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Andreatta PB, Graybill JC, Bradley MJ, Gross KR, Elster EA, Bowyer MW. Evaluation of urological and gynecological surgeons as force multipliers for mass Casualty trauma care. J Trauma Acute Care Surg 2024:01586154-990000000-00737. [PMID: 38745360 DOI: 10.1097/ta.0000000000004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients. METHODS Urological (6), gynecological surgeons (6), senior (PGY5) general surgery residents (6), and non-trauma trained general surgeons (8) completed a rigorous trauma training program (ASSET+). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures pre/post mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent, accurate completion of all procedural components within a realistic time window (90%). RESULTS General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Pre-training, general surgery and urology participants outperformed gynecologists for overall procedural abilities. Post-training, only general surgeons met the 90% benchmark. Post-hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures, however knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training. CONCLUSION For physiologically stable patients with traumatic injuries to the abdomen, pelvis or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care. LEVEL OF EVIDENCE Therapeutic/Care Management, Level III/IV.
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Affiliation(s)
- Pamela B Andreatta
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
| | - Mark W Bowyer
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
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Andreatta PB, Bowyer MW, Renninger CH, Graybill JC, Gurney JM, Elster EA. Putting the ready in readiness: A post-hoc analysis of surgeon performance during a military MASCAL in Afghanistan. J Trauma Acute Care Surg 2024:01586154-990000000-00727. [PMID: 38738895 DOI: 10.1097/ta.0000000000004381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
BACKGROUND All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient MASCAL event. METHODS The sample included orthopaedic (4) and general surgeons (8) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan on 26 August 2021. One orthopaedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1. expeditionary knowledge (exam score), 2. procedural skills competencies (performance assessment score), 3. clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases were reviewed and rated (performance score) by The Joint Trauma System's Performance Improvement Branch; a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each pre-deployment measure and MASCAL surgical care. RESULTS Pre-deployment knowledge and clinical activity measures met program benchmarks. Baseline pre-deployment procedural skills competency scores did not meet program benchmarks, however those gaps were closed through re-training, ensuring all surgeons met or exceeded the program benchmarks pre-deployment. There were very large effect sizes (Cohen's d) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. CONCLUSION The prescribed program measures ensured all surgeons achieved pre-deployment performance benchmarks and provided high quality trauma care to our nation's servicemembers. LEVEL OF EVIDENCE Prognostic, Level III/IV.
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Affiliation(s)
- Pamela B Andreatta
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
| | - Mark W Bowyer
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
| | - Christopher H Renninger
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
| | | | | | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Science and the Walter Reed National Military Medical Center, Bethesda, MD
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Choudhary T, Upadhyaya P, Davis CM, Yang P, Tallowin S, Lisboa FA, Schobel SA, Coopersmith CM, Elster EA, Buchman TG, Dente CJ, Kamaleswaran R. Derivation and Validation of Generalized Sepsis-induced Acute Respiratory Failure Phenotypes Among Critically Ill Patients: A Retrospective Study. Res Sq 2024:rs.3.rs-4307475. [PMID: 38746442 PMCID: PMC11092838 DOI: 10.21203/rs.3.rs-4307475/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background: Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate their generalizability across multi-ICU specialties, considering multi-organ dynamics. Methods: We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥24 hours. Data from two different high-volume academic hospital systems were used as a derivation set with N=3,225 medical ICU (MICU) patients and a validation set with N=848 MICU patients. For the multi-ICU validation, we utilized retrospective data from two surgical ICUs at the same hospitals (N=1,577). Clinical data from 24 hours preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts. Results: Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F=123]), C (mild hypoxia [median P/F=240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing an external MICU from second hospital and SICUs from both centers. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes ( p <0.01) and consistent across both centers. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy. Conclusion: The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.
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Schobel SA, Gann ER, Unselt D, Grey SF, Lisboa FA, Upadhyay MM, Rouse M, Tallowin S, Be NA, Zhang X, Dalgard CL, Wilkerson MD, Hauskrecht M, Badylak SF, Zamora R, Vodovotz Y, Potter BK, Davis TA, Elster EA. The influence of microbial colonization on inflammatory versus pro-healing trajectories in combat extremity wounds. Sci Rep 2024; 14:5006. [PMID: 38438404 PMCID: PMC10912443 DOI: 10.1038/s41598-024-52479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 01/19/2024] [Indexed: 03/06/2024] Open
Abstract
A combination of improved body armor, medical transportation, and treatment has led to the increased survival of warfighters from combat extremity injuries predominantly caused by blasts in modern conflicts. Despite advances, a high rate of complications such as wound infections, wound failure, amputations, and a decreased quality of life exist. To study the molecular underpinnings of wound failure, wound tissue biopsies from combat extremity injuries had RNA extracted and sequenced. Wounds were classified by colonization (colonized vs. non-colonized) and outcome (healed vs. failed) status. Differences in gene expression were investigated between timepoints at a gene level, and longitudinally by multi-gene networks, inferred proportions of immune cells, and expression of healing-related functions. Differences between wound outcomes in colonized wounds were more apparent than in non-colonized wounds. Colonized/healed wounds appeared able to mount an adaptive immune response to infection and progress beyond the inflammatory stage of healing, while colonized/failed wounds did not. Although, both colonized and non-colonized failed wounds showed increasing inferred immune and inflammatory programs, non-colonized/failed wounds progressed beyond the inflammatory stage, suggesting different mechanisms of failure dependent on colonization status. Overall, these data reveal gene expression profile differences in healing wounds that may be utilized to improve clinical treatment paradigms.
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Affiliation(s)
- Seth A Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.
| | - Eric R Gann
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Desiree Unselt
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
- Q2 Solutions, Durham, NC, USA
| | - Scott F Grey
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Felipe A Lisboa
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Meenu M Upadhyay
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Michael Rouse
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Simon Tallowin
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Nicholas A Be
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, CA, USA
| | - Xijun Zhang
- Uniformed Services University (USU) The American Genome Center (TAGC), Bethesda, MD, USA
| | - Clifton L Dalgard
- Uniformed Services University (USU) The American Genome Center (TAGC), Bethesda, MD, USA
- Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Matthew D Wilkerson
- Uniformed Services University (USU) The American Genome Center (TAGC), Bethesda, MD, USA
- Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Milos Hauskrecht
- Department of Computer Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen F Badylak
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin K Potter
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Thomas A Davis
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Uniformed Services University (USU) Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
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Baird EW, Lammers DT, Betzold RD, Brown SR, Tadlock MD, Eckert MJ, Cox DB, Kerby JD, Gurney JM, Elster EA, Holcomb JB, Jansen JO. Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education. Trauma Surg Acute Care Open 2024; 9:e001302. [PMID: 38390471 PMCID: PMC10882335 DOI: 10.1136/tsaco-2023-001302] [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: 11/01/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs. Methods We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum". Results We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs. Conclusion We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.
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Affiliation(s)
- Emily W Baird
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
- US Department of the Army, Washington, District of Columbia, USA
| | - Daniel T Lammers
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
- US Department of the Army, Washington, District of Columbia, USA
| | - Richard D Betzold
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shaun R Brown
- US Department of the Army, Washington, District of Columbia, USA
| | | | - Matthew J Eckert
- Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Daniel B Cox
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey D Kerby
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer M Gurney
- Defense Committees on Trauma, Joint Trauma System, JBSA Fort Sam Houston, Texas, USA
- Department of Surgery, San Antonio Military Health System, San Antonio, Texas, USA
| | - Eric A Elster
- Uniformed Services University, Bethesda, Maryland, USA
| | - John B Holcomb
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan O Jansen
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kok CR, Mulakken N, Thissen JB, Grey SF, Avila-Herrera A, Upadhyay MM, Lisboa FA, Mabery S, Elster EA, Schobel SA, Be NA. Targeted metagenomic assessment reflects critical colonization in battlefield injuries. Microbiol Spectr 2023; 11:e0252023. [PMID: 37874143 PMCID: PMC10714869 DOI: 10.1128/spectrum.02520-23] [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: 06/16/2023] [Accepted: 09/18/2023] [Indexed: 10/25/2023] Open
Abstract
IMPORTANCE Microbial contamination in combat wounds can lead to opportunistic infections and adverse outcomes. However, current microbiological detection has a limited ability to capture microbial functional genes. This work describes the application of targeted metagenomic sequencing to profile wound bioburden and capture relevant wound-associated signatures for clinical utility. Ultimately, the ability to detect such signatures will help guide clinical decisions regarding wound care and management and aid in the prediction of wound outcomes.
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Affiliation(s)
- Car Reen Kok
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Nisha Mulakken
- Computing Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - James B. Thissen
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Scott F. Grey
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Aram Avila-Herrera
- Computing Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Meenu M. Upadhyay
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Felipe A. Lisboa
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Shalini Mabery
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Eric A. Elster
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Seth A. Schobel
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Nicholas A. Be
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
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Wang J, de Vale JS, Gupta S, Upadhyaya P, Lisboa FA, Schobel SA, Elster EA, Dente CJ, Buchman TG, Kamaleswaran R. ClotCatcher: a novel natural language model to accurately adjudicate venous thromboembolism from radiology reports. BMC Med Inform Decis Mak 2023; 23:262. [PMID: 37974186 PMCID: PMC10652606 DOI: 10.1186/s12911-023-02369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Accurate identification of venous thromboembolism (VTE) is critical to develop replicable epidemiological studies and rigorous predictions models. Traditionally, VTE studies have relied on international classification of diseases (ICD) codes which are inaccurate - leading to misclassification bias. Here, we developed ClotCatcher, a novel deep learning model that uses natural language processing to detect VTE from radiology reports. METHODS Radiology reports to detect VTE were obtained from patients admitted to Emory University Hospital (EUH) and Grady Memorial Hospital (GMH). Data augmentation was performed using the Google PEGASUS paraphraser. This data was then used to fine-tune ClotCatcher, a novel deep learning model. ClotCatcher was validated on both the EUH dataset alone and GMH dataset alone. RESULTS The dataset contained 1358 studies from EUH and 915 studies from GMH (n = 2273). The dataset contained 1506 ultrasound studies with 528 (35.1%) studies positive for VTE, and 767 CT studies with 91 (11.9%) positive for VTE. When validated on the EUH dataset, ClotCatcher performed best (AUC = 0.980) when trained on both EUH and GMH dataset without paraphrasing. When validated on the GMH dataset, ClotCatcher performed best (AUC = 0.995) when trained on both EUH and GMH dataset with paraphrasing. CONCLUSION ClotCatcher, a novel deep learning model with data augmentation rapidly and accurately adjudicated the presence of VTE from radiology reports. Applying ClotCatcher to large databases would allow for rapid and accurate adjudication of incident VTE. This would reduce misclassification bias and form the foundation for future studies to estimate individual risk for patient to develop incident VTE.
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Affiliation(s)
- Jeffrey Wang
- Department of Biomedical Informatics, Emory University School of Medicine, 1462 Clifton Road, Suite 504, Atlanta, GA, 30322, USA.
| | - Joao Souza de Vale
- Department of Biomedical Informatics, Emory University School of Medicine, 1462 Clifton Road, Suite 504, Atlanta, GA, 30322, USA
| | - Saransh Gupta
- Department of Biomedical Informatics, Emory University School of Medicine, 1462 Clifton Road, Suite 504, Atlanta, GA, 30322, USA
| | - Pulakesh Upadhyaya
- Department of Biomedical Informatics, Emory University School of Medicine, 1462 Clifton Road, Suite 504, Atlanta, GA, 30322, USA
| | - Felipe A Lisboa
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, 20817, USA
| | - Seth A Schobel
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, 20817, USA
| | - Eric A Elster
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Christopher J Dente
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- Emory Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Timothy G Buchman
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- Emory Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Emory Critical Care Center, Atlanta, GA, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, 1462 Clifton Road, Suite 504, Atlanta, GA, 30322, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
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Abstract
OBJECTIVES 1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice. BACKGROUND Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness. METHODS We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance. RESULTS Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain. CONCLUSIONS Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.
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Affiliation(s)
- Pamela Andreatta
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Mark W Bowyer
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
| | - E Matthew Ritter
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; and
| | - Kyle Remick
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Mary Margaret Knudson
- Military Health System Strategic Partnership with the American College of Surgeons, Chicago, IL
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
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Zamora R, Forsberg JA, Shah AM, Unselt D, Grey S, Lisboa FA, Billiar TR, Schobel SA, Potter BK, Elster EA, Vodovotz Y. Central role for neurally dysregulated IL-17A in dynamic networks of systemic and local inflammation in combat casualties. Sci Rep 2023; 13:6618. [PMID: 37095162 PMCID: PMC10126120 DOI: 10.1038/s41598-023-33623-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/15/2023] [Indexed: 04/26/2023] Open
Abstract
Dynamic Network Analysis (DyNA) and Dynamic Hypergraphs (DyHyp) were used to define protein-level inflammatory networks at the local (wound effluent) and systemic circulation (serum) levels from 140 active-duty, injured service members (59 with TBI and 81 non-TBI). Interleukin (IL)-17A was the only biomarker elevated significantly in both serum and effluent in TBI vs. non-TBI casualties, and the mediator with the most DyNA connections in TBI wounds. DyNA combining serum and effluent data to define cross-compartment correlations suggested that IL-17A bridges local and systemic circulation at late time points. DyHyp suggested that systemic IL-17A upregulation in TBI patients was associated with tumor necrosis factor-α, while IL-17A downregulation in non-TBI patients was associated with interferon-γ. Correlation analysis suggested differential upregulation of pathogenic Th17 cells, non-pathogenic Th17 cells, and memory/effector T cells. This was associated with reduced procalcitonin in both effluent and serum of TBI patients, in support of an antibacterial effect of Th17 cells in TBI patients. Dysregulation of Th17 responses following TBI may drive cross-compartment inflammation following combat injury, counteracting wound infection at the cost of elevated systemic inflammation.
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Affiliation(s)
- Ruben Zamora
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jonathan A Forsberg
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Ashti M Shah
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Desiree Unselt
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Scott Grey
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Felipe A Lisboa
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
- The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | - Benjamin K Potter
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of Health Sciences, Bethesda, MD, 20814, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, W944 Starzl Biomedical Sciences Tower, 200 Lothrop St., Pittsburgh, PA, 15213, USA.
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA.
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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Bozzay JD, Walker PF, Atwood RE, DeSpain RW, Parker WJ, Chertow DS, Mares JA, Leonhardt CL, Elster EA, Bradley MJ. Development, refinement, and characterization of a nonhuman primate critical care environment. PLoS One 2023; 18:e0281548. [PMID: 36930612 PMCID: PMC10022766 DOI: 10.1371/journal.pone.0281548] [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] [Received: 04/29/2022] [Accepted: 01/17/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers. METHODS Eight adult male rhesus macaques underwent ventilation with sedation for 48-96 hours in a critical care setting. Three of these NHPs underwent "sham" procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy. RESULTS Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72-96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed. CONCLUSIONS A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model.
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Affiliation(s)
- Joseph D. Bozzay
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- * E-mail:
| | - Patrick F. Walker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Rex E. Atwood
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Robert W. DeSpain
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - William J. Parker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Daniel S. Chertow
- Emerging Pathogens Section, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - John A. Mares
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Crystal L. Leonhardt
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
| | - Eric A. Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | - Matthew J. Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, United States of America
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McKinley TO, Gaski GE, Billiar TR, Vodovotz Y, Brown KM, Elster EA, Constantine GM, Schobel SA, Robertson HT, Meagher AD, Firoozabadi R, Gary JL, O'Toole RV, Aneja A, Trochez KM, Kempton LB, Steenburg SD, Collins SC, Frey KP, Castillo RC. Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY). J Orthop Trauma 2022; 36:S14-S20. [PMID: 34924514 DOI: 10.1097/bot.0000000000002289] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.
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Affiliation(s)
- Todd O McKinley
- Department of Orthopedic Surgery, Indiana University Health Methodist Hospital, Indianapolis, IN
| | - Greg E Gaski
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Krista M Brown
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Greg M Constantine
- Department of Mathematics and Statistics, University of Pittsburgh, Pittsburgh, PA
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Surgical Critical Care Initiative, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Henry T Robertson
- Department of Surgery, Uniformed Services University of the Health Sciences, Surgical Critical Care Initiative, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX (now at Keck School of Medicine of University of Southern California, Los Angeles, CA)
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Karen M Trochez
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Scott D Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine and Indiana University Health Methodist Hospital, Indianapolis, IN; and
| | - Susan C Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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12
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Elster EA, Bowyer MW, Knudson MM. Assessing Clinical Readiness: A Paradigm Shift in Medical Education. JAMA Surg 2021; 156:999-1000. [PMID: 34406328 DOI: 10.1001/jamasurg.2021.3611] [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)
- Eric A Elster
- School of Medicine, Uniformed Services University for the Health Sciences, Bethesda, Maryland
| | - Mark W Bowyer
- School of Medicine, Uniformed Services University for the Health Sciences, Bethesda, Maryland
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13
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Kraemer LS, Gunasingha RMK, Grey SF, Benoit P, Gosztyla C, Elster EA, Bradley MJ. Neuraxial and Regional Anesthesia Reduces the Risk of Venous Thromboembolism in General Surgery Patients. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.146] [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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14
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Benoit PJ, Kalpanee D. Gunasingha RM, Kraemer L, Rolland G, Gosztyla C, Kindvall A, Elster EA, Jessie EM, Bradley MJ. Evaluation of Right Upper Quadrant Ultrasound as a Diagnostic Tool in Cholecystitis. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.315] [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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15
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Kalpanee D Gunasingha RM, Grey S, Benoit P, Gosztyla C, Learn P, Elster EA, Bradley MJ. Postoperative Pneumonia Increases the Risk of Venous Thromboembolism in Patients: A Propensity Score Analysis. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.135] [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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16
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Dalton MK, Remick KN, Mathias M, Trinh QD, Cooper Z, Elster EA, Weissman JS. Analysis of Surgical Volume in Military Medical Treatment Facilities and Clinical Combat Readiness of US Military Surgeons. JAMA Surg 2021; 157:43-50. [PMID: 34705038 DOI: 10.1001/jamasurg.2021.5331] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Low surgical volume in the US Military Health System (MHS) has been identified as a challenge to military surgeon readiness. The Uniformed Services University of Health Sciences, in partnership with the American College of Surgeons, developed the Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program that includes a tool for quantifying the clinical readiness value of surgeon workload, known as the KSA metric. Objective To describe changes in US military general surgeon procedural volume and readiness using the KSA metric. Design, Setting, and Participants This cohort study analyzed general surgery workload performed across the MHS, including military and civilian facilities, between fiscal year 2015 and 2019 and the calculated KSA metric value. The surgeon-level readiness among military general surgeons was calculated based on the KSA metric readiness threshold. Data were obtained from TRICARE, the US Department of Defense health insurance product. Main Outcomes and Measures The main outcomes were general surgery procedural volumes and the KSA metric point value of those procedures across the MHS as well as the number of military general surgeons meeting the KSA metric readiness threshold. Aggregate facility and regional market-level claims data were used to calculate the procedural volumes and KSA metric readiness value of those procedures. Annual adjusted KSA metric points earned were used to determine the number of individual US military general surgeons meeting the readiness threshold. Results The number of general surgery procedures generating KSAs in military hospitals decreased 25.6%, from 128 377 in 2015 to 95 461 in 2019, with a 19.1% decrease in the number of general surgeon KSA points (from 7 155 563 to 5 790 001). From 2015 to 2019, there was a 3.2% increase in both the number of procedures (from 419 980 to 433 495) and KSA points (from 21 071 033 to 21 748 984) in civilian care settings. The proportion of military general surgeons meeting the KSA metric readiness threshold decreased from 16.7% (n = 97) in 2015 to 10.1% (n = 68) in 2019. Conclusions and Relevance This study noted that the number of KSA metric points and procedural volume in military hospitals has been decreasing since 2015, whereas both measures have increased in civilian facilities. The findings suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the MHS to reverse the change.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joel S Weissman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
Importance Sustainment of comprehensive procedural skills in trauma surgery is a particular problem for surgeons in rural, global, and combat settings. Trauma care often requires open surgical procedures for low-frequency/high-risk injuries at a time when open surgical experience is declining in general and trauma surgery training. Objective To determine whether general surgeons participating in a 2-day standardized trauma skills course demonstrate measurable improvement in accuracy and independent performance of specific trauma skills. Design, Setting, and Participants General surgeons in active surgical practice were enrolled from a simulation center with anatomic laboratory from October 2019 to October 2020. Differences in pretraining/training and posttraining performance outcomes were examined using (1) pretraining/posttraining surveys, (2) pretraining/posttraining knowledge assessment, and (3) training/posttraining faculty assessment. Analysis took place in November 2020. Interventions A 2-day standardized, immersive, cadaver-based skills course, developed with best practices in instructional design, that teaches and assesses 24 trauma surgical procedures was used. Main Outcomes and Measures Trauma surgery capability, as measured by confidence, knowledge, abilities, and independent performance of specific trauma surgical procedures; 3-month posttraining skill transfer. Results The study cohort included 65 active-duty general surgeons, of which 16 (25%) were women and 49 (75%) were men. The mean (SD) age was 38.5 (4.2) years. Before and during training, 1 of 65 participants (1%) were able to accurately perform all 24 procedures without guidance. After course training, 64 participants (99%) met the benchmark performance requirements for the 24 trauma procedures, and 51 (78%) were able to perform them without guidance. Procedural confidence and knowledge increased significantly from before to after the course. At 3 months after training, 37 participants (56%) reported skill transfer to trauma or other procedures. Conclusions and Relevance In this study, direct measurement of procedural performance following standardized training demonstrated significant improvement in skill performance in a broad array of trauma procedures. This model may be useful for assessment of procedural competence in other specialties.
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Affiliation(s)
- Mark W Bowyer
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Pamela B Andreatta
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John H Armstrong
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland.,University of South Florida Morsani College of Medicine, Tampa
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
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18
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Dente CJ, Mina MJ, Morse BC, Hensman H, Schobel S, Gelbard RB, Belard A, Buchman TG, Kirk AD, Elster EA. Predicting the need for massive transfusion: Prospective validation of a smartphone-based clinical decision support tool. Surgery 2021; 170:1574-1580. [PMID: 34112517 DOI: 10.1016/j.surg.2021.04.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/14/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Improper or delayed activation of a massive transfusion protocol may have consequences to individuals and institutions. We designed a complex predictive algorithm that was packaged within a smartphone application. We hypothesized it would accurately assess the need for massive transfusion protocol activation and assist clinicians in that decision. METHODS We prospectively enrolled patients at an urban, level I trauma center. The application recorded the surgeon's initial opinion for activation and then prompted inputs for the model. The application provided a prediction and recorded the surgeon's final decision on activation. RESULTS Three hundred and twenty-one patients were enrolled (83% male; 59% penetrating; median Injury Severity Score 9; mean base deficit -4.11). Of 36 massive transfusion protocol activations, 26 had an app prediction of "high" or "moderate" probability. Of these, 4 (15%) patients received <10 u blood as a result of early hemorrhage control. Two hundred and eighty-five patients did not have massive transfusion protocol activated by the surgeon with 27 (9%) patients having "moderate" or "high" likelihood predicted by the application. Twenty-four of these did not require massive transfusion, and all patients had acidosis that unrelated to hemorrhagic shock. For 13 (50%) of the patients with "high" probability, the surgeon correctly altered their initial decision based on this information. The algorithm demonstrated an adjusted accuracy of 0.96 (95% confidence interval [0.93-0.98); P ≤ .001]), sensitivity = 0.99, specificity 0.72, positive predictive value 0.96, negative predictive value 0.99, and area under the receiver operating curve = 0.86. CONCLUSION A smartphone-based clinical decision tools can aid surgeons in the decision to active massive transfusion protocol in real time, although it does not completely replace clinician judgment.
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Affiliation(s)
- Christopher J Dente
- Emory University, Atlanta, GA; Department of Surgery, Grady Memorial Hospital, Atlanta, GA.
| | - Michael J Mina
- Emory University, Atlanta, GA; Department of Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Bryan C Morse
- Emory University, Atlanta, GA; Department of Surgery, Grady Memorial Hospital, Atlanta, GA
| | | | - Seth Schobel
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD
| | - Rondi B Gelbard
- Emory University, Atlanta, GA; Department of Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Arnaud Belard
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD
| | | | | | - Eric A Elster
- Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD
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19
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Holt DB, Hueman MT, Jaffin J, Sanchez M, Hamilton MA, Mabry CD, Bailey JA, Elster EA. Clinical Readiness Program: Refocusing the Military Health System. Mil Med 2021; 186:32-39. [PMID: 33499511 DOI: 10.1093/milmed/usaa385] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/24/2020] [Accepted: 09/21/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The Military Health System serves to globally provide health services and trained medical forces. Military providers possess variable levels of deployment preparedness. The aim of the Clinical Readiness Program is to develop and assess the knowledge, skills, and abilities (KSAs) needed for combat casualty care. METHODS The Clinical Readiness Program developed a KSA metric for general and orthopedic surgery. The KSA methodology underwent a proof of concept in six medical treatment facilities. RESULTS The KSA metric feasibly quantifies the combat relevance of surgical practice. Orthopedic surgeons are more likely than general surgeons to meet the threshold. Medical treatment facilities do not provide enough demand for general surgery services to achieve readiness. CONCLUSION The Clinical Readiness Program identifies imbalances between the health care delivery and readiness missions. To close the readiness gap, the Military Health System needs to recapture high KSA value procedures, expand access to care, and/or partner with civilian institutions.
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Affiliation(s)
- Danielle B Holt
- Department of Surgery at Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA.,Deloitte Consulting, LLP, Arlington, VA 22209, USA
| | - Matthew T Hueman
- Department of Surgery at Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Jonathan Jaffin
- Decision Support Division, Defense Health Agency, Falls Church, VA 22042, USA
| | - Michael Sanchez
- Decision Support Division, Defense Health Agency, Falls Church, VA 22042, USA
| | - Mark A Hamilton
- Department of Surgery, Jefferson Regional Medical Center, Pine Bluff, AR 71603, USA
| | - Charles D Mabry
- Department of Surgery, Washington University in Saint Louis, Saint Louis, MO 63110, USA
| | - Jeffrey A Bailey
- Department of Surgery at Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA.,Department of Surgery, Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - Eric A Elster
- Department of Surgery at Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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Gerardo CJ, Silvius E, Schobel S, Eppensteiner JC, McGowan LM, Elster EA, Kirk AD, Limkakeng AT. Association of a Network of Immunologic Response and Clinical Features With the Functional Recovery From Crotalinae Snakebite Envenoming. Front Immunol 2021; 12:628113. [PMID: 33790901 PMCID: PMC8006329 DOI: 10.3389/fimmu.2021.628113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background The immunologic pathways activated during snakebite envenoming (SBE) are poorly described, and their association with recovery is unclear. The immunologic response in SBE could inform a prognostic model to predict recovery. The purpose of this study was to develop pre- and post-antivenom prognostic models comprised of clinical features and immunologic cytokine data that are associated with recovery from SBE. Materials and Methods We performed a prospective cohort study in an academic medical center emergency department. We enrolled consecutive patients with Crotalinae SBE and obtained serum samples based on previously described criteria for the Surgical Critical Care Initiative (SC2i)(ClinicalTrials.gov Identifier: NCT02182180). We assessed a standard set of clinical variables and measured 35 unique cytokines using Luminex Cytokine 35-Plex Human Panel pre- and post-antivenom administration. The Patient-Specific Functional Scale (PSFS), a well-validated patient-reported outcome of functional recovery, was assessed at 0, 7, 14, 21 and 28 days and the area under the patient curve (PSFS AUPC) determined. We performed Bayesian Belief Network (BBN) modeling to represent relationships with a diagram composed of nodes and arcs. Each node represents a cytokine or clinical feature and each arc represents a joint-probability distribution (JPD). Results Twenty-eight SBE patients were enrolled. Preliminary results from 24 patients with clinical data, 9 patients with pre-antivenom and 11 patients with post-antivenom cytokine data are presented. The group was mostly female (82%) with a mean age of 38.1 (SD ± 9.8) years. In the pre-antivenom model, the variables most closely associated with the PSFS AUPC are predominantly clinical features. In the post-antivenom model, cytokines are more fully incorporated into the model. The variables most closely associated with the PSFS AUPC are age, antihistamines, white blood cell count (WBC), HGF, CCL5 and VEGF. The most influential variables are age, antihistamines and EGF. Both the pre- and post-antivenom models perform well with AUCs of 0.87 and 0.90 respectively. Discussion Pre- and post-antivenom networks of cytokines and clinical features were associated with functional recovery measured by the PSFS AUPC over 28 days. With additional data, we can identify prognostic models using immunologic and clinical variables to predict recovery from SBE.
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Affiliation(s)
| | | | - Seth Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | | | - Lauren M McGowan
- Department of Surgery, Duke University, Durham, NC, United States
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, United States
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Worlton TJ, Waller SG, Saint Laurent S, Remick K, Malone DL, Elster EA. Important and Often Forgotten Aspects of Surgical GHE: A Response to "Gynecologic SURGRETE, New Horizons Guyana 2019: An Experience of a Lifetime for Global Health Engagement and Medical Readiness". Mil Med 2021; 186:89-90. [PMID: 33253384 DOI: 10.1093/milmed/usaa456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/15/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tamara J Worlton
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA.,Department of Preventive Medicine and Biostatistics, Uniformed Service University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Stephen G Waller
- Department of Preventive Medicine and Biostatistics, Uniformed Service University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Stephanie Saint Laurent
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA.,Department of Preventive Medicine and Biostatistics, Uniformed Service University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Kyle Remick
- Department of Preventive Medicine and Biostatistics, Uniformed Service University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Debra L Malone
- Department of Preventive Medicine and Biostatistics, Uniformed Service University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Eric A Elster
- Department of Preventive Medicine and Biostatistics, Uniformed Service University of the Health Sciences, Bethesda, MD, 20814, USA
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22
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DesPain RW, Parker WJ, Kindvall AT, Learn PA, Elster EA, Jessie EM, Rodriguez CJ, Bradley MJ. Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry. J Healthc Qual 2021; 43:76-81. [PMID: 32195744 DOI: 10.1097/jhq.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes. METHODS A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases. RESULTS In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications. CONCLUSIONS National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.
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Dunn JC, Elster EA, Blair JA, Remick KN, Potter BK, Nesti LJ. There Is No Role for Damage Control Orthopedics Within the Golden Hour. Mil Med 2021; 187:e17-e21. [PMID: 33484247 DOI: 10.1093/milmed/usaa379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/03/2020] [Accepted: 09/11/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour." MATERIALS AND METHODS The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour. RESULTS Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified. CONCLUSIONS Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.
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Affiliation(s)
- John C Dunn
- Clinical and Experimental Orthopaedics, Uniformed Services University, Bethesda, MD 79922, USA.,William Beaumont Army Medical Center, Fort Bliss, TX 79922, USA
| | - Eric A Elster
- Clinical and Experimental Orthopaedics, Uniformed Services University, Bethesda, MD, USA.,Clinical and Experimental Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - James A Blair
- William Beaumont Army Medical Center, Fort Bliss, TX 79922, USA
| | - Kyle N Remick
- Clinical and Experimental Orthopaedics, Uniformed Services University, Bethesda, MD, USA.,Clinical and Experimental Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Benjamin K Potter
- Clinical and Experimental Orthopaedics, Uniformed Services University, Bethesda, MD, USA.,Clinical and Experimental Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Leon J Nesti
- Clinical and Experimental Orthopaedics, Uniformed Services University, Bethesda, MD 79922, USA.,Clinical and Experimental Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, USA
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24
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Scozzafava A, Newman DP, Jacobs AN, Sorge J, Elster EA. A Novel Approach to Assessing and Treating Musculoskeletal-Mediated Atypical Abdominal Pain: A Case Study. Cureus 2020; 12:e12359. [PMID: 33520553 PMCID: PMC7839810 DOI: 10.7759/cureus.12359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/05/2022] Open
Abstract
Abdominal pain is a common and functionally limiting complaint within the healthcare system linked to impaired quality of life and increased health care utilization. This chief complaint is associated with an extensive differential diagnosis leading to high utilization of diagnostic testing, increased healthcare cost, and delayed access to care. In patients presenting with acute or chronic abdominal pain, musculoskeletal pain often requires expensive testing, thereby delaying definitive care. An improved triage process is warranted. Performing a musculoskeletal examination to determine if pain patterns can be mechanically reproduced at the site of origin, or remote to the site of pain, warrants referral to a musculoskeletal specialist. In our young and healthy population, once the musculoskeletal mediated abdominal pain origin is determined, we see significant success in the application of a treatment approach consisting of manipulative therapy, exercise, and instrument-assisted soft tissue mobilization. A multimodal treatment approach for musculoskeletal-mediated abdominal pain has not been previously described. This case study outlines a novel management approach for musculoskeletal-mediated abdominal pain and provides an alternative diagnostic technique, when implemented early in the evaluation and management process of atypical abdominal pain, that improves the quality of life.
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Affiliation(s)
| | - David P Newman
- Interdisciplinary Pain Management Center, Tripler Army Medical Center, Honolulu, USA
| | - Aimee N Jacobs
- Physical Therapy Department, Tripler Army Medical Center, Honolulu, USA
| | - Joshua Sorge
- Physical Therapy Department, Tripler Army Medical Center, Honolulu, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, USA
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25
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Learn PA, Mullen MJ, Saldinger PF, Kreishman P, Cordts PR, Ko CY, Knudson MM, Elster EA. A Collaborative To Evaluate And Improve The Quality Of Surgical Care Delivered By The Military Health System. Health Aff (Millwood) 2020; 38:1313-1320. [PMID: 31381406 DOI: 10.1377/hlthaff.2019.00286] [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: 11/05/2022]
Abstract
In an effort to improve surgical quality and reduce clinical variability, the Military Health System (MHS) expanded its participation in the National Surgical Quality Improvement Program to all military hospitals beginning in 2015. This expansion and a partnership with the American College of Surgeons laid the foundation for a surgical quality collaborative in the MHS. We review the history of the program in the MHS and the activities that have contributed to developing the collaborative. We also report promising trends in surgical outcomes at hospitals that were already participating in the program in 2014, when a critical MHS review identified areas for improvement in surgical care. We conclude with a discussion of possible lessons for other health systems and challenges ahead for the MHS, now that full enrollment in the program has been completed.
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Affiliation(s)
- Peter A Learn
- Peter A. Learn ( ) is associate chair of surgery for quality and patient outcomes, Department of Surgery, at the Uniformed Services University of the Health Sciences (USUHS), in Bethesda, Maryland
| | - Mollie J Mullen
- Mollie J. Mullen is cochair of the Department of Defense National Surgical Quality Improvement Program Steering Panel, Directorate of Surgical Services, at the Naval Medical Center in San Diego, California
| | - Pierre F Saldinger
- Pierre F. Saldinger is chair of the Department of Surgery at NewYork-Presbyterian Hospital in Queens, New York, and a professor of clinical surgery at Weill Cornell Medicine, in New York City
| | - Peter Kreishman
- Peter Kreishman is surgeon champion in the Department of Surgery, Madigan Army Medical Center, in Tacoma, Washington
| | - Paul R Cordts
- Paul R. Cordts is deputy assistant director for medical affairs at the Defense Health Agency, in Falls Church, Virginia
| | - Clifford Y Ko
- Clifford Y. Ko is a professor of surgery in the Department of Surgery, University of California Los Angeles Health System. He also serves as director of the Division of Research and Optimal Patient Care at the American College of Surgeons
| | - M Margaret Knudson
- M. Margaret Knudson is a professor of surgery in the Department of Surgery, University of California San Francisco Health System
| | - Eric A Elster
- Eric A. Elster is chair of the Department of Surgery at USUHS
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26
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Atwood RE, Walker PF, Walper DJ, Elster EA, Bradley MJ. Levetiracetam Is Safe and Effective for Post-Traumatic Seizure Prophylaxis for Combat-Related Traumatic Brain Injury: A Retrospective Cohort Study. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.279] [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: 11/17/2022]
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27
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Wren SM, Wild HB, Gurney J, Amirtharajah M, Brown ZW, Bulger EM, Burkle FM, Elster EA, Forrester JD, Garber K, Gosselin RA, Groen RS, Hsin G, Joshipura M, Kushner AL, Norton I, Osmers I, Pagano H, Razek T, Sáenz-Terrazas JM, Schussler L, Stewart BT, Traboulsi AAR, Trelles M, Troke J, VanFosson CA, Wise PH. A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare. JAMA Surg 2020; 155:114-121. [PMID: 31722004 PMCID: PMC6865259 DOI: 10.1001/jamasurg.2019.4547] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Question What are consensus components of a framework for humanitarian surgical response in modern conflict zones? Findings This survey study using responses from 35 participants in the Stanford Humanitarian Surgical Response in Conflict Working Group suggests that humanitarian responses include both care of traumatic injury and emergency surgical needs of the population. Lessons from civilian and military trauma systems as well as humanitarian settings were translated into a tiered continuum of response from patient presentation through rehabilitation. Meaning Evidence suggests that modern trauma systems save lives but providing this standard of care in insecure conflict settings places new burdens on humanitarian systems; the framework presented herein integrates advances in surgical care to these environments. Importance Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.
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Affiliation(s)
- Sherry M Wren
- Stanford University School of Medicine, Stanford, California
| | - Hannah B Wild
- Stanford University School of Medicine, Stanford, California
| | - Jennifer Gurney
- US Army Institute of Surgical Research/Joint Trauma System, San Antonio, Texas
| | | | - Zachary W Brown
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle.,Committee on Trauma, American College of Surgeons, Chicago, Illinois
| | - Frederick M Burkle
- Harvard T. H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | | | - Kent Garber
- Department of Surgery, University of California, Los Angeles
| | | | - Reinou S Groen
- Department of Obstetrics and Gynecology, Alaska Native Medical Center, Anchorage
| | - Gary Hsin
- Stanford University School of Medicine, Stanford, California
| | | | - Adam L Kushner
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public health, Baltimore, Maryland
| | - Ian Norton
- Emergency Operations and Partnerships, Emergency Operations, World Health Organization, Geneva, Switzerland
| | - Inga Osmers
- Médecins Sans Frontières, Amsterdam, the Netherlands
| | | | - Tarek Razek
- Centre for Global Surgery, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | | - John Troke
- Samaritan's Purse, Boone, North Carolina
| | | | - Paul H Wise
- Stanford University School of Medicine, Stanford, California
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28
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Mackenzie CF, Elster EA, Bowyer MW, Sevdalis N. Scoping Evidence Review on Training and Skills Assessment for Open Emergency Surgery. J Surg Educ 2020; 77:1211-1226. [PMID: 32224033 DOI: 10.1016/j.jsurg.2020.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Scope evidence on technical performance metrics for open emergency surgery. Identify surgical performance metrics and procedures used in trauma training courses. DESIGN Structured literature searches of electronic databases were conducted from January 2010 to December 2019 to identify systematic reviews of tools to measure surgical skills employed in vascular or trauma surgery evaluation and training. SETTING AND PARTICIPANTS Faculty of Shock Trauma Anesthesiology Research Center, University of Maryland School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland and Implementation Science, King's College, London. RESULTS The evidence from 21 systematic reviews including over 54,000 subjects enrolled into over 840 eligible studies, identified that the Objective Structured Assessment of Technical Skill was used for elective surgery not for emergency trauma and vascular control surgery procedures. The Individual Procedure Score (IPS), used to evaluate emergency trauma procedures performed before and after training, distinguished performance of residents from experts and practicing surgeons. IPS predicted surgeons who make critical errors and need remediation interventions. No metrics showed Kirkpatrick's Level 4 evidence of technical skills training benefit to emergency surgery outcomes. CONCLUSIONS Expert benchmarks, errors, complication rates, task completion time, task-specific checklists, global rating scales, Objective Structured Assessment of Technical Skills, and IPS were found to identify surgeons, at all levels of seniority, who are in need of remediation of technical skills for open surgical hemorrhage control. Large-scale, multicenter studies are needed to evaluate any benefit of trauma technical skills training on patient outcomes.
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Affiliation(s)
| | - Eric A Elster
- The Uniformed Services University of Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Mark W Bowyer
- The Uniformed Services University of Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Nick Sevdalis
- Center for Implementation Science, King's College, London, United Kingdom
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30
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Muñoz B, Schobel SA, Lisboa FA, Khatri V, Grey SF, Dente CJ, Kirk AD, Buchman T, Elster EA. Clinical risk factors and inflammatory biomarkers of post-traumatic acute kidney injury in combat patients. Surgery 2020; 168:662-670. [PMID: 32600883 DOI: 10.1016/j.surg.2020.04.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Post-traumatic acute kidney injury has occurred in every major military conflict since its initial description during World War II. To ensure the proper treatment of combat casualties, early detection is critical. This study therefore aimed to investigate combat-related post-traumatic acute kidney injury in recent military conflicts, used machine learning algorithms to identify clinical and biomarker variables associated with the development of post-traumatic acute kidney injury, and evaluated the effects of post-traumatic acute kidney injury on wound healing and nosocomial infection. METHODS We conducted a retrospective clinical cohort review of 73 critically injured US military service members who sustained major combat-related extremity wounds and had collected injury characteristics, assayed serum and tissue biopsy samples for the expression of protein and messenger ribonucleic acid biomarkers. Bivariate analyses and random forest recursive feature elimination classification algorithms were used to identify associated injury characteristics and biomarker variables. RESULTS The incidence of post-traumatic acute kidney injury was 20.5%. Of that, 86% recovered baseline renal function and only 2 (15%) of the acute kidney injury group required renal replacement therapy. Random forest recursive feature elimination algorithms were able to estimate post-traumatic acute kidney injury with the area under the curve of 0.93, sensitivity of 0.91, and specificity of 0.91. Post-traumatic acute kidney injury was associated with injury severity score, serum epidermal growth factor, and tissue activin A type receptor 1, matrix metallopeptidase 10, and X-C motif chemokine ligand 1 expression. Patients with post-traumatic acute kidney injury exhibited poor wound healing and increased incidence of nosocomial infections. CONCLUSION The occurrence of acute kidney injury in combat casualties may be estimated using injury characteristics and serum and tissue biomarkers. External validations of these models are necessary to generalize for all trauma patients.
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Affiliation(s)
- Beau Muñoz
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD
| | - Seth A Schobel
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Henry Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD
| | - Felipe A Lisboa
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Henry Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD
| | - Vivek Khatri
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Henry Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD
| | - Scott F Grey
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Henry Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD
| | - Christopher J Dente
- Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Emory University, Atlanta, GA
| | - Allan D Kirk
- Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Duke University, Durham, NC
| | - Timothy Buchman
- Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD; Emory University, Atlanta, GA
| | - Eric A Elster
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD; Uniformed Services University Surgical Critical Care Initiative, Bethesda, MD.
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31
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Walker PF, Bozzay JD, Johnston LR, Elster EA, Rodriguez CJ, Bradley MJ. Outcomes of tranexamic acid administration in military trauma patients with intracranial hemorrhage: a cohort study. BMC Emerg Med 2020; 20:39. [PMID: 32410581 PMCID: PMC7222426 DOI: 10.1186/s12873-020-00335-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 05/06/2020] [Indexed: 11/30/2022] Open
Abstract
Background Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI. Methods This was a retrospective cohort study of military casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE. Results Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 h of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p = 0.003), similar discharge GCS (13.3 ± 4.0 vs. 13.8 ± 3.2, p = 0.58), and a larger improvement between initial and discharge GCS (3.7 ± 3.9 vs. 1.3 ± 3.1, p = 0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p = 1.00), progression of ICH (45.5% vs. 14.7%, p = 0.09), frequency of cranial decompression (50.0% vs. 42.1%, p = 0.76), or mean GOS (3.5 ± 0.9 vs. 3.8 ± 1.0, p = 0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p = 0.01). On multivariate analysis, however, TXA was not independently associated with VTE. Conclusions Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in military casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.
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Affiliation(s)
- Patrick F Walker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA.
| | - Joseph D Bozzay
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Luke R Johnston
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | | | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
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32
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Walker PF, Schobel S, Caruso JD, Rodriguez CJ, Bradley MJ, Elster EA, Oh JS. Trauma Embolic Scoring System in military trauma: a sensitive predictor of venous thromboembolism. Trauma Surg Acute Care Open 2019; 4:e000367. [PMID: 31897437 PMCID: PMC6924724 DOI: 10.1136/tsaco-2019-000367] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/02/2019] [Accepted: 11/19/2019] [Indexed: 01/20/2023] Open
Abstract
Introduction Clinical decision support tools capable of predicting which patients are at highest risk for venous thromboembolism (VTE) can assist in guiding surveillance and prophylaxis decisions. The Trauma Embolic Scoring System (TESS) has been shown to model VTE risk in civilian trauma patients. No such support tools have yet been described in combat casualties, who have a high incidence of VTE. The purpose of this study was to evaluate the utility of TESS in predicting VTE in military trauma patients. Methods A retrospective cohort study of 549 combat casualties from October 2010 to November 2012 admitted to a military treatment facility in the USA was performed. TESS scores were calculated through data obtained from the Department of Defense Trauma Registry and chart reviews. Univariate analysis and multivariate logistic regression were performed to evaluate risk factors for VTE. Receiver operating characteristic (ROC) curve analysis of TESS in military trauma patients was also performed. Results The incidence of VTE was 21.7% (119/549). The median TESS for patients without VTE was 8 (IQR 4–9), and the median TESS for those with VTE was 10 (IQR 9–11). On multivariate analysis, Injury Severity Score (ISS) (OR 1.03, p=0.007), ventilator days (OR 1.05, p=0.02), and administration of tranexamic acid (TXA) (OR 1.89, p=0.03) were found to be independent risk factors for development of VTE. On ROC analysis, an optimal high-risk cut-off value for TESS was ≥7 with a sensitivity of 0.92 and a specificity of 0.53 (area under the curve 0.76, 95% CI 0.72 to 0.80, p<0.0001). Conclusions When used to predict VTE in military trauma, TESS shows moderate discrimination and is well calibrated. An optimal high-risk cut-off value of ≥7 demonstrates high sensitivity in predicting VTE. In addition to ISS and ventilator days, TXA administration is an independent risk factor for VTE development. Level of evidence Level III.
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Affiliation(s)
- Patrick F Walker
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Seth Schobel
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Joseph D Caruso
- Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany
| | | | - Matthew J Bradley
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Eric A Elster
- Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - John S Oh
- Surgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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Shockcor NM, Buckingham B, Hassanein W, Dhru U, Elster EA, Davis T, Gimble J, Nam A, Barth RN. Adipose Stem Cells Promote Composite Tissue Engraftment. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1410] [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: 10/25/2022]
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Weeks SR, Oh JS, Elster EA, Learn PA. Humanitarian Surgical Care in the US Military Treatment Facilities in Afghanistan From 2002 to 2013. JAMA Surg 2019; 153:84-86. [PMID: 28903140 DOI: 10.1001/jamasurg.2017.3142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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)
- Sharon R Weeks
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John S Oh
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Peter A Learn
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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Abstract
Importance Since publication of the CRASH-2 and MATTERs studies, the US military has included tranexamic acid (TXA) in clinical practice guidelines. While TXA was shown to decrease mortality in trauma patients requiring massive transfusion, improper administration and increased risk of venous thromboembolism remain a concern. Objective To determine the appropriateness of TXA administration by US military medical personnel based on current Joint Trauma System clinical practice guidelines and to determine if TXA administration is associated with venous thromboembolism. Design, Setting, and Participants This cohort study of US military casualties in US military combat support hospitals in Afghanistan and a single US-based tertiary military treatment facility within the continental United States was conducted from 2011 to 2015, with follow-up through initial hospitalization and readmissions. Exposures Data collected for all patients included demographic information as well as Injury Severity Score; receipt of blood products, TXA, and/or a massive transfusion; and admission hemodynamics. Main Outcomes and Measures Variance from guidelines in TXA administration and venous thromboembolism. Tranexamic acid overuse was defined as a hemodynamically stable patient receiving TXA but not a massive transfusion, underuse was defined as a patient receiving a massive transfusion but not TXA, and TXA administration was considered delayed when given more than 3 hours after injury. Results Of the 455 identified patients, 443 (97.4%) were male, and the mean (SD) age was 25.3 (4.8) years. A total of 173 patients (38.0%) received a massive transfusion, and 139 (30.5%) received TXA in theater. Overuse occurred in 18 of 282 patients (6.4%) and underuse in 46 of 173 (26.6%) receiving massive transfusions, and delayed administration was found in 6 of 145 patients (4.3%) receiving TXA. Overuse increased at 3.3% per quarter (95% CI, 4.0-9.9; P < .001; R2 = 0.340) and underuse decreased at -4.4% per quarter (95% CI, -4.5 to -3.6; P < .001; R2 = 0.410). Tranexamic acid administration was an independent risk factor for venous thromboembolism (odds ratio, 2.58; 95% CI, 1.20-5.56; P = .02). Conclusions and Relevance Military medical personnel decreased missed opportunities to appropriately use TXA but also increased overuse. In addition, TXA administration was an independent risk factor for venous thromboembolism. A reevaluation of the use of TXA in combat casualties should be undertaken.
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Affiliation(s)
- Luke R Johnston
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J Rodriguez
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.,Surgical Critical Care Initiative, Bethesda, Maryland
| | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.,Surgical Critical Care Initiative, Bethesda, Maryland.,Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland
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36
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Eppensteiner J, Kwun J, Scheuermann U, Barbas A, Limkakeng AT, Kuchibhatla M, Elster EA, Kirk AD, Lee J. Damage- and pathogen-associated molecular patterns play differential roles in late mortality after critical illness. JCI Insight 2019; 4:127925. [PMID: 31434802 DOI: 10.1172/jci.insight.127925] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/26/2019] [Indexed: 12/17/2022] Open
Abstract
Multiple organ failure (MOF) is the leading cause of late mortality and morbidity in patients who are admitted to intensive care units (ICUs). However, there is an epidemiologic discrepancy in the mechanism of underlying immunologic derangement dependent on etiology between sepsis and trauma patients in MOF. We hypothesized that damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs), while both involved in the development of MOF, contribute differently to the systemic innate immune derangement and coagulopathic changes. We found that DAMPs not only produce weaker innate immune activation than counterpart PAMPs, but also induce less TLR signal desensitization, contribute to less innate immune cell death, and propagate more robust systemic coagulopathic effects than PAMPs. This differential contribution to MOF provides further insight into the contributing factors to late mortality in critically ill trauma and sepsis patients. These findings will help to better prognosticate patients at risk of MOF and may provide future therapeutic molecular targets in this disease process.
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Affiliation(s)
- John Eppensteiner
- Department of Surgery and.,Division of Emergency Medicine, Duke University, Durham, North Carolina, USA.,Surgical Critical Care Initiative (SC2i), Bethesda, Maryland, USA
| | | | | | | | - Alexander T Limkakeng
- Department of Surgery and.,Division of Emergency Medicine, Duke University, Durham, North Carolina, USA.,Surgical Critical Care Initiative (SC2i), Bethesda, Maryland, USA
| | - Maggie Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Eric A Elster
- Surgical Critical Care Initiative (SC2i), Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Allan D Kirk
- Department of Surgery and.,Surgical Critical Care Initiative (SC2i), Bethesda, Maryland, USA
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Mackenzie CF, Shackelford SA, Tisherman SA, Yang S, Puche A, Elster EA, Bowyer MW. Critical errors in infrequently performed trauma procedures after training. Surgery 2019; 166:835-843. [PMID: 31353081 DOI: 10.1016/j.surg.2019.05.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/24/2019] [Accepted: 05/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Critical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors. METHODS In a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts. RESULTS Resident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error. CONCLUSION Low trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.
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Affiliation(s)
- Colin F Mackenzie
- Shock Trauma Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD.
| | - Stacy A Shackelford
- Joint Trauma System, Defense Center of Excellence for Trauma, San Antonio, TX
| | - Samuel A Tisherman
- Shock Trauma Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD; Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shiming Yang
- Shock Trauma Anesthesiology Research, University of Maryland School of Medicine, Baltimore, MD
| | - Adam Puche
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of Health Sciences, and the Walter Reed National Military Medical Center, Bethesda, MD
| | - Mark W Bowyer
- Department of Surgery, Uniformed Services University of Health Sciences, and the Walter Reed National Military Medical Center, Bethesda, MD
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38
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Potter BK, Forsberg JA, Silvius E, Wagner M, Khatri V, Schobel SA, Belard AJ, Weintrob AC, Tribble DR, Elster EA. Combat-Related Invasive Fungal Infections: Development of a Clinically Applicable Clinical Decision Support System for Early Risk Stratification. Mil Med 2019; 184:e235-e242. [PMID: 30124943 DOI: 10.1093/milmed/usy182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benjamin K Potter
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Jonathan A Forsberg
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD.,Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD
| | - Elizabeth Silvius
- Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD.,DecisionQ Corporation, 2500 Wilson Blvd #325, Arlington, VA
| | - Matthew Wagner
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Vivek Khatri
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Arnaud J Belard
- Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Amy C Weintrob
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive #100, Bethesda, MD.,Veterans Affairs Medical Center, 50 Irving St NW, Washington, DC
| | - David R Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
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39
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DesPain RW, Parker WJ, Kindvall AT, Elster EA, Jessie EM, Rodriguez CJ, Bradley MJ. Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement by an Emergency General Surgery Service: Long-Term Follow-Up is Lacking. Am Surg 2019. [DOI: 10.1177/000313481908500704] [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: 11/16/2022]
Affiliation(s)
- Robert W. DesPain
- Department of Surgery Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center Bethesda, Maryland
| | - William J. Parker
- Department of Surgery Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center Bethesda, Maryland
| | - Angela T. Kindvall
- Department of Surgery Walter Reed National Military Medical Center Bethesda, Maryland
| | - Eric A. Elster
- Department of Surgery Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center Bethesda, Maryland
| | - Elliot M. Jessie
- Department of Surgery Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center Bethesda, Maryland
| | | | - Matthew J. Bradley
- Department of Surgery Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center Bethesda, Maryland
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40
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DesPain RW, Parker WJ, Kindvall AT, Elster EA, Jessie EM, Rodriguez CJ, Bradley MJ. Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement by an Emergency General Surgery Service: Long-Term Follow-Up Is Lacking. Am Surg 2019; 85:e323-e325. [PMID: 31405433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Barr J, Cancio LC, Smith DJ, Bradley MJ, Elster EA. From Trench to Bedside: Military Surgery During World War I Upon Its Centennial. Mil Med 2019; 184:214-220. [DOI: 10.1093/milmed/usz130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Justin Barr
- Department of Surgery, Duke University, DUMC 3443, Durham
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, 3698 Chambers Pass STE B, Ft. Sam Houston, TX
| | - David J Smith
- Department of Plastic Surgery, 2 Tampa General Circle, University of South Florida, Tampa, Fl
| | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD
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42
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Darrabie MD, Cheeseman J, Limkakeng AT, Borawski J, Sullenger BA, Elster EA, Kirk AD, Lee J. Toll-like receptor activation as a biomarker in traumatically injured patients. J Surg Res 2018; 231:270-277. [PMID: 30278940 DOI: 10.1016/j.jss.2018.05.059] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/25/2018] [Accepted: 05/25/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Surgical insult and trauma have been shown to cause dysregulation of the immune and inflammatory responses. Interaction of damage-associated molecular patterns (DAMPs) with toll-like receptors (TLRs) initiates innate immune response and systemic inflammatory responses. Given that surgical patients produce high levels of circulating damage-associated molecular patterns, we hypothesized that plasma-activated TLR activity would be correlated to injury status and could be used to predict pathological conditions involving tissue injury. METHODS An observational study was performed using samples from a single-institution prospective tissue and data repository from a Level-1 trauma center. In vitro TLR 2, 3, 4, and 9 activation was determined in a TLR reporter assay after isolation of plasma from peripheral blood. We determined correlations between plasma-activated TLR activity and clinical course measures of severity. RESULTS Eighteen patients were enrolled (median Injury Severity Score 15 [interquartile range 10, 23.5]). Trauma resulted in significant elevation in circulation high mobility group box 1 as well as increase of plasma-activated TLR activation (2.8-5.4-fold) compared to healthy controls. There was no correlation between circulating high mobility group box 1 and trauma morbidity; however, the plasma-activated TLR activity was correlated with acute physiology and chronic health evaluation II scores (R square = 0.24-0.38, P < 0.05). Patients who received blood products demonstrated significant increases in the levels of plasma-activated TLRs 2, 3, 4, and 9 and had a trend toward developing systemic inflammatory response syndrome. CONCLUSIONS Further studies examining TLR modulation and signaling in surgical patients may assist in predictive risk modeling and reduction in morbidity and mortality.
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Affiliation(s)
| | | | | | - Joseph Borawski
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Eric A Elster
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, North Carolina
| | - Jaewoo Lee
- Department of Surgery, Duke University, Durham, North Carolina.
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Bradley MJ, Kindvall AT, Logeman J, Bailey JA, Elster EA, Rodriguez CJ. Successful Implementation of an Appendectomy Process Improvement Protocol. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.108] [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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44
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Learn PA, Saldinger PF, Mullen MJ, Kreishman P, Cordts PR, Ko CY, Knudson MM, Elster EA. Military and Civilian Collaborative Partnership and Surgical Care Quality: A Blueprint for Success. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.107] [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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45
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Radowsky JS, Neely R, Forsberg JA, Lisboa FA, Dente CJ, Elster EA, Crane NJ. Preclosure spectroscopic differences between healed and dehisced traumatic wounds. PLoS One 2018; 13:e0204453. [PMID: 30261011 PMCID: PMC6160065 DOI: 10.1371/journal.pone.0204453] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The complexity and severity of traumatic wounds in military and civilian trauma demands improved wound assessment, before, during, and after treatment. Here, we explore the potential of 3 charge-coupled device (3CCD) imaging values to distinguish between traumatic wounds that heal following closure and those that fail. Previous studies demonstrate that normalized 3CCD imaging values exhibit a high correlation with oxygen saturation and allow for comparison of values between diverse clinical settings, including utilizing different equipment and lighting. METHODS We screened 119 patients at Walter Reed National Military Medical Center and at Grady Memorial Hospital with at least one traumatic extremity wound of ≥ 75 cm2. We collected images of each wound during each débridement surgery for a total of 66 patients. An in-house written computer application selected a region of interest in the images, separated the pixel color values, calculated relative values, and normalized them. We followed patients until the enrolled wounds were surgically closed, quantifying the number of wounds that dehisced (defined as wound failure or infection requiring return to the operating room after closure) or healed. RESULTS Wound failure occurred in 20% (19 of 96) of traumatic wounds. Normalized intensity values for patients with wounds that healed successfully were, on average, significantly different from values for patients with wounds that failed (p ≤ 0.05). Simple thresholding models and partial least squares discriminant analysis models performed poorly. However, a hierarchical cluster analysis model created with 17 variables including 3CCD data, wound surface area, and time from injury predicts wound failure with 76.9% sensitivity, 76.5% specificity, 76.6% accuracy, and a diagnostic odds ratio of 10.8 (95% confidence interval: 2.6-45.9). CONCLUSIONS Imaging using 3CCD technology may provide a non-invasive and cost-effective method of aiding surgeons in deciding if wounds are ready for closure and could potentially decrease the number of required débridements and hospital days. The process may be automated to provide real-time feedback in the operating room and clinic. The low cost and small size of the cameras makes this technology attractive for austere and shipboard environments where space and weight are at a premium.
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Affiliation(s)
- Jason S. Radowsky
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- * E-mail:
| | - Romon Neely
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
| | - Jonathan A. Forsberg
- Orthopaedics, USUHS-Walter Reed Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Orthopaedics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Felipe A. Lisboa
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- Surgical Critical Care Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Christopher J. Dente
- Surgical Critical Care Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Trauma/Surgical Critical Care, Grady Memorial Hospital, Atlanta, Georgia, United States of America
| | - Eric A. Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
- Surgical Critical Care Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Nicole J. Crane
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (USUHS-Walter Reed Surgery), Bethesda, Maryland, United States of America
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland, United States of America
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46
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Carr MJ, Oxner C, Elster EA, Ritter EM, Vicente D. Management of Acute Upper Gastrointestinal Disease While at Sea. Mil Med 2018; 183:e658-e662. [PMID: 29420777 DOI: 10.1093/milmed/usx103] [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: 08/15/2017] [Revised: 10/21/2017] [Indexed: 11/14/2022] Open
Abstract
Management of complex acute surgical pathology in austere environments necessitates rapid evaluation and resource appropriate management to avoid time-associated morbidity and potentially mortality. Obstructive upper gastrointestinal (UGI) pathologies can be particularly challenging and associated with significant morbidity. Herein, we present six patients with UGI obstructions encountered over the course of an 8-mo deployment onboard a US Navy Aircraft Carrier. Each patient presented to our medical department with signs and symptoms of obstructive UGI pathology including one gastric volvulus requiring operative management at sea, one with a new diagnosis of achalasia requiring transportation and continental United States outpatient evaluation, and four patients with food impaction requiring urgent endoscopic management. Although UGI pathology is seldom encountered at sea, definitive surgical interventions, including prompt evaluation and management of these acute pathologies, can be performed in an austere environment. We wish to call attention to these potential encounters in order that underway deployed medical units and supporting resources ashore are prepared and equipped to intervene on acute UGI obstructive pathology.
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Affiliation(s)
- Matthew J Carr
- Aviation Medicine, Carrier Airwing Seven, 1640 Tomcat blvd STE 300, Virginia Beach, VA
| | - Christopher Oxner
- Department of General Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA
| | - Eric A Elster
- The Department of Surgery at Uniformed Services University of the Health Sciences & The Walter Reed National Military Medical Center
| | - Eric M Ritter
- The Department of Surgery at Uniformed Services University of the Health Sciences & The Walter Reed National Military Medical Center
| | - Diego Vicente
- The Department of Surgery at Uniformed Services University of the Health Sciences & The Walter Reed National Military Medical Center
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47
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Knudson MM, Elster EA, Bailey JA, Woodson J. Military Health System Strategic Partnership with the American College of Surgeons. J Am Coll Surg 2018; 227:296-297. [DOI: 10.1016/j.jamcollsurg.2018.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 10/28/2022]
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Abstract
The intent of this study was to characterize the management and subsequent complications of combat injury tube thoracostomies and to determine risk factors for the development of pneumonia (PNA) and retained hemothorax (RH). One hundred fifteen patients with 173 tube thoracostomies met the inclusion criteria and were analyzed. The mean injury severity score was 30.8 1 11.6, 23.5 per cent had traumatic amputations, 49.7 per cent had a hemothorax, and 50.3 per cent had a pneumothorax as indications for tube thoracostomy (TT) placement. Within 24 hours of injury, 89.6 per cent were intubated, the majority (54%) were injured by improvised explosive devices, 35.6 per cent sustained rib fractures, and 12.2 per cent had a diaphragm injury. A mean of 1.5 1 0.7(range 1–4) tube thoracostomies were placed, 18.3 per cent of patients had bilateral tube thoracostomies, and the average TT duration was 6.7 1 3.9 days. The incidence of PNA was 27 per cent (n = 31), RH was 9.6 per cent (n = 11), and empyema was 1.7 per cent (n = 2). Multivariable analysis identified the duration of ventilation [OR 1.2, 95% confidence interval (CI): 1.097–1.313, P < 0.001] as independently associated with the development of PNA. Bilateral TT placement (OR 3.848, 95% CI: 1.219–12.143, P = 0.0216) and injury severity score (OR 1.050, 95% CI: 1.001–1.102, P = 0.0443) were independently associated with PNA development when a patient was intubated for eight days or less. The number of tube thoracostomies placed (OR 3.08, 95% CI: 1.03–9.18, P = 0.0439) was independently associated with the development of RH. Further research is warranted to identify modifiable risk factors to reduce the incidence of PNA and RH in patients with TT placed for traumatic injuries.
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Affiliation(s)
- Joseph D. Bozzay
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Patrick F. Walker
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Alley E. Ronaldi
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A. Elster
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J. Rodriguez
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew J. Bradley
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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Knudson MM, Elster EA, Bailey JA, Johannigman JA, Bailey PV, Schwab CW, Kirk GG, Woodson JA. Military–Civilian Partnerships in Training, Sustaining, Recruitment, Retention, and Readiness: Proceedings from an Exploratory First-Steps Meeting. J Am Coll Surg 2018; 227:284-292. [DOI: 10.1016/j.jamcollsurg.2018.04.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 10/16/2022]
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Bozzay JD, Walker PF, Ronaldi AE, Elster EA, Rodriguez CJ, Bradley MJ. Tube Thoracostomy Management in the Combat Wounded. Am Surg 2018; 84:1355-1362. [PMID: 30185316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The intent of this study was to characterize the management and subsequent complications of combat injury tube thoracostomies and to determine risk factors for the development of pneumonia (PNA) and retained hemothorax (RH). One hundred fifteen patients with 173 tube thoracostomies met the inclusion criteria and were analyzed. The mean injury severity score was 30.8 + 11.6, 23.5 per cent had traumatic amputations, 49.7 per cent had a hemothorax, and 50.3 per cent had a pneumothorax as indications for tube thoracostomy (TT) placement. Within 24 hours of injury, 89.6 per cent were intubated, the majority (54%) were injured by improvised explosive devices, 35.6 per cent sustained rib fractures, and 12.2 per cent had a diaphragm injury. A mean of 1.5 + 0.7(range 1-4) tube thoracostomies were placed, 18.3 per cent of patients had bilateral tube thoracostomies, and the average TT duration was 6.7 + 3.9 days. The incidence of PNA was 27 per cent (n = 31), RH was 9.6 per cent (n = 11), and empyema was 1.7 per cent (n = 2). Multivariable analysis identified the duration of ventilation [OR 1.2, 95% confidence interval (CI): 1.097-1.313, P < 0.001] as independently associated with the development of PNA. Bilateral TT placement (OR 3.848, 95% CI: 1.219-12.143, P = 0.0216) and injury severity score (OR 1.050, 95% CI: 1.001-1.102, P = 0.0443) were independently associated with PNA development when a patient was intubated for eight days or less. The number of tube thoracostomies placed (OR 3.08, 95% CI: 1.03-9.18, P = 0.0439) was independently associated with the development of RH. Further research is warranted to identify modifiable risk factors to reduce the incidence of PNA and RH in patients with TT placed for traumatic injuries.
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