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Carmichael SP, Chandra PK, Vaughan JW, Kline DM, Ip EH, Holcomb JB, Atala A. Prevention of post-operative adhesions: Model development and pilot outcomes of human placental stem cell-based interventions. Transfusion 2024. [PMID: 38693056 DOI: 10.1111/trf.17859] [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: 01/17/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Abdominal adhesions are the most common surgical complication and without reliable prophylactics. This study presents a novel rat model for abdominal adhesions and reports pilot results of human placental stem cell (hPSC)-based therapies. METHODS Forty-four (n = 44) male Sprague-Dawley rats (250-350 g) were used in the experiment. Of these, thirty-eight (n = 38) were included in a preliminary data set to determine a minimum treatment effect. Adhesions were created in a reproducible model to the abdominal wall and between organs. Experimental groups included the control group (Model No Treatment, MNT), Plasmalyte A (Media Alone, MA, 10 mL), hPSC (5 × 106 cells/10 mL Plasmalyte A), hPSC-CM (hPSC secretome, conditioned media) in 10 mL Plasmalyte A, Seprafilm™ (Baxter, Deerfield, IL), and sham animals (laparotomy only). Treatments were inserted intraperitoneally (IP) and the study period was 14 days post-operation. Results are reported as the difference between means of an index statistic (AIS, Animal Index Score) and compared by ANOVA with pairwise comparison. RESULTS The overall mean AIS was 23 (SD 6.16) for the MNT group with an average of 75% of ischemic buttons involved in abdominal adhesions. Treatment groups MA (mean overall AIS 17.33 SD 6.4), hPSC (mean overall AIS 13.86 SD 5.01), hPSC-CM (mean overall AIS 13.13 SD 6.15), and Seprafilm (mean overall AIS 13.43 SD 9.11) generated effect sizes of 5.67, 9.14, 9.87, and 9.57 decrease in mean overall AIS, respectively, versus the MNT. DISCUSSION The presented rat model and scoring system represent the clinical adhesion disease process. hPSC-based interventions significantly reduce abdominal adhesions in this pilot dataset.
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Affiliation(s)
- Samuel P Carmichael
- Wake Forest School of Medicine, Department of Surgery, Medical Center Boulevard, Winston-Salem, North Carolina, USA
- Wake Forest School of Medicine, Institute for Regenerative Medicine, Winston-Salem, North Carolina, USA
| | - Prafulla K Chandra
- Wake Forest School of Medicine, Institute for Regenerative Medicine, Winston-Salem, North Carolina, USA
| | - John W Vaughan
- Wake Forest School of Medicine, Institute for Regenerative Medicine, Winston-Salem, North Carolina, USA
| | - David M Kline
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Biostatistics and Data Science, Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Edward H Ip
- Wake Forest School of Medicine, Division of Public Health Sciences, Department of Biostatistics and Data Science, Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - John B Holcomb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anthony Atala
- Wake Forest School of Medicine, Institute for Regenerative Medicine, Winston-Salem, North Carolina, USA
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Carmichael SP, Kline DM, Mowery NT, Miller PR, Meredith JW, Hanchate AD. Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction. J Surg Res 2023; 286:57-64. [PMID: 36753950 PMCID: PMC10034859 DOI: 10.1016/j.jss.2022.12.040] [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: 07/26/2022] [Revised: 10/06/2022] [Accepted: 12/25/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. MATERIALS AND METHODS A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. RESULTS Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission. CONCLUSIONS Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.
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Affiliation(s)
- Samuel P Carmichael
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina.
| | - David M Kline
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Nathan T Mowery
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Preston R Miller
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - J Wayne Meredith
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Amresh D Hanchate
- Division of Public Health Sciences, Department of Social Science and Health Policy, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
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Carmichael SP, Kline DA. Categories of Evidence and Methods in Surgical Decision-Making. Surg Clin North Am 2023; 103:233-245. [PMID: 36948715 DOI: 10.1016/j.suc.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
Surgical decision-making is a continuum of judgments that take place during the preoperative, intraoperative, and postoperative periods. The fundamental, and most challenging, step is determining whether a patient will benefit from an intervention given the dynamic interplay of diagnostic, temporal, environmental, patient-centric, and surgeon-centric factors. The myriad combinations of these considerations generate a wide spectrum of reasonable therapeutic approaches within the standards of care. Although surgeons may seek evidenced-based practices to support their decision-making, threats to the validity of evidence and appropriate application of evidence may influence implementation. Furthermore, a surgeon's conscious and unconscious biases may additionally determine individual practice.
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Affiliation(s)
- Samuel P Carmichael
- Department of Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - David A Kline
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA. https://twitter.com/dm_kline
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Carmichael SP, Appelbaum RD, Renaldo A, Hauser N, Rahbar E, Nunn AM. ENDOTHELIAL GLYCOCALYX SHEDDING IN INTRA-ABDOMINAL SEPSIS: A FEASIBILITY STUDY. Shock 2023; 59:540-546. [PMID: 36625488 DOI: 10.1097/shk.0000000000002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
ABSTRACT Background: The endothelial glycocalyx layer (EGL) is a complex meshwork of glycosaminoglycans and proteoglycans that protect the vascular endothelium. Cleavage or shedding of EGL-specific biomarkers, such as hyaluronic acid (HA) and syndecan-1 (SDC-1, CD138) in plasma, have been shown to be associated with poor clinical outcomes. However, it is unclear whether levels of circulating EGL biomarkers are representative of the EGL injury within the tissues. The objective of the present feasibility study was to describe a pathway for plasma and tissue procurement to quantify EGL components in a cohort of surgical patients with intra-abdominal sepsis. We sought to compare differences between tissue and plasma EGL biomarkers and to determine whether EGL shedding within the circulation and/or tissues correlated with clinical outcomes. Methods: This was a prospective, observational, single-center feasibility study of adult patients (N = 15) with intra-abdominal sepsis, conducted under an approved institutional review boards. Blood and resected tissue (pathologic specimen and unaffected peritoneum) samples were collected from consented subjects at the time of operation and 24-48 hours after surgery. Endothelial glycocalyx layer biomarkers (i.e., HA and SDC-1) were quantified in both tissue and plasma samples using a CD138 stain and ELISA kit, respectively. Pairwise comparisons were made between plasma and tissue levels. In addition, we tested the relationships between measured EGL biomarkers and clinical status and patient outcomes. Results: Fifteen patients with intra-abdominal sepsis were enrolled in the study. Elevations in EGL-specific circulating biomarkers (HA, SDC-1) were positively correlated with postoperative SOFA scores and weakly associated with resuscitative volumes at 24 hours. Syndecan-1 levels from resected pathologic tissue significantly correlated with SOFA scores at all time points ( R = 0.69 and P < 0.0001) and positively correlated with resuscitation volumes at 24 hours ( R = 0.41 and P = 0.15 for t = 24 hours). Tissue and circulating HA and SDC-1 positively correlated with SOFA >6. Conclusions: Elevations in both circulating and tissue EGL biomarkers were positively correlated with postoperative SOFA scores at 24 hours, with resected pathologic tissue EGL levels displaying significant correlations with SOFA scores at all time points. Tissue and circulating EGL biomarkers were positively correlated at higher SOFA scores (SOFA > 6) and could be used as indicators of resuscitative needs within 24 hours of surgery. The present study demonstrates the feasibility of tissue and plasma procurement in the operating room, although larger studies are needed to evaluate the predictive value of these EGL biomarkers for patients with intra-abdominal sepsis.
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Affiliation(s)
- Samuel P Carmichael
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Rachel D Appelbaum
- Department of Surgery, Division of Acute Care Surgery, Nashville, Tennessee
| | - Antonio Renaldo
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Andrew M Nunn
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Spencer AL, Nunn AM, Miller PR, Russell GB, Carmichael SP, Neri KE, Marterre B. The value of compassion: Healthcare savings of palliative care consults in trauma. Injury 2023; 54:249-255. [PMID: 36307268 DOI: 10.1016/j.injury.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. STUDY DESIGN We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. RESULTS 140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01). Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01). Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01). Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01). Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group. Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01). Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). CONCLUSION Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.
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Affiliation(s)
- Audrey L Spencer
- Department of Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Room 5411, Tower 4, Tucson, AZ 85724, United States of America.
| | - Andrew M Nunn
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Preston R Miller
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Gregory B Russell
- Department of Biostatistics & Data Science, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Samuel P Carmichael
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Kristina E Neri
- Wake Forest University School of Medicine, Bowman Gray Center for Medical Education, 475 Vine Street, Winston-Salem, NC 27101, United States of America.
| | - Buddy Marterre
- Departments of Surgery & Internal Medicine, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
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McCullough MA, Cairns AL, Shin J, Appelbaum RD, Couture DE, Nunn AM, Miller PR, Martin RS, Carmichael SP. Above the Clavicle: A Simplified Screening Method for Asymptomatic Blunt Cerebral Vascular Injury. Am Surg 2023; 89:79-83. [PMID: 33877928 DOI: 10.1177/00031348211011141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Blunt cerebrovascular injury (BCVI) is an increasingly detected pattern in trauma with significant morbidity, putting patients at risk for subsequent stoke. Complex screening protocols exist to determine who should undergo CT angiography of the neck (CTAN) to evaluate for BCVI. Once identified, stroke incidence may be reduced with appropriate treatment across grades. We hypothesize that an expanded and simplified method for identifying patients with clinical suspicion for BCVI based upon injury above the clavicle (ATC) will illustrate a previously undiagnosed cohort of patients. METHODS A single-institution retrospective review of adult (age ≥18 years) blunt trauma patients with BCVI from January 1, 2010 to December 31, 2019 was conducted at a tertiary academic medical center. Patients undergoing CTAN were divided into 2 groups based upon qualification by either the expanded Denver criteria or clinical evidence of any injury ATC. RESULTS A total of 219 patients were diagnosed with BCVI (25 566 blunt trauma admissions, .9% incidence). Seventeen patients (8%) who did not satisfy expanded Denver were diagnosed with BCVI by ATC, most commonly undergoing CTAN due to facial trauma (n = 8). There were no differences in distribution of carotid artery injuries (CAI) and vertebral artery injuries (VAI) in the expanded Denver criteria group compared to the ATC group. CONCLUSIONS CTAN for blunt trauma with any injury ATC is an easy-to-use screening tool and may be seamlessly included with initial whole-body imaging.
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Affiliation(s)
- Mary A McCullough
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ashley L Cairns
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jaewook Shin
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Rachel D Appelbaum
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Daniel E Couture
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew M Nunn
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Preston R Miller
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Robert S Martin
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Samuel P Carmichael
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Seshadri A, Appelbaum R, Carmichael SP, Farrell MS, Filiberto DM, Jawa R, Kodadek L, Mandell S, Miles MVP, Paul J, Robinson B, Michetti CP. Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e001010. [PMCID: PMC9680182 DOI: 10.1136/tsaco-2022-001010] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Randeep Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M Victoria P Miles
- College of Medicine Chattanooga, The University of Tennessee Health Science Center, Chattanooga, Tennessee, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
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Stettler GR, Hildreth AN, Hoth JJ, Carmichael SP. Management of bladder neck injury after complex pelvic fracture. Trauma Surg Acute Care Open 2022; 7:e001033. [PMID: 36338507 PMCID: PMC9628684 DOI: 10.1136/tsaco-2022-001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Gregory R Stettler
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Amy N Hildreth
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - J Jason Hoth
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Seshadri A, Appelbaum R, Carmichael SP, Cuschieri J, Hoth J, Kaups KL, Kodadek L, Kutcher ME, Pathak A, Rappold J, Rudnick SR, Michetti CP. Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e000936. [PMID: 35991906 PMCID: PMC9345092 DOI: 10.1136/tsaco-2022-000936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 11/04/2022] Open
Abstract
Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Joseph Cuschieri
- Department of Surgery, San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jason Hoth
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Krista L Kaups
- Department of Surgery, UCSF Fresno, Fresno, California, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew E Kutcher
- Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, Oregon, USA
| | - Sean R Rudnick
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Appelbaum RD, Neri KE, Rebo KA, Carmichael SP. Penetrating brain injury with hypopituitarism. Trauma Case Rep 2022; 38:100628. [PMID: 35280495 PMCID: PMC8914367 DOI: 10.1016/j.tcr.2022.100628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 12/02/2022] Open
Abstract
A 34-year-old healthy male presented as a trauma activation after sustaining a gunshot wound to his face. CT head imaging was suggestive of a ballistic fragment adjacent to a posterior wall sphenoid sinus fracture with likely a small volume of adjacent blood products. He was ultimately diagnosed with hypopituitarism which included central diabetes insipidus, central hypothyroid, and adrenocorticotropic hormone deficiency secondary to cortisol deficiency. This case illustrates the spectrum of endocrine dysfunction that can occur with skull base injuries, and the appropriate pituitary-function screening and treatment that should be performed if there is clinical concern. Early recognition and prompt treatment of pituitary insufficiency can facilitate overall rehabilitation after TBI.
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Affiliation(s)
- Rachel D. Appelbaum
- Wake Forest School of Medicine, Department of Surgery, Winston-Salem, NC, USA
- Corresponding author at: Department of Surgery, 1 Medical Center Blvd, Winston-Salem, NC 27103, USA. @AppelbaumMD
| | | | - Kristin A. Rebo
- Wake Forest School of Medicine, Department of Pharmacy, NC, USA
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11
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Cairns AL, Hess AB, Rieken H, Lin N, Rao S, Jee Y, Ashburn JH, Miller PR, Carmichael SP, Mowery NT. Equivalent Operative Outcomes for Emergency Colon Cancer Resections Among Acute Care Surgeons and Specialists in Colorectal Surgery. Am Surg 2022; 88:959-963. [PMID: 35199571 DOI: 10.1177/00031348211050820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Improved screening has decreased but not eliminated the need for emergent surgery for colon cancer (CC), many of which are performed by acute care surgery (ACS) surgeons. This retrospective review compares outcomes for CC resections on the ACS service to the surgical oncology and colorectal services (SO/CRS). METHODS Retrospective review was performed for CC operations between 2014 and 2019. Data for margin status, cancer stage, number of lymph nodes dissected, time to medical oncology follow-up, and time to initiation of chemotherapy were collected. Patients with curative resection, who chose comfort care, presented on alternative services or with non-CC indications as well as those were lost to follow-up were excluded. RESULTS 36 ACS patients and 269 SO/CRS patients underwent CC resections. Most ACS patients presented emergently compared to the SO/CC group (83.3% vs 1%, P < .05) as well as with more advanced tumor stage. There were no statistically significant differences for presence of metastatic disease, number of lymph nodes obtained, or time to post-surgical care (in days) and chemotherapy initiation (in days). 3 (8%) EGS patients had positive margins compared to 6 (2%) CRS/SO patients due to the presence of perforated tumors in the ACS group (p < .05). There were no statistically significant differences in 30- day or 1-year mortality despite the emergent presentation of the ACS patients. DISCUSSION These findings suggest that despite emergent presentation and advanced disease burden, ACS surgeons provide quality care to CC patients, both in the operating room and in coordination of care.
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Affiliation(s)
- Ashley L Cairns
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Alexis B Hess
- 12325The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Holly Rieken
- 19902Wright Patterson Air Force Base, Wright Patterson AFB, OH, USA
| | - Nicholas Lin
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Shambavi Rao
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Yoonsun Jee
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Jean H Ashburn
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | - Preston R Miller
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
| | | | - Nathan T Mowery
- 12280Wake Forest Baptist Health Medical Center, Winston Salem, NC, USA
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12
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Kodadek L, Carmichael SP, Seshadri A, Pathak A, Hoth J, Appelbaum R, Michetti CP, Gonzalez RP. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e000836. [PMID: 35136842 PMCID: PMC8804685 DOI: 10.1136/tsaco-2021-000836] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022] Open
Abstract
Rhabdomyolysis is a clinical condition characterized by destruction of skeletal muscle with release of intracellular contents into the bloodstream. Intracellular contents released include electrolytes, enzymes, and myoglobin, resulting in systemic complications. Muscle necrosis is the common factor for traumatic and non-traumatic rhabdomyolysis. The systemic impact of rhabdomyolysis ranges from asymptomatic elevations in bloodstream muscle enzymes to life-threatening acute kidney injury and electrolyte abnormalities. The purpose of this clinical consensus statement is to review the present-day diagnosis, management, and prognosis of patients who develop rhabdomyolysis.
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Affiliation(s)
- Lisa Kodadek
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anupamaa Seshadri
- Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jason Hoth
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Rachel Appelbaum
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Richard P Gonzalez
- Department of Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
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Carmichael SP, Chandra PK, Vaughan JW, Holcomb JB, Atala AJ. Anti-fibrotic Therapies for Prevention of Abdominal Adhesion. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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McCullough MA, Cairns AL, Appelbaum RD, Couture DE, Nunn AM, Miller PR, Martin RS, Carmichael SP. Response to Letter to the Editor-Expanding the Expanded Denver Criteria. Am Surg 2021; 88:1376. [PMID: 34544294 DOI: 10.1177/00031348211047469] [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)
- Mary A McCullough
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ashley L Cairns
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Rachel D Appelbaum
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Daniel E Couture
- Department of Neurosurgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew M Nunn
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Preston R Miller
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Robert S Martin
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Samuel P Carmichael
- Department of Surgery, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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15
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Carmichael SP, Lin N, Evangelista ME, Holcomb JB. The Story of Blood for Shock Resuscitation: How the Pendulum Swings. J Am Coll Surg 2021; 233:644-653. [PMID: 34390843 DOI: 10.1016/j.jamcollsurg.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/18/2022]
Abstract
Whole blood transfusion (WBT) began in 1667 as a treatment for mental illness with predictably poor results. Its therapeutic utility and widespread use were initially limited by deficiencies in transfusion science and antisepsis. James Blundell, a British obstetrician, was recognized for the first allotransfusion in 1825. However, WBT did not become safe and therapeutic until the early 20th century with the advent of reliable equipment, sterilization and blood typing. The discovery of citrate preservation in World War I allowed a separation of donor from recipient and introduced the practice of blood banking. During World War II, Elliott and Strumia were the first to separate whole blood into blood component therapy (BCT), producing dried plasma as a resuscitative product for "traumatic shock". During the 1970s, infectious disease, blood fractionation and financial opportunities further drove the change from WBT to BCT with little supporting data. Following a period of high-volume crystalloid and BCT resuscitation well into the early 2000's, measures to avoid the resulting iatrogenic resuscitation injury were developed under the concept of damage control resuscitation. Modern transfusion strategies for hemorrhagic shock target balanced BCT to reapproximate whole blood. Contemporary research has expanded the role of WBT to therapy for the acute coagulopathy of trauma and the damaged endothelium. Many US trauma centers are now using WBT as a front-line treatment in tandem with BCT for patients suffering hemorrhagic shock. Looking ahead, it is likely that WBT will once again be the resuscitative fluid of choice for patients in hemorrhagic shock.
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Affiliation(s)
- Samuel P Carmichael
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Nicholas Lin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Meagan E Evangelista
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - John B Holcomb
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
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Carmichael SP, Krebs JR, Mowery NT. Acute Care Surgery Model Leads to Shorter Length of Stay in Mild Gallstone Pancreatitis. Am Surg 2020; 86:e188-e190. [PMID: 32391774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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17
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Carmichael SP, Krebs JR, Mowery NT. Acute Care Surgery Model Leads to Shorter Length of Stay in Mild Gallstone Pancreatitis. Am Surg 2020. [DOI: 10.1177/000313482008600408] [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: 11/17/2022]
Affiliation(s)
- Samuel P. Carmichael
- Division of Acute Care Surgery Wake Forest Baptist Medical Center Winston-Salem, North Carolina
| | - Jonathan R. Krebs
- Department of Surgery University of Florida College of Medicine Gainesville, Florida
| | - Nathan T. Mowery
- Division of Acute Care Surgery Wake Forest Baptist Medical Center Winston-Salem, North Carolina
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Carmichael SP, Veasey EC, Davenport DL, Jay K, Bernard AC. Patient-Surgeon Relationship Influences Outcomes in Bariatric Patients. Am Surg 2018; 84:1850-1855. [PMID: 30606338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22-84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as "average" to "very good." Thirteen per cent (n = 43) rated their relationship as "poor" to "very poor." Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up (P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship (P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship (P = 0.6) or presence of complication (P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.
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Abstract
Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22–84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as “average” to “very good.” Thirteen per cent (n = 43) rated their relationship as “poor” to “very poor.” Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up ( P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship ( P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship ( P = 0.6) or presence of complication ( P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.
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Affiliation(s)
- Samuel P. Carmichael
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | | | | | - Katie Jay
- The National Association for Weight Loss Surgery (NAWLS), Wilmington, North Carolina
| | - Andrew C. Bernard
- Section of Trauma and Acute Care Surgery, Division of General Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
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Stearns E, Plymale MA, Davenport DL, Totten C, Carmichael SP, Tancula CS, Roth JS. Early outcomes of an enhanced recovery protocol for open repair of ventral hernia. Surg Endosc 2017; 32:2914-2922. [PMID: 29270803 DOI: 10.1007/s00464-017-6004-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 08/05/2017] [Accepted: 12/04/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes. The purpose of this study was to compare short-term outcomes for open ventral hernia repair (VHR) before and after implementation of an ERAS protocol. METHODS After obtaining IRB approval, surgical databases were searched for VHR cases for two years prior and eleven months after protocol implementation for retrospective review. Groups were compared on perioperative characteristics and clinical outcomes using chi-square, Fisher's exact, or Mann-Whitney U test, as appropriate. RESULTS One hundred and seventy-one patients underwent VHR (46 patients with ERAS protocol in place and 125 historic controls). Age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups. Body mass index was lower among ERAS patients (p = .038). ERAS patients had earlier return of bowel function (median 3 vs. 4 days) (p = .003) and decreased incidence of superficial surgical site infection (SSI) (7 vs. 25%) (p = .008) than controls. CONCLUSION An ERAS protocol for VHR demonstrated improved patient outcomes. A system-wide culture focused on enhanced recovery is needed to ensure improved patient outcomes.
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Affiliation(s)
- Evan Stearns
- University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Crystal Totten
- Division of General Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Charles S Tancula
- Division of General Surgery, University of Kentucky, Lexington, KY, USA
| | - John Scott Roth
- Division of General Surgery, University of Kentucky, Lexington, KY, USA.
- Division of General Surgery, Department of Surgery, University of Kentucky College of Medicine, 800 Rose Street, C 225, Lexington, KY, 40536, USA.
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Carmichael SP, Bounds MC, Shafii AE, Chang PK. Emergency department repair of blunt right atrial rupture utilizing cardiopulmonary bypass. Trauma Case Rep 2017; 12:1-3. [PMID: 29644273 PMCID: PMC5887067 DOI: 10.1016/j.tcr.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/26/2022] Open
Abstract
Blunt cardiac injury (BCI) with free wall rupture carries a high risk of pre-hospital death. Cardiopulmonary bypass (CPB) has been utilized as a bridge to repair of cardiac lesions in select patients. We present an interesting case of emergency department repair of right atrial rupture with cardiopulmonary bypass.
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Affiliation(s)
- Samuel P. Carmichael
- General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, United States
- Corresponding author at: University of Kentucky, 800 Rose Street, C-234, Lexington, KY 40536-0298, United States.University of Kentucky800 Rose StreetC-234LexingtonKY40536-0298United States
| | - Michael C. Bounds
- General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Alexis E. Shafii
- Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Phillip K. Chang
- Division of General Surgery – Section of Trauma and Critical Care, University of Kentucky College of Medicine, Lexington, KY, United States
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Carmichael SP, Davenport DL, Kearney PA, Bernard AC. On and off the horse: mechanisms and patterns of injury in mounted and unmounted equestrians. Injury 2014; 45:1479-83. [PMID: 24767580 PMCID: PMC4125461 DOI: 10.1016/j.injury.2014.03.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/08/2014] [Accepted: 03/22/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study is to determine whether discrepant patterns of horse-related trauma exist in mounted vs. unmounted equestrians from a single Level I trauma center to guide awareness of injury prevention. METHODS Retrospective data were collected from the University of Kentucky Trauma Registry for patients admitted with horse-related injuries between January 2003 and December 2007 (n=284). Injuries incurred while mounted were compared with those incurred while unmounted. RESULTS Of 284 patients, 145 (51%) subjects were male with an average age of 37.2 years (S.D. 17.2). Most injuries occurred due to falling off while riding (54%) or kick (22%), resulting in extremity fracture (33%) and head injury (27%). Mounted equestrians more commonly incurred injury to the chest and lower extremity while unmounted equestrians incurred injury to the face and abdomen. Head trauma frequency was equal between mounted and unmounted equestrians. There were 3 deaths, 2 of which were due to severe head injury from a kick. Helmet use was confirmed in only 12 cases (6%). CONCLUSION This evaluation of trauma in mounted vs. unmounted equestrians indicates different patterns of injury, contributing to the growing body of literature in this field. We find interaction with horses to be dangerous to both mounted and unmounted equestrians. Intervention with increased safety equipment practice should include helmet usage while on and off the horse.
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Affiliation(s)
- Samuel P Carmichael
- General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, USA.
| | - Daniel L Davenport
- General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Paul A Kearney
- Department of Surgery, Section of Acute Care Surgery and Trauma, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Andrew C Bernard
- Department of Surgery, Section of Acute Care Surgery and Trauma, University of Kentucky College of Medicine, Lexington, KY, USA
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Carmichael SP, Pulliam JF, D'Orazio JA. Delayed tumor resection in a 5-year-old child with bilateral Wilms tumor. J Surg Case Rep 2013; 2013:rjt012. [PMID: 24964423 PMCID: PMC3635223 DOI: 10.1093/jscr/rjt012] [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] [Indexed: 11/17/2022] Open
Abstract
We describe the case of a 5-year-old girl whose abdominal pain and distension were caused by Wilms tumor of the kidney. Because of the bilateral nature of her disease, she was spared biopsy or initial nephrectomy as part of her treatment course. Rather, she was treated presumptively for Wilms tumor based primarily on radiologic findings. Neoadjuvant chemotherapy consisting of vincristine, dactinomycin and doxorubicin was given to facilitate nephron-sparing surgery for tumor resection. Her initial chemotherapeutic course was complicated by tumor lysis syndrome manifested by elevated serum uric acid and was treated effectively with hyperhydration and alkalization of intravenous fluids. The patient's disease responded well to chemotherapy, and she underwent successful tumor excision after 12 weeks of chemotherapy. The resected tumor was identified as anaplastic Wilms tumor, illustrating that pathologic identification of Wilms tumor is possible even after multiple cycles of neoadjuvant chemotherapy and marked tumor shrinkage.
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Affiliation(s)
| | - Joseph F Pulliam
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - John A D'Orazio
- Department of Pediatrics (Hematology-Oncology) and the Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY, USA
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Abstract
1. Accumulating evidence in both humans and animals indicates that acute increases in plasma osmolality elevate sympathetic nerve activity (SNA). In addition, plasma hyperosmolality (or hypernatraemia) can produce sustained increases in SNA and arterial blood pressure (ABP) through stimulation of forebrain osmoreceptors. 2. Although an abundance of information exists regarding the osmoregulatory circuits for thirst and secretion of antidiuretic hormone, much less is known about those pathways and synaptic mechanisms linking osmotic perturbations and SNA. To date, the available evidence suggests that osmosensitive sites within the forebrain lamina terminalis, such as the organum vasculosum of the lamina terminalis, are key elements that link plasma hypertonicity to elevated SNA. 3. The major efferent target of osmosensitive regions in the forebrain lamina terminalis is the hypothalamic paraventricular nucleus (PVH). Evidence from a number of studies indicates that the PVH contributes to both acute and chronic osmotically driven increases in SNA. In turn, PVH neurons increase SNA through a direct vasopressinergic spinal pathway and/or a glutamatergic pathway to bulbospinal sympathetic neurons of the rostral ventrolateral medulla. 4. Future studies are needed to: (i) define the contribution of various osmosensitive regions of the forebrain lamina terminalis to acute and chronic osmotically driven increases in SNA; (ii) identify the cellular mechanisms and neural circuitry linking plasma osmolality and SNA; and (iii) define whether such mechanisms contribute to elevated SNA in salt-sensitive hypertension.
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Affiliation(s)
- Sean D Stocker
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536-0298, USA
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Collett JA, Carmichael SP, Fain A, Wyatt EA, Osborn JL. Expression of Hypertension over Six Generations in Spontaneous Hypertension/Brown Norway (SHR/BN) Congenic Rats. FASEB J 2007. [DOI: 10.1096/fasebj.21.6.a893-b] [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: 11/11/2022]
Affiliation(s)
| | | | - Aaron Fain
- BiologyUniversity of Kentucky101 T.H. MorganLexingtonKY40503
| | - Erin A. Wyatt
- BiologyUniversity of Kentucky101 T.H. MorganLexingtonKY40503
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