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Martin ND, Schott LL, Miranowski MK, Desai AM, Lowen CC, Cao Z, Araujo Torres K. Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis. PLoS One 2024; 19:e0302074. [PMID: 38669262 PMCID: PMC11051586 DOI: 10.1371/journal.pone.0302074] [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: 10/02/2023] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas. METHODS Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay. RESULTS 3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001). CONCLUSIONS Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.
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Affiliation(s)
- Niels D. Martin
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Laura L. Schott
- PINC AI Applied Sciences, Applied Research, Premier Inc., Charlotte, North Carolina, United States of America
| | - Mary K. Miranowski
- Regulatory and Medical Affairs, Research and Development, Active and Medical Nutrition, Nestlé Health Science, Bridgewater Township, New Jersey, United States of America
| | - Amarsinh M. Desai
- Market Access, Active and Medical Nutrition, Nestlé Health Science, Bridgewater Township, New Jersey, United States of America
| | - Cynthia C. Lowen
- Regulatory and Medical Affairs, Research and Development, Active and Medical Nutrition, Nestlé Health Science, Bridgewater Township, New Jersey, United States of America
| | - Zhun Cao
- PINC AI Applied Sciences, Applied Research, Premier Inc., Charlotte, North Carolina, United States of America
| | - Krysmaru Araujo Torres
- Regulatory and Medical Affairs, Research and Development, Nestlé Health Science, Bridgewater Township, New Jersey, United States of America
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Silvestre J, Weldeslase TA, Williams M, Martin ND. Analysis of the National Resident Matching Program for Surgical Critical Care Training in the United States: 2008-2022. Surgery 2024; 175:862-867. [PMID: 37953145 DOI: 10.1016/j.surg.2023.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Few studies have assessed the pipeline for surgical intensivists despite projected shortages in the United States' critical care workforce. We had 3 primary objectives in analyzing the Surgical Critical Care Match: (1) understand growth in the number of applicants relative to training positions; (2) compare match rates for United States Allopathic Graduates versus non-United States Allopathic Graduates; and (3) analyze the number of unfilled training positions over time. METHODS This was a national cohort study of Surgical Critical Care Match applicants (2008-2022). Annual match rates and applicant-to-training position ratios were calculated. Cochrane-Armitage tests elucidated temporal trends during the study period. RESULTS There was a greater increase in the number of annual applicants (276% increase) relative to training positions (128% increase) during the study period (P < .001). The applicant-to-training position ratio increased (0.5-0.9, P < .001). Annual match rates increased for both United States Allopathic (92%-97%, P = .015) and non-United States Allopathic (81%-96%, P < .001) Graduates. Match rates for United States Allopathic Graduates exceeded those for non-United States Allopathic Graduates (P < .05) but were similar from 2020 to 2022 (P > .05). The percentage of applicants that matched at their top fellowship choice decreased from 69%-50% (P < .001). From 2008 to 2022, fewer available training positions went unfilled (52%-13%, P < .001). CONCLUSION The pipeline for surgical intensivists in the United States appears to be increasing along with rising interest in Surgical Critical Care training. Future research is needed to understand disparities in match rates by applicant and fellowship program characteristics.
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Hatchimonji JS, Meredyth NA, Gummadi S, Kaufman EJ, Yelon JA, Cannon JW, Martin ND, Seamon MJ. The Role of Emergency Department Thoracotomy in Patients with Cranial Gunshot Wounds. J Trauma Acute Care Surg 2024:01586154-990000000-00641. [PMID: 38374530 DOI: 10.1097/ta.0000000000004282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
BACKGROUND Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS We used Pennsylvania Trauma Outcomes Study (PTOS) data, 2002-2021, and included EDTs for GSWs. We defined EDT by ICD codes for thoracotomy or procedures requiring one, with a location flagged as ED. We defined head injuries as any head abbreviated injury scale (AIS) ≥1 and severe head injuries as head AIS ≥ 4. Head injuries were "isolated" if all other body regions AIS < 2. Descriptive statistics were performed. Discharge functional status was measured in 5 domains. RESULTS Over 20 years in Pennsylvania, 3,546 EDTs were performed, 2,771 (78.1%) for penetrating injuries. Most penetrating EDTs (2,003, 72.3%) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head-injured (n = 94/1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound - 0% (0/81) with a severe head injury (p = 0.035 vs no severe head injury), and 4.5% (5/110) with a non-severe head injury. Of the 5 head-injured survivors, 2 were fully dependent for transfer mobility, and 3 were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSIONS Though there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head-injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE Level II, retrospective observational cohort study.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nicole A Meredyth
- Division of Trauma and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sriharsha Gummadi
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Jeremy W Cannon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Niels D Martin
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark J Seamon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Niziolek GM, Mangan L, Weaver C, Prendergast V, Lamore R, Zielke M, Martin ND. Inadequate prophylaxis in patients with trauma: anti-Xa-guided enoxaparin dosing management in critically ill patients with trauma. Trauma Surg Acute Care Open 2024; 9:e001287. [PMID: 38362006 PMCID: PMC10868176 DOI: 10.1136/tsaco-2023-001287] [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: 10/31/2023] [Accepted: 01/27/2024] [Indexed: 02/17/2024] Open
Abstract
Venous thromboembolism (VTE) causes significant morbidity in patients with trauma despite advances in pharmacologic therapy. Prior literature suggests standard enoxaparin dosing may not achieve target prophylactic anti-Xa levels. We hypothesize that a new weight-based enoxaparin protocol with anti-Xa monitoring for dose titration in critically injured patients is safe and easily implemented. Methods This prospective observational study included patients with trauma admitted to the trauma intensive care unit (ICU) from January 2021 to September 2022. Enoxaparin dosing was adjusted based on anti-Xa levels as standard of care via a performance improvement initiative. The primary outcome was the proportion of subtarget anti-Xa levels (<0.2 IU/mL) on 30 mg two times per day dosing of enoxaparin. Secondary outcomes included the dosing modifications to attain goal anti-Xa levels, VTE and bleeding events, and hospital and ICU lengths of stay. Results A total of 282 consecutive patients were included. Baseline demographics revealed a median age of 36 (26-55) years, and 44.7% with penetrating injuries. Of these, 119 (42.7%) achieved a target anti-Xa level on a starting dose of 30 mg two times per day. Dose modifications for subtarget anti-Xa levels were required in 163 patients (57.8%). Of those, 120 underwent at least one dose modification, which resulted in 78 patients (47.8%) who achieved a target level prior to hospital discharge on a higher dose of enoxaparin. Overall, only 69.1% of patients achieved goal anti-Xa level prior to hospital discharge. VTE occurred in 25 patients (8.8%) and major bleeding in 3 (1.1%) patients. Conclusion A majority of critically injured patients do not meet target anti-Xa levels with 30 mg two times per day enoxaparin dosing. This study highlights the need for anti-Xa-based dose modification and efficacy of a pharmacy-driven protocol. Further optimization is warranted to mitigate VTE events. Level of evidence Therapeutic/care management, level III.
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Affiliation(s)
| | - Lauren Mangan
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cassidi Weaver
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Raymond Lamore
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Megan Zielke
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Vail EA, Tam VW, Sonnenberg EM, Lavu NR, Reese PP, Abt PL, Martin ND, Hasz RD, Olthoff KM, Kerlin MP, Christie JD, Neuman MD, Potluri VS. Characterizing proximity and transfers of deceased organ donors to donor care units in the United States. Am J Transplant 2024:S1600-6135(24)00133-3. [PMID: 38346499 DOI: 10.1016/j.ajt.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
Some United States organ procurement organizations transfer deceased organ donors to donor care units (DCUs) for recovery procedures. We used Organ Procurement and Transplantation Network data, from April 2017 to June 2021, to describe the proximity of adult deceased donors after brain death to DCUs and understand the impact of donor service area (DSA) boundaries on transfer efficiency. Among 19 109 donors (56.1% of the cohort) in 25 DSAs with DCUs, a majority (14 593 [76.4%]) were in hospitals within a 2-hour drive. In areas with DCUs detectable in the study data set, a minority of donors (3582 of 11 532 [31.1%]) were transferred to a DCU; transfer rates varied between DSAs (median, 27.7%, range, 4.0%-96.5%). Median hospital-to-DCU driving times were not meaningfully shorter among transferred donors (50 vs 51 minutes for not transferred, P < .001). When DSA boundaries were ignored, 3241 cohort donors (9.5%) without current DCU access were managed in hospitals within 2 hours of a DCU and thus potentially eligible for transfer. In summary, approximately half of United States deceased donors after brain death are managed in hospitals in DSAs with a DCU. Transfer of donors between DSAs may increase DCU utilization and improve system efficiency.
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Vicky W Tam
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Niels D Martin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Richard D Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Meeta P Kerlin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vishnu S Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Schmidt LE, Hinton MS, Martin ND. Real-World Reversal of Factor Xa Inhibition in the Setting of Major Life-Threatening Bleeding or Urgent Surgery. J Pharm Pract 2024; 37:74-79. [PMID: 36083782 DOI: 10.1177/08971900221125516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Management of major life-threatening bleeding with factor Xa (FXa) inhibition poses complex challenges involving novel direct reversal agents competing with non-specific preexisting strategies. The recent availability of andexanet alfa (AA) led to a health-system guideline incorporating its use alongside the most commonly used historic agent, four-factor prothrombin complex concentrate (4F-PCC). Objectives: The objective was to characterize the use and efficacy of AA and 4F-PCC for reversal of FXa inhibition after implementation of the health-system guideline. Methods: This multi-hospital, retrospective cohort study included patients aged >18 years administered either AA or 4F-PCC between October 2018 to June 2020 with the indication for urgent reversal of FXa inhibitor-induced coagulopathy. The primary outcome assessed hemostatic efficacy between treatment groups. Secondary outcomes evaluated adjunct blood product administration, incidence of repeat pharmacologic reversal, incidence of thromboembolism, intensive care unit and hospital length of stays, and in-hospital mortality. Results: Eighty-five patients were included; 33 patients received AA and 52 patients received 4F-PCC. Effective hemostasis was achieved at similar rates in both treatment groups (84.8% vs 76.9%; P = .373). Thrombotic events occurring during the observed hospitalization were more frequent among the AA treated group (18% vs 3.8%, P = .027). No differences were observed for other secondary outcomes. Conclusion: Guideline use resulted in similar rates of effective hemostasis with a higher incidence of VTE in patients receiving AA. Further exploration with a larger, prospective study to evaluate these findings is warranted.
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Affiliation(s)
- Lauren E Schmidt
- Department of Pharmacy, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Matthew S Hinton
- Department of Pharmacy, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Hynes AM, Murali S, Bass GA, Kheirbek T, Qasim Z, George N, Yelon JA, Chreiman KC, Martin ND, Cannon JW. Effectiveness of Sternal Intraosseous Device in Patients Presenting with Circulatory Shock: A Retrospective Observational Study. J Spec Oper Med 2023; 23:81-86. [PMID: 38064650 DOI: 10.55460/aazw-r052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Hemorrhagic shock requires timely administration of blood products and resuscitative adjuncts through multiple access sites. Intraosseous (IO) devices offer an alternative to intravenous (IV) access as recommended by the massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia (MARCH) algorithm of Tactical Combat Casualty Care (TCCC). However, venous injuries proximal to the site of IO access may complicate resuscitative attempts. Sternal IO access represents an alternative pioneered by military personnel. However, its effectiveness in patients with shock is supported by limited evidence. We conducted a pilot study of two sternal-IO devices to investigate the efficacy of sternal-IO access in civilian trauma care. METHODS A retrospective review (October 2020 to June 2021) involving injured patients receiving either a TALON® or a FAST1® sternal-IO device was performed at a large urban quaternary academic medical center. Baseline demographics, injury characteristics, vascular access sites, blood products and medications administered, and outcomes were analyzed. The primary outcome was a successful sternal-IO attempt. RESULTS Nine males with gunshot wounds transported to the hospital by police were included in this study. Eight patients were pulseless on arrival, and one became pulseless shortly thereafter. Seven (78%) sternal-IO placements were successful, including six TALON devices and one of the three FAST1 devices, as FAST1 placement required attention to Operator positioning following resuscitative thoracotomy. Three patients achieved return of spontaneous circulation, two proceeded to the operating room, but none survived to discharge. CONCLUSIONS Sternal-IO access was successful in nearly 80% of attempts. The indications for sternal-IO placement among civilians require further evaluation compared with IV and extremity IO access.
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Vail EA, Schaubel DE, Potluri VS, Abt PL, Martin ND, Reese PP, Neuman MD. Deceased Organ Donor Management and Organ Distribution From Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals. Prog Transplant 2023; 33:283-292. [PMID: 37941335 PMCID: PMC10691289 DOI: 10.1177/15269248231212918] [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] [Indexed: 11/10/2023]
Abstract
Introduction: Organ recovery facilities address the logistical challenges of hospital-based deceased organ donor management. While more organs are transplanted from donors in facilities, differences in donor management and donation processes are not fully characterized. Research Question: Does deceased donor management and organ transport distance differ between organ procurement organization (OPO)-based recovery facilities versus hospitals? Design: Retrospective analysis of Organ Procurement and Transplant Network data, including adults after brain death in 10 procurement regions (April 2017-June 2021). The primary outcomes were ischemic times of transplanted hearts, kidneys, livers, and lungs. Secondary outcomes included transport distances (between the facility or hospital and the transplant program) for each transplanted organ. Results: Among 5010 deceased donors, 51.7% underwent recovery in an OPO-based recovery facility. After adjustment for recipient and system factors, mean differences in ischemic times of any transplanted organ were not significantly different between donors in facilities and hospitals. Transplanted hearts recovered from donors in facilities were transported further than hearts from hospital donors (median 255 mi [IQR 27, 475] versus 174 [IQR 42, 365], P = .002); transport distances for livers and kidneys were significantly shorter (P < .001 for both). Conclusion: Organ recovery procedures performed in OPO-based recovery facilities were not associated with differences in ischemic times in transplanted organs from organs recovered in hospitals, but differences in organ transport distances exist. Further work is needed to determine whether other observed differences in donor management and organ distribution meaningfully impact donation and transplantation outcomes.
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Affiliation(s)
- Emily A. Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Perelman School of Medicine, Blockley Hall, Philadelphia, PA, USA
| | - Vishnu S. Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Peter L. Abt
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Niels D. Martin
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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Seng SS, Kaufman EJ, Song J, Moran B, Stawicki SP, Koenig G, Timinski M, Martin ND, Ratnasekera A. A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health? J Surg Res 2023; 291:620-626. [PMID: 37542776 DOI: 10.1016/j.jss.2023.06.032] [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: 12/05/2022] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic. METHODS A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests. RESULTS There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts. CONCLUSIONS During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.
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Affiliation(s)
- Sirivan S Seng
- Department of Surgery, Crozer Chester Medical Center, Upland, Pennsylvania.
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jamie Song
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Moran
- Department of Surgery, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Stanislaw P Stawicki
- Department of Research & Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - George Koenig
- Department of Surgery, Thomas Jefferson University, Philadelphia Pennsylvania
| | - Marie Timinski
- Department of Surgery, Geisinger Wyoming Valley, Wilkes Barre, Pennsylvania
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Asanthi Ratnasekera
- Department of Surgery, Crozer Chester Medical Center, Upland, Pennsylvania; Department of Surgery, Christiana Care, Newark, Delaware
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Ginzberg SP, Roberson JL, Nehemiah A, Ballester JMS, Warshauer AK, Wachtel H, Erdman MS, Dlugosz KL, George LJ, Lynn JC, Martin ND, Myers JS. Time to Transfer as a Quality Improvement Imperative: Implications of a Hub-and-Spoke Health System Model on the Timing of Emergency Procedures. Jt Comm J Qual Patient Saf 2023; 49:539-546. [PMID: 37422425 DOI: 10.1016/j.jcjq.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND In the increasingly prevalent hub-and-spoke health system model, specialized services are centralized at a hub hospital, while spoke hospitals offer more limited services and transfer patients to the hub as needed. In one urban, academic health system, a community hospital without procedural capabilities was recently incorporated as a spoke. The goal of this study was to assess the timeliness of emergent procedures for patients presenting to the spoke hospital under this model. METHODS The authors performed a retrospective cohort study of patients transferred from the spoke hospital to the hub hospital for emergency procedures after the health system restructuring (April 2021-October 2022). The primary outcome was the proportion of patients who arrived within their goal transfer time. Secondary outcomes were time from transfer request to procedure start and whether procedure start occurred within guideline-recommended treatment time frames for ST-elevation myocardial infarction (STEMI), necrotizing soft tissue infection (NSTI), and acute limb ischemia (ALI). RESULTS A total of 335 patients were transferred for emergency procedural intervention during the study period, most commonly for interventional cardiology (23.9%), endoscopy or colonoscopy (11.0%), or bone or soft tissue debridement (10.7%). Overall, 65.7% of patients were transferred within the goal time. 23.5% of patients with STEMI met goal door-to-balloon time, and more patients with NSTI (55.6%) and ALI (100%) underwent intervention within the guideline-recommended time frame. CONCLUSION A hub-and-spoke health system model can provide access to specialized procedures in a high-volume, resource-rich setting. However, ongoing performance improvement is required to ensure that patients with emergency conditions receive timely intervention.
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Zeineddin A, Tominaga GT, Crandall M, Almeida M, Schuster KM, Jawad G, Maqbool B, Sheffield AC, Dhillon NK, Radow BS, Moorman ML, Martin ND, Jacovides CL, Lowry D, Kaups K, Horwood CR, Werner NL, Proaño-Zamudio JA, Kaafarani HMA, Marshall WA, Haines LN, Schaffer KB, Staudenmayer KL, Kozar RA. Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale. J Trauma Acute Care Surg 2023; 95:213-219. [PMID: 37072893 DOI: 10.1097/ta.0000000000003969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
INTRODUCTION The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes. METHODS This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion. RESULTS We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13). CONCLUSION This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Ahmad Zeineddin
- From the Department of Surgery (A.Z.), Howard University Hospital, Washington, DC; Department of Surgery (A.Z., N.K.D., R.A.K.), Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (M.A., K.M.S.), Yale University, New Haven, Connecticut; Department of Surgery (G.J., B.M.), University of New Mexico Health Science Center, Albuquerque, New Mexico; Department of Surgery (M.C., A.C.S.), College of Medicine, University of Florida, Jacksonville, Florida; Department of Surgery (B.S.R., M.L.M.), University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (N.D.M., C.L.J.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.L., K.K.), Community Regional Medical Center, UCSF Fresno, Fresno, California; Department of Surgery (C.R.H., N.L.W.), Denver Health, Denver, Colorado; Department of Surgery (J.A.P.-Z., H.M.A.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (W.A.M., L.N.H.), University of California San Diego Health, San Diego; Department of Surgery (G.T.T., K.B.S.), Scripps Memorial Hospital, La Jolla; and Department of Surgery (K.L.S.), Stanford University, Stanford, California
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12
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Niziolek GM, Dowzicky P, Joergensen S, Zone A, Brinson MM, Martin ND, Seamon MJ, Raza S, Yelon J, Cannon J. Brief report on the development of hemorrhagic pericardial effusion after thoracic surgery for traumatic injuries. Trauma Surg Acute Care Open 2023; 8:e001090. [PMID: 37441460 PMCID: PMC10335439 DOI: 10.1136/tsaco-2023-001090] [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: 01/15/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Hemorrhagic pericardial effusion (HPE) is a rare but life-threatening diagnosis that may occur after thoracic trauma. Previous reports have concentrated on delayed HPE in those who did not require initial surgical intervention for their traumatic injuries. In this report, we identify and characterize the phenomenon of HPE after emergent thoracic surgery for trauma. Methods This is a retrospective review of patients who required emergent thoracic surgery for trauma at a level 1 trauma center from 2017 to 2021. Using the institutional trauma database, demographics, injury characteristics, and outcomes were compared between patients with HPE and those without HPE after thoracic surgery for trauma. Results Ninety-one patients were identified who underwent emergent thoracic surgery for trauma. Most were young men who sustained a penetrating thoracic injury. Seven patients (7.7%) went on to develop HPE. Patients who developed HPE were younger (18 vs. 32 years, p=0.034), required bilateral anterolateral thoracotomy (85% vs. 7%, p<0.001), and were more likely to have pulmonary injuries (100% vs. 52.4%, p<0.001). Five patients with HPE survived to hospital discharge. The two patients with HPE who died were both coagulopathic and had HPE diagnosed within 4 days of injury. The median time to HPE diagnosis in survivors was 24 days with four of five HPE survivors on therapeutic anticoagulation at the time of diagnosis. Conclusions HPE may occur after emergent thoracic surgery for trauma. Those at highest risk of HPE include younger patients with bilateral thoracotomy incisions and pulmonary injuries. Early HPE, clinical signs of tamponade, and/or coagulopathy in patients with HPE portend a worse prognosis. Surgeons and trauma team members caring for patients after emergent thoracic exploration for trauma should be aware of this potentially devastating complication and should consider postoperative echocardiography in high-risk patients.
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Affiliation(s)
- Grace Martin Niziolek
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip Dowzicky
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarah Joergensen
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alea Zone
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Martha M Brinson
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark J Seamon
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shariq Raza
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jay Yelon
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jeremy Cannon
- Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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13
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Vail EA, Schaubel DE, Abt PL, Martin ND, Reese PP, Neuman MD. Organ Transplantation Outcomes of Deceased Organ Donors in Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals. Prog Transplant 2023; 33:110-120. [PMID: 36942433 PMCID: PMC10150267 DOI: 10.1177/15269248231164176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Recovery of donated organs at organ procurement organization (OPO)-based recovery facilities has been proposed to improve organ donation outcomes, but few data exist to characterize differences between facilities and acute-care hospitals. RESEARCH QUESTION To compare donation outcomes between organ donors that underwent recovery procedures in OPO-based recovery facilities and hospitals. DESIGN Retrospective study of Organ Procurement and Transplantation Network data. From a population-based sample of deceased donors after brain death April 2017 to June 2021, donation outcomes were examined in 10 OPO regions with organ recovery facilities. Primary exposure was organ recovery procedure in an OPO-based organ recovery. Primary outcome was the number of organs transplanted per donor. Multivariable regression models were used to adjust for donor characteristics and managing OPO. RESULTS Among 5010 cohort donors, 2590 (51.7%) underwent recovery procedures in an OPO-based facility. Donors in facilities differed from those in hospitals, including recovery year, mechanisms of death, and some comorbid diseases. Donors in OPO-based facilities had higher total numbers of organs transplanted per donor (mean 3.5 [SD1.8] vs 3.3 [SD1.8]; adjusted mean difference 0.27, 95% confidence interval 0.18-0.36). Organ recovery at an OPO-based facility was also associated with more lungs, livers, and pancreases transplanted. CONCLUSION Organ recovery procedures at OPO-based facilities were associated with more organs transplanted per donor than in hospitals. Increasing access to OPO-based organ recovery facilities may improve rates of organ transplantation from deceased organ donors, although further data are needed on other important donor management quality metrics.
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter L Abt
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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14
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Michetti CP, Evans SL, Martin ND, Ahmad S, Greene WR, Codner PA. Does Practice Match Training? Consultation Practices in Surgical Critical Care. J Surg Res 2023; 288:71-78. [PMID: 36948035 DOI: 10.1016/j.jss.2023.02.019] [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: 07/31/2022] [Revised: 01/16/2023] [Accepted: 02/17/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.
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Affiliation(s)
| | - Susan L Evans
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Niels D Martin
- Division of Trauma, SCC & EGS, University of Pennsylvania, Philadephia, Pennsylvania
| | - Salman Ahmad
- Department of Surgery, University of Missouri Health Care, University Hospital, Columbia, Missouri
| | - Wendy R Greene
- Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - Panna A Codner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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15
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Bailey JA, Jacovides CL, Butler D, Bass GA, Seamon MJ, Cannon J, Martin ND. Adolescent Gun Violence Shows an Age Group to Focus Trauma Prevention. J Surg Res 2023; 283:853-857. [PMID: 36915012 DOI: 10.1016/j.jss.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 10/03/2022] [Accepted: 10/17/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Gun violence continues to escalate in America's urban areas. Peer groups of gun wound victims are potential targets for violence prevention initiatives; identification of this cohort is pivotal to efficient deployment strategies. We hypothesize a specific age at which the incidence of penetrating trauma increases significantly in adolescence, below which should be the focus on future trauma prevention. METHODS Adolescent trauma patients with gunshot wounds seen from July 2011 through June 2021 at a well-established, urban, academic level 1 trauma center were reviewed retrospectively and grouped by age. A linear regression and repeated measured analysis of variance evaluated the change in gunshot wound victims over this time, grouped by age. Demographics were extrapolated, and standard statistical analysis was performed. RESULTS A total of 1304 adolescent trauma patients were included. Those aged 15 y and under had an unchanged incidence of gunshot wounds. However, those aged 16 y and more experienced the majority of increased gun violence; 92% were Black and 90% were male with a mortality of 12%. Adolescents aged 15 y and below were 95% Black and 84% male, with a mortality of 18%. CONCLUSIONS Primary prevention efforts to mitigate gun violence should be focused on adolescents below 16 y of age. Prevention of gun violence should include community outreach efforts directed toward middle school-aged children and younger, hoping to decrease the incidence of injury due to gun violence in older adolescents in the future.
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Affiliation(s)
- Joanelle A Bailey
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.
| | - Christina L Jacovides
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Dale Butler
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Gary A Bass
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Mark J Seamon
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jeremy Cannon
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Niels D Martin
- University of Pennsylvania, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
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16
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York TJ, Ajmera S, Lutfi W, Su S, Chandler JM, Michaels MJ, Schuster JM, Zager EL, Weber KL, Braslow B, Martin ND, Sharoky CE, Malhotra NR, Cannon J. Prone Zone 3 REBOA Rescue for Postoperative Hemorrhagic After Sacrococcygeal Tumor Resection. JEVTM 2023. [DOI: 10.26676/jevtm.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this report, we describe a 41-year-old man who underwent resection of a large chordoma. During his post-operative recovery, he experienced delayed-onset non-compressive pelvic hemorrhage in the surgical resection bed resulting in nerve root compression. Zone 3 REBOA was prepositioned intra-operatively prior to placing the patient in the prone position for hematoma evacuation and exploration for surgical hemostasis. The balloon was completely inflated to facilitate exposure to the site of hemorrhage in this patient with a high risk for neurologic injury during this operative re-exploration.
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17
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Streeter SS, Ray GS, Bateman LM, Hebert KA, Bushee FE, Rodi SW, Gitajn IL, Ahn J, Singhal S, Martin ND, Bernthal NM, Lee C, Obremskey WT, Schoenecker JG, Elliott JT, Henderson ER. Early identification of life-threatening soft-tissue infection using dynamic fluorescence imaging: first-in-kind clinical study of first-pass kinetics. Proc SPIE Int Soc Opt Eng 2023; 12361:123610B. [PMID: 37034555 PMCID: PMC10078977 DOI: 10.1117/12.2648408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Necrotizing soft-tissue infections (NSTIs) are aggressive and deadly. Immediate surgical debridement is standard-of-care, but patients often present with non-specific symptoms, thereby delaying treatment. Because NSTIs cause microvascular thrombosis, we hypothesized that perfusion imaging using indocyanine green (ICG) would show diminished fluorescence signal in NSTI-affected tissues, particularly compared to non-necrotizing, superficial infections. Through a first-in-kind clinical study, we performed first-pass ICG fluorescence perfusion imaging of patients with suspected NSTIs. Early results support our hypothesis that ICG signal voids occur in NSTI-affected tissues and that dynamic contrast-enhanced fluorescence parameters reveal tissue kinetics that may be related to disease progression and extent.
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Affiliation(s)
- Samuel S. Streeter
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - Gabrielle S. Ray
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - Logan M. Bateman
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| | - Kendra A. Hebert
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| | | | - Scott W. Rodi
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - I. Leah Gitajn
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
| | - Jaimo Ahn
- Michigan Medicine, U. of Michigan, Ann Arbor, MI 48109
| | - Sunil Singhal
- Perelman School of Medicine, U. of Pennsylvania, Philadelphia, PA 19104
| | - Niels D. Martin
- Perelman School of Medicine, U. of Pennsylvania, Philadelphia, PA 19104
| | - Nicholas M. Bernthal
- David Geffen School of Medicine, U. of California Los Angeles, Santa Monica, CA 90404
| | - Christopher Lee
- David Geffen School of Medicine, U. of California Los Angeles, Santa Monica, CA 90404
| | | | | | - Jonathan Thomas Elliott
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
| | - Eric R. Henderson
- Department of Orthopaedics, Dartmouth Health, Lebanon, NH 03756
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755
- Thayer School of Engineering, Dartmouth College, Hanover, NH 03755
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18
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Bass GA, Duffy CC, Kaplan LJ, Sarani B, Martin ND, Ismail AM, Cao Y, Forssten MP, Mohseni S. The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures. Injury 2023; 54:56-62. [PMID: 36402584 DOI: 10.1016/j.injury.2022.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/23/2022] [Accepted: 11/10/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture. METHODS All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders. RESULTS 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome. CONCLUSIONS Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; School of Medical Sciences, Orebro University, Orebro, Sweden; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA
| | - Caoimhe C Duffy
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA
| | - Lewis J Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, USA; Corporal Michael Cresenscz Veterans Affairs Medical Center (CMCVAMC), Philadelphia, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University School of Medicine & Health Sciences, Washington D.C., USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | | | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden.
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19
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Hatchimonji JS, Raza SS, Martin ND, Cannon JW, Wang GJ, Glaser JD. The Traveling Pelvic Bullet: A Case of Retrograde Ballistic Migration Through the Venous System. J Vasc Surg Cases Innov Tech 2022; 8:587-591. [PMID: 36248402 PMCID: PMC9556566 DOI: 10.1016/j.jvscit.2022.08.016] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
Migration of a ballistic missile through the vasculature is rare but important to recognize. It can lead to diagnostic confusion and seemingly unexplainable bullet trajectories. We have described the case of a young man with a gunshot wound to the axillary vein and initial embolus to the inferior vena cava. The bullet subsequently migrated to the right common iliac vein, allowing for straightforward retrieval.
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Affiliation(s)
- Justin S. Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Correspondence: Justin S. Hatchimonji, MD, MBE, MSCE, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA 19104
| | - Shariq S. Raza
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Niels D. Martin
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jeremy W. Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Grace J. Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Julia D. Glaser
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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20
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Hynes AM, Scantling DR, Murali S, Bormann BC, Paul JS, Reilly PM, Seamon MJ, Martin ND. What happens after they survive? The role of anticoagulants and antiplatelets in IVC injuries. Trauma Surg Acute Care Open 2022; 7:e000923. [PMID: 35813557 PMCID: PMC9214426 DOI: 10.1136/tsaco-2022-000923] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/07/2022] Open
Abstract
Background Venous thromboembolism (VTE) after an inferior vena cava (IVC) injury is a devastating complication. Current practice involves variable use of anticoagulation and antiplatelet (AC/AP) agents. We hypothesized that AC/AP can reduce the incidence of VTE and that delayed institution of AC/AP is associated with increased VTE events. Methods We retrospectively reviewed IVC injuries cared for at a large urban adult academic level 1 trauma center between January 1, 2008 and December 31, 2020, surviving 72 hours. Patient demographics, injury mechanism, surgical repair, type and timing of AC, and type and timing of VTE events were characterized. Postoperative AC status during hospital course before an acute VTE event was delineated by grouping patients into four categories: full, prophylactic, prophylactic with concomitant AP, and none. The primary outcome was the incidence of an acute VTE event. IVC ligation was excluded from analysis. Results Of the 76 patients sustaining an IVC injury, 26 were included. The incidence of a new deep vein thrombosis distal to the IVC injury and a new pulmonary embolism was 31% and 15%, respectively. The median onset of VTE was 5 days (IQR 1–11). Four received full AC, 10 received prophylactic AC with concomitant AP, 8 received prophylactic AC, and 4 received no AC/AP. New VTE events occurred in 0.0% of full, in 30.0% of prophylactic with concomitant AP, in 50.0% of prophylactic, and in 50.0% without AC/AP. There was no difference in baseline demographics, injury mechanisms, surgical interventions, and bleeding complications. Discussion This is the first study to suggest that delay and degree of antithrombotic initiation in an IVC-injured patient may be associated with an increase in VTE events. Consideration of therapy initiation should be performed on hemostatic stabilization. Future studies are necessary to characterize the optimal dosing and temporal timing of these therapies. Level of evidence Therapeutic, level 3.
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Affiliation(s)
- Allyson M Hynes
- Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Dane R Scantling
- Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Shyam Murali
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jasmeet S Paul
- Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Patrick M Reilly
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark J Seamon
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Ziegler MJ, Babcock HH, Welbel SF, Warren DK, Trick WE, Tolomeo P, Omorogbe J, Garcia D, Habrock-Bach T, Donceras O, Gaynes S, Cressman L, Burnham JP, Bilker W, Reddy SC, Pegues D, Lautenbach E, Kelly BJ, Fuchs B, Martin ND, Han JH. Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit. Clin Infect Dis 2022; 75:1217-1223. [PMID: 35100614 PMCID: PMC9525084 DOI: 10.1093/cid/ciac070] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 10/01/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness. METHODS Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline. RESULTS The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline. CONCLUSIONS Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.
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Affiliation(s)
- Matthew J Ziegler
- Correspondence: M. Ziegler, 719 Blockley Hall—423 Guardian Dr, Philadelphia, PA 19104 ()
| | - Hilary H Babcock
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sharon F Welbel
- Cook County Health, Chicago, Illinois, USA,Rush Medical College, Chicago, Illinois, USA
| | - David K Warren
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - William E Trick
- Cook County Health, Chicago, Illinois, USA,Rush Medical College, Chicago, Illinois, USA
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacqueline Omorogbe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Tracy Habrock-Bach
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Steven Gaynes
- Hospital of the University of Pennsylvania, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Warren Bilker
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sujan C Reddy
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Pegues
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brendan J Kelly
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Barry Fuchs
- Division of Pulmonary Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Hynes AM, Lambe LD, Scantling DR, Bormann BC, Atkins JH, Rassekh CH, Seamon MJ, Martin ND. A surgical needs assessment for airway rapid responses: A retrospective observational study. J Trauma Acute Care Surg 2022; 92:126-134. [PMID: 34252060 DOI: 10.1097/ta.0000000000003348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.
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Affiliation(s)
- Allyson M Hynes
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (A.M.H., D.R.S., B.C.B., M.J.S., N.D.M.), Nursing Rapid Response Team (L.D.L.), Department of Anesthesiology and Critical Care (J.H.A.), and Department of Otorhinolaryngology: Head and Neck Surgery (C.H.R.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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23
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Smith RN, Tracy BM, Smith S, Johnson S, Martin ND, Seamon MJ. Retained Bullets After Firearm Injury: A Survey on Surgeon Practice Patterns. J Interpers Violence 2022; 37:NP306-NP326. [PMID: 32370593 DOI: 10.1177/0886260520914557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Retained bullets are common after firearm injuries, yet their management remains poorly defined. Surgeon members of the Eastern Association for the Surgery of Trauma (N = 427) were surveyed using an anonymous, web-based questionnaire during Spring 2016. Indications for bullet removal and practice patterns surrounding this theme were queried. Also, habits around screening and diagnosing psychological illness in victims of firearm injury were asked. Most respondents were male (76.5%, n = 327) and practiced at urban (84.3%, n = 360), academic (88.3%, n = 377), Level 1 trauma centers (72.8%, n = 311). Only 14.5% (n = 62) of surgeons had institutional policies for bullet removal and 5.6% (n = 24) were likely to remove bullets. Half of the surgeons (52.0%, n = 222) preferred to remove bullets after the index hospitalization and pain (88.1%, n = 376) and a palpable bullet (71.2%, n = 304) were the most frequent indications for removal. Having the opportunity to follow-up with patients to discuss bullet removal was significantly predictive of removal (odds ratio (OR) = 2.25, 95% confidence interval (CI) = [1.05, 4.85], p = .04). Furthermore, routinely asking about retained bullets during outpatient follow-up was predictive of new psychological illness screening (OR = 1.94, 95% CI [1.19, 3.16], p = .01) and diagnosis (OR = 1.86, 95% CI = [1.12, 3.09], p = .02) in victims of firearm injury. Thus, surgeons should be encouraged to allot time for patients concerning retained bullet management so that a shared decision can be reached.
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Affiliation(s)
- Randi N Smith
- Emory University School of Medicine, Atlanta, GA, USA
| | - Brett M Tracy
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sean Johnson
- University of Pennsylvania, Philadelphia, PA, USA
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24
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Byrne JP, Witiw CD, Schuster JM, Pascual JL, Cannon JW, Martin ND, Reilly PM, Nathens AB, Seamon MJ. Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality. JAMA Surg 2021; 157:e215794. [PMID: 34910096 DOI: 10.1001/jamasurg.2021.5794] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI). Objective To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications. Design, Setting, and Participants This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020. Exposures Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods). Main Outcomes and Measures The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics. Results The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99). Conclusions and Relevance In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.
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Affiliation(s)
- James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher D Witiw
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James M Schuster
- Department of Neurosurgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jose L Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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25
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Kaufman EJ, Holena D, Koenig G, Martin ND, Maish GO, Moran BJ, Ratnasekera A, Stawicki SP, Timinski M, Brown J. Increase in Motor Vehicle Crash Severity: An Unforeseen Consequence of COVID-19. Am Surg 2021:31348211047466. [PMID: 34645324 PMCID: PMC8524247 DOI: 10.1177/00031348211047466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The 2019 coronavirus (COVID-19) pandemic led to stay-at-home (SAH) orders in Pennsylvania targeted at reducing viral transmission. Limitations in population mobility under SAH have been associated with decreased motor vehicle collisions (MVC) and related injuries, but the impact of these measures on severity of injury remains unknown. The goal of this study is to measure the incidence, severity, and outcomes of MVC-related injuries associated with SAH in Pennsylvania. MATERIALS & METHODS We conducted a retrospective geospatial analysis of MVCs during the early COVID-19 pandemic using a state-wide trauma registry. We compared characteristics of patients with MVC-related injuries admitted to Pennsylvania trauma centers during SAH measures (March 21-July 31, 2020) with those from the corresponding periods in 2018 and 2019. We also compared incidence of MVCs for each zip code tabulation area (ZCTA) in Pennsylvania for the same time periods using geospatial mapping. RESULTS Of 15,550 trauma patients treated during the SAH measures, 3486 (22.4%) resulted from MVCs. Compared to preceding years, MVC incidence decreased 10% under SAH measures with no change in mortality rate. However, in ZCTA where MVC incidence decreased, there was a 16% increase in MVC injury severity. CONCLUSIONS Stay-at-home orders issued in response to the COVID-19 pandemic in Pennsylvania were associated with significant changes in MVC incidence and severity. Identifying such changes may inform resource allocation decisions during future pandemics or SAH events.
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Affiliation(s)
- Elinore J Kaufman
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Holena
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - George Koenig
- 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Niels D Martin
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - George O Maish
- Division of Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | | | - Stanislaw P Stawicki
- Department of Research & Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | | | - Joshua Brown
- Division of Trauma and General Surgery, Department of Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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26
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Kaufman EJ, Ong AW, Cipolle MD, Whitehorn G, Ratnasekera A, Stawicki SP, Martin ND. The impact of COVID-19 infection on outcomes after injury in a state trauma system. J Trauma Acute Care Surg 2021; 91:559-565. [PMID: 34074996 DOI: 10.1097/ta.0000000000003310] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE Level II, Prognostic Study.
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Affiliation(s)
- Elinore J Kaufman
- From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery (E.J.K.), University of Pennsylvania, Philadelphia; Department of Surgery (A.W.O.), Reading Hospital and Medical Center, Reading; Division of Trauma and Acute Care Surgery (M.D.C.), Lehigh Valley Health Network, Allentown; Department of Surgery (G.W.), University of Pennsylvania, Philadelphia; Department of Surgery (A.R.), Crozer-Chester Medical Center Upland; Department of Research & Innovation (S.P.S.), St. Luke's University Health Network, Bethlehem; and Division of Traumatology, Surgical Critical Care, and Emergency Surgery (N.D.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Russell PS, Hong J, Trevaskis NL, Windsor JA, Martin ND, Phillips ARJ. Lymphatic Contractile Function: A Comprehensive Review of Drug Effects and Potential Clinical Application. Cardiovasc Res 2021; 118:2437-2457. [PMID: 34415332 DOI: 10.1093/cvr/cvab279] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/18/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The lymphatic system and the cardiovascular system work together to maintain body fluid homeostasis. Despite that, the lymphatic system has been relatively neglected as a potential drug target and a source of adverse effects from cardiovascular drugs. Like the heart, the lymphatic vessels undergo phasic contractions to promote lymph flow against a pressure gradient. Dysfunction or failure of the lymphatic pump results in fluid imbalance and tissue oedema. While this can due to drug effects, it is also a feature of breast cancer-associated lymphoedema, chronic venous insufficiency, congestive heart failure and acute systemic inflammation. There are currently no specific drug treatments for lymphatic pump dysfunction in clinical use despite the wealth of data from pre-clinical studies. AIM To identify (1) drugs with direct effects on lymphatic tonic and phasic contractions with potential for clinical application, and (2) drugs in current clinical use that have a positive or negative side effect on lymphatic function. METHODS We comprehensively reviewed all studies that tested the direct effect of a drug on the contractile function of lymphatic vessels. RESULTS Of the 208 drugs identified from 193 studies, about a quarter had only stimulatory effects on lymphatic tone, contraction frequency and/or contraction amplitude. Of FDA-approved drugs, there were 14 that increased lymphatic phasic contractile function. The most frequently used class of drug with inhibitory effects on lymphatic pump function were the calcium channels blockers. CONCLUSION This review highlights the opportunity for specific drug treatments of lymphatic dysfunction in various disease states and for avoiding adverse drug effects on lymphatic contractile function.
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Affiliation(s)
- Peter S Russell
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jiwon Hong
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Natalie L Trevaskis
- Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - John A Windsor
- Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Niels D Martin
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anthony R J Phillips
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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28
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Haines LK, Cook AC, Hatchimonji JS, Ho VP, Kalbfell EL, O'Connell KM, Robenstine JC, Schlögl M, Toevs CC, Jones CA, Krouse RS, Martin ND. Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery. J Palliat Med 2021; 24:1072-1077. [PMID: 34128716 DOI: 10.1089/jpm.2021.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.
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Affiliation(s)
- Lindsay K Haines
- Department of Medicine and the Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson C Cook
- Department of Medicine and University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elle L Kalbfell
- Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Kathleen M O'Connell
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jacinta C Robenstine
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Christine C Toevs
- Department of Surgery, Terre Haute Regional Hospital, Indiana University School of Medicine, Terre Haute, Indiana, USA
| | | | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania and the Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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29
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Ratnasekera AM, Seng SS, Jacovides CL, Kolb R, Hanlon A, Stawicki SP, Martin ND, Kaufman EJ. Rising incidence of interpersonal violence in Pennsylvania during COVID-19 stay-at home order. Surgery 2021; 171:533-540. [PMID: 34294449 PMCID: PMC8782280 DOI: 10.1016/j.surg.2021.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic and associated policies have had important downstream consequences for individuals, communities, and the healthcare system, and they appear to have been accompanied by rising interpersonal violence. The objective of this study was to evaluate the incidence of injuries owing to interpersonal violence after implementation of a statewide stay-at-home order in Pennsylvania in March 2020. METHODS Using the Pennsylvania Trauma Outcome Study registry, we conducted a retrospective cohort study of patients with gunshot wounds, stab wounds, and blunt assault-related injuries attributable to interpersonal violence treated at Pennsylvania trauma centers from March 16 to July 31 of 2018, 2019, and 2020. RESULTS There were fewer total trauma admissions in 2020 (17,489) vs 2018 (19,290) and 2019 (19,561). Gunshot wounds increased in 2020 to 737 vs 647 for 2019 and 565 for 2018 (P = .028), whereas blunt assault injuries decreased (P = .03). In all time periods, interpersonal violence primarily impacted urban counties. African American men were predominantly affected by gunshot wounds and stab wounds, whereas Caucasian men were predominantly affected by blunt assault injuries. There were more patients with substance abuse disorders and positive drug screens during coronavirus disease than in comparison periods: (stab wound population 52.3% vs 33.9% vs 45.9%, coronavirus disease era vs 2018 vs 2019, respectively P = .0001), (blunt assault injury population 41.4% vs 33.1% vs 33.5%, coronavirus disease era vs 2018 vs 2019, respectively P < .0001). There was no correlation between the incidence of interpersonal violence and coronavirus disease 2019 rates at the county level. CONCLUSION The implementation of a stay-at-home order was accompanied by rising incidence of gunshot and stab wound injuries in Pennsylvania. Preparedness for future resurgences of coronavirus disease 2019 and other pandemics calls for plans to address injury prevention, recidivism, and access to mental health and substance abuse prevention services.
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Affiliation(s)
| | - Sirivan S Seng
- Department of Surgery, Crozer-Chester Medical Center, Upland, PA
| | | | - Ryann Kolb
- Department of Criminal Justice, Temple University, Philadelphia PA
| | - Alexandra Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University Statistics, Roanoke, VA
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Anesi GL, Jablonski J, Harhay MO, Atkins JH, Bajaj J, Baston C, Brennan PJ, Candeloro CL, Catalano LM, Cereda MF, Chandler JM, Christie JD, Collins T, Courtright KR, Fuchs BD, Gordon E, Greenwood JC, Gudowski S, Hanish A, Hanson CW, Heuer M, Kinniry P, Kornfield ZN, Kruse GB, Lane-Fall M, Martin ND, Mikkelsen ME, Negoianu D, Pascual JL, Patel MB, Pugliese SC, Qasim ZA, Reilly JP, Salmon J, Schweickert WD, Scott MJ, Shashaty MGS, Sicoutris CP, Wang JK, Wang W, Wani AA, Anderson BJ, Gutsche JT. Characteristics, Outcomes, and Trends of Patients With COVID-19-Related Critical Illness at a Learning Health System in the United States. Ann Intern Med 2021; 174:613-621. [PMID: 33460330 PMCID: PMC7901669 DOI: 10.7326/m20-5327] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN Single-health system, multihospital retrospective cohort study. SETTING 5 hospitals within the University of Pennsylvania Health System. PATIENTS Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- George L Anesi
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Juliane Jablonski
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Michael O Harhay
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Joshua H Atkins
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jasmeet Bajaj
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Cameron Baston
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Patrick J Brennan
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Christina L Candeloro
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Lauren M Catalano
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Maurizio F Cereda
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John M Chandler
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jason D Christie
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Tara Collins
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Katherine R Courtright
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Barry D Fuchs
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Emily Gordon
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John C Greenwood
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Steven Gudowski
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Asaf Hanish
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - C William Hanson
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Monica Heuer
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Paul Kinniry
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Zev Noah Kornfield
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Gregory B Kruse
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Meghan Lane-Fall
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Niels D Martin
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Mark E Mikkelsen
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Dan Negoianu
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jose L Pascual
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Maulik B Patel
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Steven C Pugliese
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Zaffer A Qasim
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John P Reilly
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John Salmon
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - William D Schweickert
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Michael J Scott
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Michael G S Shashaty
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Corinna P Sicoutris
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John K Wang
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Wei Wang
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Arshad A Wani
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Brian J Anderson
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jacob T Gutsche
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
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Henry LE, Paul EA, Atkins JH, Martin ND, Chalian AA, Rassekh CH. Institutional analysis of intra- and post-operative tracheostomy management for risk reduction. World J Otorhinolaryngol Head Neck Surg 2021; 8:370-377. [DOI: 10.1016/j.wjorl.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/18/2021] [Indexed: 11/29/2022] Open
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Ong AW, Stephenson J, Gile KJ, Aronow RA, Wang X, Xu Y, Martin ND, Kim PK, Fernandez FB. Outcome of Hypotensive Trauma Patients by Time and Day of Arrival. J Surg Res 2020; 258:113-118. [PMID: 33010555 DOI: 10.1016/j.jss.2020.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/08/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although most studies of trauma patients have not demonstrated a "weekend" or "night" effect on mortality, outcomes of hypotensive (systolic blood pressure <90 mm Hg) patients have not been studied. We sought to evaluate whether outcomes of hypotensive patients were associated with admission time and day. METHODS We retrospectively analyzed patients from Pennsylvania Level 1 and Level 2 trauma centers with systolic blood pressure of <90 mm Hg over 5 y. Patients were stratified into four groups by arrival day and time: Group 1, weekday days; Group 2, weekday nights; Group 3, weekend days; and Group 4, weekend nights. Patient characteristics and outcomes were compared for the four groups. Adjusted mortality risks for Groups 2, 3, and 4 with Group 1 as the reference were determined using a generalized linear mixed effects model. RESULTS After exclusions, 27 trauma centers with a total of 4937 patients were analyzed. Overall mortality was 44%. Compared with patients arriving during the day (Groups 1 and 3), those arriving at night (Groups 2 and 4) were more likely to be younger, to be male, to have lower Glasgow Coma Scale scores and blood pressures, to have penetrating injuries, and to die in the emergency room. Controlled for admission variables, odds ratios (95% confidence intervals) for Groups 2, 3, and 4 were 0.92 (0.72-1.17), 0.89 (0.65-1.23), and 0.76 (0.56-1.02), respectively, for mortality with Group 1 as reference. CONCLUSIONS Patients arriving in shock to Pennsylvania Level 1 and Level 2 trauma centers at night or weekends had no increased mortality risk compared with weekday daytime arrivals.
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Affiliation(s)
- Adrian W Ong
- Department of Surgery, Reading Hospital, Reading, Pennsylvania; Division of Traumatology, Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jacqueline Stephenson
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Krista J Gile
- Department of Mathematics and Statistics, University of Massachusetts at Amherst, Amherst, Massachusetts
| | - Rachel A Aronow
- Department of Mathematics and Statistics, University of Massachusetts at Amherst, Amherst, Massachusetts
| | - Xiaoyun Wang
- Department of Mathematics and Statistics, University of Massachusetts at Amherst, Amherst, Massachusetts
| | - Yuting Xu
- Department of Mathematics and Statistics, University of Massachusetts at Amherst, Amherst, Massachusetts
| | - Niels D Martin
- Division of Traumatology, Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick K Kim
- Division of Traumatology, Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Forrest B Fernandez
- Department of Surgery, Reading Hospital, Reading, Pennsylvania; Division of Traumatology, Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Chao TN, Harbison SP, Braslow BM, Hutchinson CT, Rajasekaran K, Go BC, Paul EA, Lambe LD, Kearney JJ, Chalian AA, Cereda MF, Martin ND, Haas AR, Atkins JH, Rassekh CH. Outcomes After Tracheostomy in COVID-19 Patients. Ann Surg 2020; 272:e181-e186. [PMID: 32541213 PMCID: PMC7467054 DOI: 10.1097/sla.0000000000004166] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ± 6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ± 6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.
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Affiliation(s)
- Tiffany N Chao
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean P Harbison
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Braslow
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christoph T Hutchinson
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Beatrice C Go
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellen A Paul
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leah D Lambe
- Department of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James J Kearney
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maurizio F Cereda
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew R Haas
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua H Atkins
- Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Martin ND, Pascual JL, Hirsch J, Holena DN, Kaplan LJ. Excluded but not forgotten: Veterinary emergency care during emergencies and disasters. Am J Disaster Med 2020; 15:25-31. [PMID: 32804383 DOI: 10.5055/ajdm.2020.0352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Disasters or crises impact humans, pets, and service animals alike. Current preparation at the federal, state, and local level focuses on preserving human life. Hospitals, shelters, and other human care facilities generally make few to no provisions for companion care nor service animal care as part of their disaster management plan. Aban-doned animals have infectious disease, safety and psychologic impact on owners, rescue workers, and those involved in reclamation efforts. Animals working as first responder partners may be injured or exposed to biohazards and require care. DATA SOURCES English language literature available via PubMed as well as lay press publications on emergency care, veterinary care, disaster management, disasters, biohazards, infection, zoonosis, bond-centered care, prepared-ness, bioethics, and public health. No year restrictions were set. CONCLUSIONS Human clinician skills share important overlaps with veterinary clinician skills; similar overlaps occur in medical and surgical emergency care. These commonalities offer the potential to craft-specific and disaster or crisis-deployable skills to care for humans, pets (dogs and cats), service animals (dogs and miniature horses) and first-responder partners (dogs) as part of national disaster healthcare preparedness. Such a platform could leverage the skills and resources of the existing US trauma system to underpin such a program.
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Affiliation(s)
- Niels D Martin
- Program Director, Trauma & Surgical Critical Care Fellowship; Section Chief, Surgical Critical Care; Associate Professor, Surgery, Hospital of the University of Pennsylvania and Presbyterian Medical Center of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jose L Pascual
- Associate Professor, Surgery, Hospital of the University of Pennsylvania and the Presbyterian Medical Center of Philadelphia, Division of Trauma & Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julie Hirsch
- Education Coordinator/Medical Liaison, North Penn Animal Hospital, Lansdale, Pennsylvania
| | - Daniel N Holena
- Associate Professor, Surgery, Hospital of the University of Pennsylvania and Presbyterian Medical Center of Philadelphia, Division of Trauma & Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, Phila-delphia, Pennsylvania
| | - Lewis J Kaplan
- Professor of Surgery, Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Affiliation(s)
- Jeremy W Cannon
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Niels D Martin
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zaffer Qasim
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Affiliation(s)
- Tiffany N Chao
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Braslow
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Atkins
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew R Haas
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Shiroff AM, Gale SC, Martin ND, Marchalik D, Petrov D, Ahmed HM, Rotondo MF, Gracias VH. Penetrating Neck Trauma: A Review of Management Strategies and Discussion of the ‘No Zone’ Approach. Am Surg 2020; 79:23-9. [DOI: 10.1177/000313481307900113] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The evaluation and management of hemodynamically stable patients with penetrating neck injury has evolved considerably over the previous four decades. Algorithms developed in the 1970s focused on anatomic neck “zones” to distinguish triage pathways resulting from the operative constraints associated with very high or very low penetrations. During that era, mandatory endoscopy and angiography for Zone I and III penetrations, or mandatory neck exploration for Zone II injuries, became popularized, the so-called “selective approach.” Currently, modern sensitive imaging technology, including computed tomographic angiography (CTA), is widely available. Imaging triage can now accomplish what operative or selective evaluation could not: a safe and noninvasive evaluation of critical neck structures to identify or exclude injury based on trajectory, the key to penetrating injury management. In this review, we discuss the use of CTA in modern screening algorithms introducing a “No Zone” paradigm: an evidence-based method eliminating “neck zone” differentiation during triage and management. We conclude that a comprehensive physical examination, combined with CTA, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma. Zone-based algorithms lead to an increased reliance on invasive diagnostic modalities (endoscopy and angiography) with their associated risks and to a higher incidence of nontherapeutic neck exploration. Therefore, surgeons evaluating hemodynamically stable patients with penetrating neck injuries should consider departing from antiquated, invasive algorithms in favor of evidence-based screening strategies that use physical examination and CTA.
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Affiliation(s)
- Adam M. Shiroff
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Stephen C. Gale
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Niels D. Martin
- Department of Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Marchalik
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Dmitriy Petrov
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Hesham M. Ahmed
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
| | - Michael F. Rotondo
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - Vicente H. Gracias
- Department of Surgery, Division of Acute Care Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey; the
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Ratnasekera A, Pulido O, Durgin S, Nichols S, Lozano A, Sienko D, Hanlon A, Martin ND. Venous thromboembolism after penetrating femoral and popliteal artery injuries: an opportunity for increased prevention. Trauma Surg Acute Care Open 2020; 5:e000468. [PMID: 32566757 PMCID: PMC7295438 DOI: 10.1136/tsaco-2020-000468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma patients with penetrating vascular injuries have a higher rate of venous thromboembolism (VTE). The objective of this study was to determine the risk of VTE formation in penetrating femoral and popliteal vascular injuries and the effects of endovascular management of these injuries. Methods A retrospective study of Pennsylvania Trauma Outcome Study registry was conducted during a 5-year period (2013–2017). All adult patients with a penetrating mechanism with femoral/popliteal vascular injuries were studied. Primary outcome was incidence of VTE in patients with isolated arterial injuries versus combined arterial/venous injuries. Secondary endpoints were intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality. Statistical comparisons were accomplished using Fisher’s exact tests, and parametric two-sample t-tests or non-parametric Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Results Of the 865 patients with penetrating extremity vascular injuries, 207 had femoral or popliteal artery injuries. Patients with isolated arterial injuries (n=131) had a significantly lower deep venous thrombosis (DVT) rate compared with those with concurrent venous injuries (n=76) (3.1% vs. 13.2%, p=0.008). There were 14 patients in the study who developed DVTs. Among the four patients with isolated femoral or popliteal arterial injuries who had developed DVTs, three had an open repair. Among patients with isolated arterial injuries, those with DVT spend significantly more time on the ventilator (median=2 vs. 0, p=0.0020) compared with patients without DVT. Patients with DVT also had longer stay in the hospital (median=17.5 vs. 8, p=0.0664) and in the ICU (median=3 vs. 1, p=0.0585). Conclusions Risk of DVT exists in patients with penetrating isolated femoral and popliteal artery trauma. Open repair was associated with significantly higher DVT rates in isolated arterial injuries. Level of evidence Level IV therapeutic care/management.
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Affiliation(s)
- Asanthi Ratnasekera
- Department of Surgery, Crozer-Keystone Health System, Upland, Pennsylvania, USA
| | - Odessa Pulido
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Sandra Durgin
- Department of Surgery, Crozer-Keystone Health System, Upland, Pennsylvania, USA
| | - Sharon Nichols
- Department of Surgery, Crozer-Keystone Health System, Upland, Pennsylvania, USA
| | - Alicia Lozano
- Department of Statisitics, Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, Virginia, USA
| | - Danielle Sienko
- Department of Statisitics, Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, Virginia, USA
| | - Alexandra Hanlon
- Department of Statisitics, Virginia Polytechnic Institute and State University, Center for Biostatistics and Health Data Science, Roanoke, Virginia, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Haines L, Ganta N, Jones CA, Martin ND. Palliative Care for Trauma Patients: Today and into the Next Decade. J Palliat Med 2020; 23:1147-1148. [PMID: 32877280 DOI: 10.1089/jpm.2020.0156] [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: 11/12/2022] Open
Affiliation(s)
- Lindsay Haines
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis School of Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niharika Ganta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher A Jones
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hatchimonji JS, Huston-Paterson HH, Dortche K, Orji W, Ganta N, O'Connor N, Kaplan LJ, Martin ND. Do we know our patients' goals? Evaluating preoperative discussions in emergency surgery. Am J Surg 2020; 220:861-862. [PMID: 32560921 DOI: 10.1016/j.amjsurg.2020.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Hattie H Huston-Paterson
- Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA.
| | - Kristina Dortche
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Whitney Orji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Niharika Ganta
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Nina O'Connor
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. nina.o'
| | - Lewis J Kaplan
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Niels D Martin
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Martin ND, Codner P, Greene W, Brasel K, Michetti C. Contemporary hemodynamic monitoring, fluid responsiveness, volume optimization, and endpoints of resuscitation: an AAST critical care committee clinical consensus. Trauma Surg Acute Care Open 2020; 5:e000411. [PMID: 32201737 PMCID: PMC7066619 DOI: 10.1136/tsaco-2019-000411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/31/2019] [Accepted: 01/29/2020] [Indexed: 01/20/2023] Open
Abstract
This article, on hemodynamic monitoring, fluid responsiveness, volume assessment, and endpoints of resuscitation, is part of a compendium of guidelines provided by the AAST (American Association for the Surgery of Trauma) critical care committee. The intention of these guidelines is to inform practitioners with practical clinical guidance. To do this effectively and contemporarily, expert consensus via the critical care committee was obtained. Strict guideline methodology such a GRADE (Grading of Recommendations Assessment, Development and Evaluation) was purposefully NOT used so as not to limit the possible clinical guidance. The critical care committee foresees this methodology as practically valuable to the bedside clinician.
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Affiliation(s)
- Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Panna Codner
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Wendy Greene
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Christopher Michetti
- Department of Surgery, Inova Fairfax Medical Center, Falls Church, Virginia, USA
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Compher C, Martin ND, Heyland DK. Reservations about Permissive Underfeeding in Low versus High NUTRIC Patients? Am J Respir Crit Care Med 2019; 197:1226-1227. [PMID: 29236518 DOI: 10.1164/rccm.201710-2064le] [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] Open
Affiliation(s)
| | - Niels D Martin
- 1 University of Pennsylvania Philadelphia, Pennsylvania and
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Moore SA, Maduka RC, Tung L, Reilly PM, Morris J, Seamon MJ, Holena DN, Kaplan LJ, Martin ND. Training Disparities of Our Future Workforce: A Survey of Trauma Fellowship Candidates. J Surg Res 2019; 243:198-205. [PMID: 31185436 DOI: 10.1016/j.jss.2019.04.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/15/2019] [Accepted: 04/26/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Training in Acute Care Surgery (ACS) is an integral component of general surgery residency and serves as a critical base experience for the added educational qualifications of fellowship. How this training varies between programs is not well characterized. We sought to describe the variation in clinical exposure between residencies in a sample of residents applying to an ACS fellowship. We hypothesized that applicants have significant variations in clinical exposure as well as unique and specific expectations for educational experiences. MATERIALS AND METHODS We offered an anonymous 82-question survey focused on residency clinical exposure and self-perceived confidence in key areas of ACS training, as well as fellowship training and career expectations to all applicants interviewed at a single trauma, critical care, and emergency surgery fellowship program. Responses were assessed via absolute numbers and confidence via a 5-point Likert scale; data are reported using descriptive statistics and linear regression models. RESULTS Forty-two interviewing applicants completed the survey, for a 96% response rate. Applicants reported heterogeneous levels of comfort across most ACS domains. There was good correlation between experience and comfort in most procedural areas. During fellowship training, respondents placed highest priority on operative experience, with 43% rating this as their highest priority, followed by penetrating trauma experience (33%). CONCLUSIONS We found significant variations in both experience and comfort within key ACS domains among fellowship applicants. Despite training variability, there was good correlation between experience and self-reported comfort. Collaboration between residency and fellowship governing bodies may help address areas of limited exposure before entry into clinical practice.
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Affiliation(s)
- Sarah A Moore
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico.
| | - Richard C Maduka
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lily Tung
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jon Morris
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mark J Seamon
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lewis J Kaplan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Surgery, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Zonies D, Codner P, Park P, Martin ND, Lissauer M, Evans S, Cocanour C, Brasel K. AAST Critical Care Committee clinical consensus: ECMO, nutrition. Trauma Surg Acute Care Open 2019; 4:e000304. [PMID: 31058243 PMCID: PMC6461143 DOI: 10.1136/tsaco-2019-000304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 01/15/2023] Open
Abstract
The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.
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Affiliation(s)
- David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Panna Codner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pauline Park
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Lissauer
- Department of Surgery, Rutgers-Robert Wood Johnson, Rutgers, New Jersey, USA
| | - Susan Evans
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Christine Cocanour
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Linden JA, Schneider JI, Cotter A, Drexel S, Frosch E, Martin ND, Canavan C, Holtman M, Mitchell PM, Feldman JA. Variability in Institutional Board Review for a Multisite Assessment of Resident Professionalism. J Empir Res Hum Res Ethics 2019; 14:117-125. [DOI: 10.1177/1556264619831895] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Residents serve as both trainees and employees and can be considered potentially vulnerable research participants. This can lead to variation in the institutional review board (IRB) review. We studied sites participating in the Assessment of Professional Behaviors Study sponsored by the National Board of Medical Examiners (2009-2011). Of the 19 sites, all but one were university affiliated. IRB review varied; 2/19 did not submit to a local IRB, 4/17 (23%) were exempt, 11/17 (65%) were expedited, and 2/17 (12%) required full Board review; 12/17 (71%) required written informed consent. The interval from submission to approval was 1 to 2 months (8/17); the range was 1 to 7 months. Although most stated there were no major barriers to approval, the most common concern was resident coercion and loss of confidentiality. Local IRB review of this educational research study varied.
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Affiliation(s)
- Judith A. Linden
- Boston Medical Center, MA, USA
- Boston University School of Medicine, MA, USA
| | | | - Andrea Cotter
- Boston Medical Center, MA, USA
- Boston University School of Medicine, MA, USA
| | - Sabrina Drexel
- Boston Medical Center, MA, USA
- Boston University School of Medicine, MA, USA
| | - Emily Frosch
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | - James A. Feldman
- Boston Medical Center, MA, USA
- Boston University School of Medicine, MA, USA
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Asfaw SH, Martin ND, Seamon MJ, Pascual JL, Reilly PM, Holena DN. Is it Cool to Cool Post-Cardiac Arrest Trauma Patients? Am Surg 2019. [DOI: 10.1177/000313481908500315] [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)
- Sofya H. Asfaw
- Department of Surgery Division of Traumatology and Surgical Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
| | - Niels D. Martin
- Department of Surgery Division of Traumatology and Surgical Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
| | - Mark J. Seamon
- Department of Surgery Division of Traumatology and Surgical Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
| | - Jose L. Pascual
- Department of Surgery Division of Traumatology and Surgical Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
| | - Patrick M. Reilly
- Department of Surgery Division of Traumatology and Surgical Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
| | - Daniel N. Holena
- Department of Surgery Division of Traumatology and Surgical Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
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Asfaw SH, Martin ND, Seamon MJ, Pascual JL, Reilly PM, Holena DN. Is It Cool to Cool Post-Cardiac Arrest Trauma Patients? Am Surg 2019; 85:e157-e159. [PMID: 30947795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Michetti CP, Fakhry SM, Brasel K, Martin ND, Teicher EJ, Newcomb A. Trauma ICU Prevalence Project: the diversity of surgical critical care. Trauma Surg Acute Care Open 2019; 4:e000288. [PMID: 30899799 PMCID: PMC6407564 DOI: 10.1136/tsaco-2018-000288] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 11/08/2022] Open
Abstract
Background Surgical critical care is crucial to the care of trauma and surgical patients. This study was designed to provide a contemporary assessment of patient types, injuries, and conditions in intensive care units (ICU) caring for trauma patients. Methods This was a multicenter prevalence study of the American Association for the Surgery of Trauma; data were collected on all patients present in participating centers’ trauma ICU (TICU) on November 2, 2017 and April 10, 2018. Results Forty-nine centers submitted data on 1416 patients. Median age was 58 years (IQR 41–70). Patient types included trauma (n=665, 46.9%), non-trauma surgical (n=536, 37.8%), medical (n=204, 14.4% overall), or unspecified (n=11). Surgical intensivists managed 73.1% of patients. Of ICU-specific diagnoses, 57% were pulmonary related. Multiple high-intensity diagnoses were represented (septic shock, 10.2%; multiple organ failure, 5.58%; adult respiratory distress syndrome, 4.38%). Hemorrhagic shock was seen in 11.6% of trauma patients and 6.55% of all patients. The most common traumatic injuries were rib fractures (41.6%), brain (38.8%), hemothorax/pneumothorax (30.8%), and facial fractures (23.7%). Forty-four percent were on mechanical ventilation, and 17.6% had a tracheostomy. One-third (33%) had an infection, and over half (54.3%) were on antibiotics. Operations were performed in 70.2%, with 23.7% having abdominal surgery. At 30 days, 5.4% were still in the ICU. Median ICU length of stay was 9 days (IQR 4–20). 30-day mortality was 11.2%. Conclusions Patient acuity in TICUs in the USA is very high, as is the breadth of pathology and the interventions provided. Non-trauma patients constitute a significant proportion of TICU care. Further assessment of the global predictors of outcome is needed to inform the education, research, clinical practice, and staffing of surgical critical care providers. Level of evidence IV, prospective observational study.
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Affiliation(s)
| | | | - Karen Brasel
- Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Niels D Martin
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik J Teicher
- Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Anna Newcomb
- Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
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Miano TA, Abelian G, Seamon MJ, Chreiman K, Reilly PM, Martin ND. Whose Benchmark Is Right? Validating Venous Thromboembolism Events Between Trauma Registries and Hospital Administrative Databases. J Am Coll Surg 2019; 228:752-759.e3. [PMID: 30772443 DOI: 10.1016/j.jamcollsurg.2019.02.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) events are tracked in trauma registries and by administrative data sets. Both databases are used to assess outcomes, despite having varying processes for data capture. STUDY DESIGN This study was performed at an urban, university-based, Level I trauma center from 2004 to 2014. Retrospective review of the trauma registry and the hospital's administrative database was performed querying for all VTEs. Each VTE was then validated through manual chart review. Confirmed events were those with radiographic evidence of VTE by ultrasound, CT, and/or ventilation-perfusion scan. Sensitivity, specificity, and predictive values were calculated and compared between databases. RESULTS There were 19,353 trauma patients admitted during the study period; 656 VTEs were identified in the registry and 890 were identified via administrative data; 527 potential events were identified by both databases; 129 events were only in registry; and 363 were only found in the administrative database. We confirmed 636 of 656 events in registry (positive predictive value, 97%; 95% CI, 95.6% to 98.3%) vs 815 of 890 events in administrative data (positive predictive value, 91.6%; 95% CI, 89.75% to 93.4%; p < 0.001). Sensitivity was higher for administrative (87.2% vs 68.0%; p < 0.001), as 299 confirmed VTE events were not in the registry. Differences between the 2 databases were diminished when the analysis excluded untreated events and those present on admission. Twenty-three percent of validated deep vein thrombosis events in the registry were upper extremity events. CONCLUSIONS The trauma registry showed higher specificity and lower sensitivity compared with administrative data. The low false-positive rate of the trauma registry supports its validity in VTE outcomes research. Additional investigation is needed to evaluate the relevance of the variable sensitivity, likely due to definitional differences. Supplementation of trauma registry data with administrative data can strengthen its completeness.
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Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Grigor Abelian
- Department of Clinical Pharmacology and Pharmacometrics, Bristol-Myers Squibb, Philadelphia, PA
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kristen Chreiman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Vasquez CR, Martin ND. What's New in Critical Illness and Injury Science? Identifying Sources of Nosocomial Infections to Improve Patient Outcomes in the Surgical Intensive Care Unit. Int J Crit Illn Inj Sci 2019; 9:1-2. [PMID: 30989059 PMCID: PMC6423932 DOI: 10.4103/2229-5151.253768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Charles R. Vasquez
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D. Martin
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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