whether these findings can be validated in a clinically relevant model of severe TBI, HS, and polytrauma. Female Yorkshire swine were subjected to TBI (controlled cortical impact), hemorrhage (40% volume), grade III liver and splenic injuries, rib fracture, and rectus abdominis crush. The animals were maintained in a state of shock (mean arterial pressure 30-35 mm Hg) for 2 h, and then randomized to resuscitation with normal saline (NS), FFP, or LP (n = 5 swine/group). Animals were recovered and monitored for 30 d, during which time neurological recovery was assessed. Brain lesion sizes were measured via magnetic resonance imaging (MRI) on post-injury days (PID) three and 10. Animals were euthanized on PID 30. The severity of shock and response to resuscitation was similar in all groups. When compared with NS-treated animals, plasma-treated animals (FFP and LP) had significantly lower neurologic severity scores (PID 1-7) and a faster return to baseline neurological function. There was no significant difference in brain lesion sizes between groups. LP treatment was well tolerated and similar to FFP. In this clinically relevant large animal model of severe TBI, HS, and polytrauma, we have shown that plasma-based resuscitation strategies are safe and result in neurocognitive recovery that is faster than recovery after NS-based resuscitation.
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Affiliation(s)
- Patrick E Georgoff
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Vahagn C Nikolian
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Ihab Halaweish
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Kiril Chtraklin
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Peter J Bruhn
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Hassan Eidy
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Monica Rasmussen
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Yongqing Li
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Ashok Srinivasan
- 2 Department of Radiology, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
| | - Hasan B Alam
- 1 Department of Surgery, Section of Neuroradiology, University of Michigan , Ann Arbor, Michigan
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Nikolian VC, Magas CP, Church J, Horne DC, Barrett M, Stansfield BR, Minter RM, Sandhu G. Intraoperative Observation and Evaluation Improves Teaching and Increases Resident Autonomy. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bruhn PJ, Nikolian VC, Halaweish I, Chang Z, Sillesen M, Svenningsen P, Liu B, Li Y, Alam HB. Tubastatin A Prevents Hemorrhage-Induced Endothelial Barrier Dysfunction. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nikolian VC, Georgoff PE, Bruhn PJ, Halaweish I, Chtraklin K, Pan B, Liu B, Li Y, Alam HB. Resuscitation with Lyophillized Plasma Is Safe and Provides Neuroprotection in a Long-Term Survival Model of Swine Subjected to Traumatic Brain Injury, Hemorrhagic Shock, and Polytrauma. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Georgoff PE, Higgins G, Nikolian VC, Bambakidis T, Dekker SE, Sillesen M, Athey B, Alam HB. Valproic Acid Induces the NEUROD1 Transcriptional Program of Neurogenesis after Traumatic Brain Injury. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
BACKGROUND Seven isoforms of histone deacetylase Class III have been reported - Sirtuin (SIRT) 1-7. We recently demonstrated that EX-527, an inhibitor of SIRT1, reduces mortality in a mouse model of lethal-cecal-ligationand- puncture (CLP)-induced septic shock. Our present study was aimed at determining whether selective inhibition of SIRT2, with AGK2, would decrease animal death and attenuate the inflammatory response in a septic model. METHODS Experiment I: C57BL/6J mice were intraperitoneally given either AGK2 (82 mg/kg) in dimethyl sulfoxide (DMSO) or DMSO alone, and 2 h later subjected to CLP. Survival was monitored for 240 hours. Experiment II: mice treated the same way as Experiment I, were grouped into (i) DMSO vehicle, and (ii) AGK2, with sham mice (operating but without any treatment) serving as controls. Peritoneal fluid and peripheral blood were examined at 24 and 48 hours for cytokine production. Samples of blood at 48 h were also allocated to assess coagulability using Thrombelastography (TEG). Morphological changes of bone marrow were evaluated from long bones (femurs and tibias) with hematoxylin and eosin (H&E) staining. Bone marrow atrophy was quantified by a blinded pathologist. Experiment III: cytokines in supernatant of the cultured normal primary splenocytes were measured after the cells were stimulated by lipopolysaccharide and treated with or without AGK2 (10 µM) for 6 hours. RESULTS AGK2 significantly reduced mortality and decreased levels of cytokines in blood (TNF-α: 298.3±24.6 vs 26.8±2.8 pg/ml, p=0.0034; IL-6: 633.4±82.8 vs 232.6±133.0 pg/ml, p=0.0344) and peritoneal fluid (IL-6: 704.8±67.7 vs 391.4±98.5 pg/ml, p=0.033) compared to vehicle control. Also, AGK2 suppressed the TNF-α and IL-6 production in the cultured splenocytes (TNF-α: 68.1±6.4 vs 23.9±2.8 pg/ml, p=0.0009; IL-6: 73.1±4.2 vs 49.6±3.0 pg/ml; p=0.0051). The TEG data showed that the mice subjected to CLP displayed prolonged fibrin formation and fibrin cross-linkage time, slower clot formation, decreased platelet function, and clot rigidity. AGK2 treatment was associated with dramatic improvements in fibrin cross-linkage and clot formation times, without a significant impact on the clot initiation parameters or platelet function. Additionally, AGK2 significantly attenuated the bone marrow atrophy (58.3±6.5 vs 30.0±8.2%, p=0.0262). CONCLUSION Selective inhibition of SIRT2 significantly improves survival, and attenuates sepsis-associated "cytokine storm", coagulopathy, and bone marrow atrophy in a mouse model of lethal septic shock.
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Affiliation(s)
| | | | | | | | | | | | - W Chong
- Department of Emergency, The First Hospital of China Medical University, 155 North Nanjing Street, Shenyang, Liaoning 110001, China.
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