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Sharma J, Harris R, Blatt M, Zielonka T, Kuo YH, Manalac Martinez MA, Menda B, Canfora P, DiBenedetto R, Cohn SM. Evaluating the Reliability of Transcranial Doppler Ultrasonography in Healthy Normal Adults. Am Surg 2023; 89:4902-4904. [PMID: 34459283 DOI: 10.1177/00031348211041569] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jyoti Sharma
- Division of Trauma, Surgical Critical Care & Injury Prevention, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Rachel Harris
- Department of Surgery, Hackensack Meridian Palisades Medical Center, North Bergen, NJ, USA
| | - Melissa Blatt
- Department of Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tania Zielonka
- Department of Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health, Neptune, NJ, USA
| | | | - Babita Menda
- Department of Vascular Services, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Paula Canfora
- Department of Vascular Services, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Rose DiBenedetto
- Department of Vascular Services, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Stephen M Cohn
- Division of Trauma, Surgical Critical Care & Injury Prevention, Hackensack University Medical Center, Hackensack, NJ, USA
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Hawkins S, Miller M, Zhu H, Shi M, Zielonka T, Blatt M, Kuo YH, Cohn SM. Faecaliths do not predict severity of acute appendicitis. Br J Surg 2022; 109:638-639. [PMID: 35531748 DOI: 10.1093/bjs/znac118] [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] [Received: 03/03/2022] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Samuel Hawkins
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Mitchell Miller
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Hongfa Zhu
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Meiyi Shi
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Tania Zielonka
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Melissa Blatt
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health, 19 Davis Avenue, Neptune, New Jersey 07753, USA
| | - Stephen M Cohn
- Departments of Surgery, Radiology, and Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
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Hawkins S, Blau S, Zielonka T, Blatt M, Kuo YH, Cohn SM. Inferior Vena Cava Filters Lack Benefit in High-Risk Trauma Patients. Am Surg 2022:31348221086787. [PMID: 35451868 DOI: 10.1177/00031348221086787] [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 Hawkins
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Steven Blau
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tania Zielonka
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Melissa Blatt
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health, Neptune, NJ, USA
| | - Stephen M Cohn
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Omer DM, Hawkins S, Zielonka T, Blatt M, Kuo YH, Cohn SM. Emergency Ileostomies in Older Patients. Am Surg 2022:31348221086785. [PMID: 35438575 DOI: 10.1177/00031348221086785] [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)
- Dana M Omer
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Samuel Hawkins
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tania Zielonka
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Melissa Blatt
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health, Neptune, NJ, USA
| | - Stephen M Cohn
- Trauma and Surgical Critical Care, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Dalal S, Tucker S, Zielonka T, Kinney J, Magdich A, Parr D, Parulekar M, Blatt M, Hawkins S, Kuo Y, Cohn SM. A CT-Derived Measurement of Sarcopenia Fails to Predict Falls. Am Surg 2022:31348221075593. [PMID: 35142564 DOI: 10.1177/00031348221075593] [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
Sarcopenia and frailty have both emerged as risk factors for elderly falls. We investigated whether radiologic sarcopenia or frailty are associated with falls in a high-risk geriatric outpatient population. We reviewed 114 patients followed at the Center for Healthy Senior Living who had undergone a computerized tomography (CT) of the abdomen and pelvis for any reason from 2013 to 2019. Sarcopenia was determined by psoas muscle cross-sectional area at L3 on CT scan. Their individual frailty score was calculated. The primary outcome was admission to hospital for falls. There were no statistical differences in frailty score or sarcopenia between the 2 groups (left/right psoas muscle: no hospital admission = 6.8 ± 2.4/6.4 ± 2.5 vs falls requiring hospital admission 6.5 ± 2.3/6.5 ± 2.3 cm2). We concluded that neither frailty score nor sarcopenia predicted the occurrence of falls in our high-risk geriatric outpatient population.
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Affiliation(s)
- Setu Dalal
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Scarlett Tucker
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Tania Zielonka
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - JacqueLyn Kinney
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Andrew Magdich
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - David Parr
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Manisha Parulekar
- Department of Medicine, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Melissa Blatt
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Samuel Hawkins
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - YenHung Kuo
- Office of Research Administration, 3139Hackensack Meridian Health, Neptune, NJ, USA
| | - Stephen M Cohn
- Department of Surgery, 3673Hackensack Meridian School of Medicine, Hackensack, NJ, USA
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Omer D, Cohn SM, Blatt M, Zielonka CCRP T, Kaul S, Kuo YH. Should Emergency Ileostomy Be Performed in the Elderly? J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.094] [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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Hernandez SM, Kiselak EA, Zielonka T, Tucker S, Blatt M, Perez JM, Kaul S, Dayal S, Sharma J, Dalal S, Rippey K, Kuo YH, Cohn SM. Umbilical Fascial Defects are Common and Predict Trocar Site Hernias After Laparoscopic Appendectomy. Am Surg 2021:3134821995063. [PMID: 33596098 DOI: 10.1177/0003134821995063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Investigations have demonstrated that trocar site hernia (TSH) is an under-appreciated complication of laparoscopic surgery, occurring in as many as 31%. We determined the incidence of fascial defects prior to laparoscopic appendectomy and its impact relative to other risk factors upon the development of TSH. METHODS TSH was defined as a fascial separation of ≥ 1 cm in the abdominal wall umbilical region on abdominal computerized tomography scan (CT) following laparoscopic appendectomy. Patients admitted to our medical center who had both a preoperative CT and postoperative CT for any reason (greater than 30 days after surgery) were reviewed for the presence of TSH from May 2010 to December 2018. CT scans were measured for fascial defects, while investigators were blinded to film timing (preoperative or postoperative) and patient identity. Demographic information was collected. RESULTS 241 patients undergoing laparoscopic appendectomy had both preoperative and late postoperative CT. TSH was identified in 49 (20.3%) patients. Mean preoperative fascial gap was 3.3 ± 4.3 mm in those not developing a postoperative hernia versus 14.8 ± 7.3 mm in those with a postoperative hernia (P < .0001). Preoperative fascial defect on CT was predictive of TSH (P < .001, OR = 1.44), with an Area Under the Curve (AUC) of .921 (95%CI: .88-.92). Other major risk factors for TSH were: age greater than 59 years (P < .031, OR = 2.48); and obesity, BMI > 30 (P < .012, OR = 2.14). CONCLUSIONS The incidence of trocar site hernia was one in five following laparoscopic appendectomy. The presence of a pre-existing fascial defect, advanced age, and obesity were strong predictors for the development of trocar site hernia.
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Affiliation(s)
- Steven M Hernandez
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Elizabeth A Kiselak
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tania Zielonka
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Scarlett Tucker
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Melissa Blatt
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Javier M Perez
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Sanjeev Kaul
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Saraswati Dayal
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Jyoti Sharma
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Setu Dalal
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Kelly Rippey
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Yen-Hong Kuo
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Stephen M Cohn
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Kruse M, Perez M, Blatt M, Zielonka T, Dolich M, Keric N, Schreiber M, Bini J, Hofmann L, Cohn SM. Marijuana Legalization and Rates of Crashing Under the Influence of Tetrahydrocannabinol and Alcohol. Am Surg 2021:3134821995053. [PMID: 33586994 DOI: 10.1177/0003134821995053] [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: 11/17/2022]
Abstract
OBJECTIVE To determine if statewide marijuana laws impact upon the detection of drugs and alcohol in victims of motor vehicle collisions (MVC). METHODS A retrospective analysis of data collected at trauma centers in Arizona, California, Ohio, Oregon, New Jersey, and Texas between 2006 and 2018 was performed. The percentage of patients testing positive for marijuana tetrahydrocannabinol (THC) was compared to the percentage of patients driving under the influence of alcohol (blood alcohol level >0.08 g/dL) that were involved in an MVC. RESULTS The data were analyzed to evaluate the trends in THC and alcohol use in victims of MVC, related to marijuana legalization. The change in incidence of THC detection (percentage) over the time period where data were available are as follows: Arizona 9.5% (0.4 to 9.9), California 5.4% (20.8 to 26.2), Ohio 5.9% (6.7 to 12.6), Oregon 3% (3.0 to 6.0), New Jersey 2.3% (2.7 to 5.0), and Texas 15.3% (3.0 to 18.3). Alcohol use did not change over time in most states. There did not appear to be a relationship between the legalization of marijuana and the likelihood of finding THC in patients admitted after MVC. In fact, in Texas, where marijuana remains illegal, there was the largest change in detection of THC. CONCLUSIONS There was no apparent increase in the incidence of driving under the influence of marijuana after legalization. In addition, the changes in marijuana legislation did not appear to impact alcohol use.
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Affiliation(s)
- Michelle Kruse
- 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Martin Perez
- 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Melissa Blatt
- 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tania Zielonka
- 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mathew Dolich
- 8788School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Natasha Keric
- 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | | | - John Bini
- 2829Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Luke Hofmann
- 12340University of Texas Health Science Center, San Antonio, TX, USA
| | - Stephen M Cohn
- 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Abstract
BACKGROUND Acetaminophen is a non-opioid analgesic commonly utilized for pain control after several types of surgical procedures. METHODS This scoping primary literature review provides recommendations for intravenous (IV) acetaminophen use based on type of surgery. RESULTS Intravenous acetaminophen has been widely studied for postoperative pain control and has been compared to other agents such as NSAIDs, opioids, oral/rectal acetaminophen, and placebo. Some of the procedures studied include abdominal, gynecologic, orthopedic, neurosurgical, cardiac, renal, and genitourinary surgeries. Results of these studies have been conflicting and largely have not shown consistent clinical benefit. CONCLUSION Overall, findings from this review did not support the notion that IV acetaminophen has significant efficacy for postoperative analgesia. Given the limited clinical benefit of IV acetaminophen, especially when compared to the oral or rectal formulations, use is generally not justifiable.
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Affiliation(s)
- Danielle M Tompkins
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA.,Department of Pharmacy, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Arielle DiPasquale
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Michelle Segovia
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Stephen M Cohn
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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10
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Chang RW, Tompkins DM, Cohn SM. Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management. Am Surg 2020; 87:872-879. [DOI: 10.1177/0003134820952834] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this article, we review controversies in assessing the risk of serious adverse effects caused by administration of nonsteroidal anti-inflammatory drugs (NSAIDs). Our focus is upon NSAIDs used in short courses for the management of acute postoperative pain. In our review of the literature, we found that the risks of short-term NSAID use may be overemphasized. Specifically, that the likelihood of renal dysfunction, bleeding, nonunion of bone, gastric complications, and finally, cardiac dysfunction do not appear to be significantly increased when NSAIDs are used appropriately after surgery. The importance of this finding is that in light of the opioid epidemic, it is crucial to be aware of alternative analgesic options that are safe for postoperative pain control.
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Affiliation(s)
| | - Danielle M. Tompkins
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
- Hackensack University Medical Center, Hackensack, NJ, USA
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Harris R, Sharma J, Zielonka T, Blatt M, Kuo YH, Canfora P, Alice Manalac Martinez M, Menda B, DiBenedetto R, Cohn SM. Evaluating the Reliability of Transcranial Doppler Ultrasonography in Healthy Normal Adults. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Abstract
Background Platelets are commonly administered to trauma patients to reverse the effects of pre-injury anti-platelet drugs if these individuals are judged to be at risk for ongoing bleeding (i.e., traumatic brain injury). In the U.S. blood banks, platelets are maintained at room temperature and are not infused prior to 72 hours storage due to rigorous screening methods. Recent work suggested that cold refrigerated platelets may be effective at restoring platelet function. We hypothesized that refrigerated platelets might be superior to room temperature platelets in reversing aspirin and clopidogrel-induced platelet dysfunction. Methods Using a cross-over design, 10 healthy, adult subjects underwent platelet removal by apheresis, received anti-platelet drugs (aspirin 325 mg and clopidogrel 75 mg) daily for three days, and then had return of their own platelets (about 3 x 1011 platelets). Five subjects were randomly assigned to receive platelets stored at 4°C, and five received platelets stored at room temperature. One month later, this entire process was repeated with each subject receiving platelets stored by the alternative method. Thus, subjects served as their own controls. At multiple time points during the study in vivo platelet function was assessed by bleeding times, which were measured by a single observer blinded to patient group. Results Bleeding times rose dramatically after anti-platelet drugs were given, but remained well above the normal range (seven minutes) despite reinfusion of platelets. There were no differences in platelet function according to the method of storage. Conclusions Transfusion with autologous platelets appears to be ineffective in reversing the anti-platelet effects of aspirin and clopidogrel. Cold refrigerated platelets were no more effective than room temperature stored platelets in restoring platelet function. This abstract was presented at American College of Surgeons-clinical congress, Boston 10-22-2018. (Khoury L, Cohn S, Panzo M. Inability to Reverse Aspirin and Clopidogrel-Induced Platelet Dysfunction with Platelet Infusion. Journal of the American College of Surgeons. 2018. 227. S265. DOI: 10.1016/j.jamcollsurg.2018.07.546).
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Affiliation(s)
- Stephen M Cohn
- Surgery, Staten Island University Hospital, Staten Island, USA
| | | | - Leen Khoury
- Surgery, Staten Island University Hospital, Staten Island, USA
| | | | - Melissa Panzo
- Emergency Medicine, Staten Island University Hospital, Staten Island, USA
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13
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Abstract
Background Drugged driving, or driving under the influence of any drug, is a growing public health concern, especially with the recent legislation legalizing marijuana use in certain states in the USA. We sought to gain a better understanding of the surgeons' perspective regarding marijuana (MJ) and alcohol (ETOH) and the relationship of recent laws to identification of MJ and ETOH in trauma victims. Methods Members of a national trauma surgical organization were asked to participate in an Institutional Review Board (IRB)-approved, web-based survey which centered on attitudes, knowledge, and beliefs regarding ETOH and MJ as they related to injury. Two Level I trauma center registries (located in TX and CA) were queried for the incidence of motor vehicular collision (MVC) and the presence of ETOH (defined as > 0.08 g/dL) or MJ from 2006 thru 2012. Results A total of 127 trauma surgeons participated in the survey. The majority were male (84%, n = 107) and with a median age of 52. Most were in surgical practice for greater than 11 years (78%, n = 99) and worked at a Level I trauma center (78%, n = 99) in an academic institution (65%, n = 83). MJ was illegal in the states where most of the participants were in practice (79%, n = 100), but 90% (n = 114) of respondents from states where MJ is legal stated they have not seen an increase in MVC since MJ was legalized. At the TX trauma center, only 4% of patients involved in a vehicular trauma tested positive for MJ, 21% of patients had the presence of ETOH, and 3% had both. For both MJ and also ETOH, the incidence remained the same each year. In CA, there was little yearly variation in the incidence of patients that tested positive for MJ (23%), ETOH (50%), and both (7%). In addition, the incidence of MJ was essentially unchanged after the decriminalization law was passed in 2010. Conclusion The prevalence of cannabis and alcohol varies among the states studied, TX and CA. The impact of decriminalization of marijuana did not seem to affect the incidence of drugged driving with marijuana in CA.
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Affiliation(s)
- Natash Keric
- Surgery, Banner University Medical, Phoenix, USA
| | - Luke J Hofmann
- Surgery, University of Texas Health Science Center, San Antonio, USA
| | | | - Joel Michalek
- Epidemiology and Biostatistics, University of Texas at San Antonio, San Antonio, USA
| | | | - Leen Khoury
- Surgery, Staten Island University Hospital, Staten Island, USA
| | | | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Staten Island, USA
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14
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Hofmann LJ, Babbitt-Jonas R, Khoury L, Perez JM, Cohn SM. Fact and Fiction Regarding Motorcycle Helmet Use, Associated Injuries, and Related Costs in the United States. Cureus 2018; 10:e3610. [PMID: 30693163 PMCID: PMC6343861 DOI: 10.7759/cureus.3610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Despite evidence that helmet use decreases motorcycle-associated injuries and mortality, the use of motorcycle helmets is not universal. As trauma surgeons are frequently the primary providers responsible for motorcycle crash victims, we sought to gain a better understanding of trauma surgeons’ perspectives on helmet use with motorcycles. Methods Members of the American Association for the Surgery of Trauma (AAST) were asked to participate in a survey that centered on attitudes, knowledge, and beliefs regarding motorcycle helmet use, associated injuries, and related costs. Demographic data were analyzed. In addition, we performed a literature search to attempt to clarify the current data on this subject. Results A total of 127 surgeons participated. The majority were male (64%, n=81), in academic practice (67%, n=85), and worked at a Level I trauma center (80%, n=102). Of those that owned a motorcycle, 100% wear a helmet when riding. Seven percent (n=9) of respondents believe helmet use increases cervical spine injury, although the majority (78%, n=99) disagree. In regards to head injuries and helmet use, most (93%, n=118) believe that helmets decrease the severity of head injury, improve outcomes (98%, n=124), and impact long-term disability (93%, n=118). Ninety percent (n=114) of surgeons believe that state legislation mandating motorcycle helmet use increases helmet utilization, and 82% (n=104) believe that the decision to wear a helmet should not be a personal decision. The majority (83%, n=106) of trauma surgeons agreed that helmet use would likely lead to a major reduction in motorcycle-related health care costs. Conclusions North American trauma surgeons wear helmets when they ride motorcycles and believe that these devices are highly protective, leading to a reduction in brain injury and the subsequent health care costs.
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Affiliation(s)
- Luke J Hofmann
- Surgery, University of Texas Health Science Center, San Antonio, USA
| | | | - Leen Khoury
- Surgery, Staten Island University Hospital, Staten Island, USA
| | | | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Staten Island, USA
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15
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Hofmann LJ, Keric N, Cestero RF, Babbitt-Jonas R, Khoury L, Panzo M, Perez JM, Cohn SM. Trauma Surgeons' Perspective on Gun Violence and a Review of the Literature. Cureus 2018; 10:e3599. [PMID: 30680260 PMCID: PMC6338409 DOI: 10.7759/cureus.3599] [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] [Indexed: 11/10/2022] Open
Abstract
Background In the United States, there is a constant debate between the proponents of the right to bear arms and those desiring to reduce the epidemic of gun violence. We sought to capture the trauma surgeons' perspective on gun control. Methods We presented an on-line based survey to the members of the American Association for the Surgery of Trauma (AAST). Survey questions were chosen to reflect the popular media poll questions as well as trauma-specific perspectives. We compared the trauma surgeons' perspectives to that of the general populace from a poll conducted by the New York Times (NYT). Results A total of 120 trauma surgeons responded to the survey. The age group ranged from 34 to 82 years, and the median age was 51. Most respondents were male (64%, n = 67) and worked at a Level I trauma center (80%, n = 96) in an academic setting (67%, n = 80). About half of the responding surgeons owned a household firearm (40%; n = 48 of the AAST members vs. 47%; n = 521 of the general populace). Sixty-one percent of the trauma surgeons (n = 73) and 53% (n = 588) of the NYT respondents favor stricter gun control laws. While 80% (n = 888) of the NYT respondents felt that mental health screening and treatment would decrease gun violence, only 56% (n = 67) of surgeons felt that mental health screening would be beneficial. The majority (90%, n = 999) of the NYT poll respondents favor a law restricting the sale of guns only by licensed dealers. Only (66%, n = 79) of the trauma surgeons were in agreement with the stricter gun sale legislation by licensed dealers. Conclusion Trauma surgeons appear to share similar views with the general American populace regarding gun violence and injury control.
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Affiliation(s)
- Luke J Hofmann
- Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Natasha Keric
- Surgery, Banner University Medical Center, Phoenix, USA
| | - Ramon F Cestero
- Surgery, University of Texas Health Science Center, San Antonio, USA
| | | | - Leen Khoury
- Surgery, Staten Island University Hospital, Staten Island, USA
| | - Melissa Panzo
- Emergency Medicine, Staten Island University Hospital, Staten Island, USA
| | | | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Staten Island, USA
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16
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Abstract
Background General surgery chief residents are typically well equipped for board examinations but poorly trained to deal with the business challenges of surgical practice. We began a business leadership course to better prepare them for their careers. Methods Chief residents were given one-hour lectures with topics that included: Differences between private/academic practice, personal finances, contracts, practice management, legal issues and health law, and time management. Results Initial evaluations revealed that the topics covered and the presentations were well received. Subsequently, the course was moved to earlier in the academic year to prepare them for contract negotiations and then to Sunday nights to decrease interruptions and allow spouse participation. Conclusions The course evolved into a program that the chief residents feel is an important addition to their education. Moving the meetings to a weekend evening improved attendance, decreased interruptions, and allowed participation by spouses and significant others.
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Affiliation(s)
- Adham R Saad
- Surgery, University of South Florida, Tampa, USA
| | - Clinton E Baisden
- Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Daniel L Dent
- Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Leen Khoury
- Surgery, Staten Island University Hospital, Staten Island, USA
| | - Melissa Panzo
- Emergency Medicine, Staten Island University Hospital, Staten Island, USA
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Staten Island, USA
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Isbell C, Cohn SM, Inaba K, O'Keeffe T, De Moya M, Demissie S, Ghneim M, Davis ML. Cirrhosis, Operative Trauma, Transfusion, and Mortality: A Multicenter Retrospective Observational Study. Cureus 2018; 10:e3087. [PMID: 30324043 PMCID: PMC6171781 DOI: 10.7759/cureus.3087] [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] [Indexed: 11/29/2022] Open
Abstract
Background: In trauma patients with cirrhosis who require laparotomy, little data exists to establish clinical predictors of the outcome. We sought to determine the prognosticators of mortality in this population. Methods: We performed a 10-year review at four, busy Level I trauma centers of patients with cirrhosis identified during trauma laparotomy. We compared vital signs, laboratory values, and transfusion requirements for those who survived versus those who died. A linear regression was then conducted to determine the variables associated with death in this population. Results: A total of 66 patients were included and 47% (31/66) died. The model for end-stage liver disease (MELD) score was low (7.8 in Lived, 10.2 in Died). Packed red blood cell (PRBC) transfusion at six hours was greater in those who died; those receiving > 6 units of PRBCs at 6 hours had an increased likelihood of death (odds ratio OR 5.8 (95% CI 1.9, 17.4)). All patients receiving ≥ 17 units of PRBCs died. We found an association between lower preoperative platelets (PLTs), higher preoperative international normalized ratio (INR) and partial thromboplastin time (PTT), lower preoperative pH (presence of profound acidemia), increased intraoperative crystalloid use, and increased intraoperative blood product administration to be associated with death (p < 0.05). Conclusions: Cirrhotic trauma patients requiring laparotomy should be considered to have a high chance of mortality if they receive six or more PRBCs, are acidotic (pH ≤ 7.25) at the time of hospital arrival, or have coagulopathy at the time of admission (INR > 1.2, PTT > 40).
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Affiliation(s)
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
| | | | | | - Marc De Moya
- Surgery, Medical College of Wisconsin, Wisconsin, USA
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18
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Khoury L, Hill D, Kopp M, Panzo M, Bajaj T, Schell C, Corrigan A, Rodriguez R, Cohn SM. The Natural History of Gastrointestinal Bleeding in Patients without an Obvious Source. Am Surg 2018. [DOI: 10.1177/000313481808400850] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma “the most common cause of lower GI bleeding is upper GI bleeding” may no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and their clinical outcomes. We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious sources such as hematemesis or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena, or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required, and types of interventions performed. Ninety-three patients were admitted with GI bleeding as defined previously: mean age was 74 years and mean hemoglobin was 8.2. Seventy-four per cent received blood transfusions with an average of 2 units transfused per patient; 22 per cent received 3 or more units of blood. The etiology of bleeding was 17 per cent upper GI source, 15 per cent lower GI source, and in 68 per cent, the source remained unknown. Bleeding stopped spontaneously in 86 per cent of patients and 9 per cent died. Endoscopy was performed in 71 per cent, but only 6 per cent underwent therapeutic endoscopic intervention. No patient had surgical or interventional radiologic procedures related to their GI bleed. Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative intervention or interventional radiologic procedure. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6 per cent of patients.
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Affiliation(s)
- Leen Khoury
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - David Hill
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Miroslav Kopp
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Melissa Panzo
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Tushar Bajaj
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Carson Schell
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Andrew Corrigan
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Ryan Rodriguez
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
| | - Stephen M. Cohn
- From the Department of Surgery, Hofstra Northwell School of Medicine, Staten Island University Hospital, Staten Island, New York
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19
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Khoury L, Hill D, Kopp M, Panzo M, Bajaj T, Schell C, Corrigan A, Rodriguez R, Cohn SM. The Natural History of Gastrointestinal Bleeding in Patients without an Obvious Source. Am Surg 2018; 84:1345-1349. [PMID: 30185314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma "the most common cause of lower GI bleeding is upper GI bleeding" may no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and their clinical outcomes. We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious sources such as hematemesis or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena, or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required, and types of interventions performed. Ninety-three patients were admitted with GI bleeding as defined previously: mean age was 74 years and mean hemoglobin was 8.2. Seventy-four per cent received blood transfusions with an average of 2 units transfused per patient; 22 per cent received 3 or more units of blood. The etiology of bleeding was 17 per cent upper GI source, 15 per cent lower GI source, and in 68 per cent, the source remained unknown. Bleeding stopped spontaneously in 86 per cent of patients and 9 per cent died. Endoscopy was performed in 71 per cent, but only 6 per cent underwent therapeutic endoscopic intervention. No patient had surgical or interventional radiologic procedures related to their GI bleed. Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative intervention or interventional radiologic procedure. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6 per cent of patients.
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20
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Hassan S, Alarhayema AQ, Cohn SM, Wiersch JC, Price MR. Natural History of Isolated Skull Fractures in Children. Cureus 2018; 10:e3078. [PMID: 30280073 PMCID: PMC6167063 DOI: 10.7759/cureus.3078] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Head injury is the most common cause of neurologic disability and mortality in children. We had hypothesized that in children with isolated skull fractures (SFs) and a normal neurological examination on presentation, the risk of neurosurgical intervention is very low. We retrospectively reviewed the medical records of all children aged six to sixteen years presenting to our Level 1 trauma center with traumatic brain injuries between January 1, 2006 and December 31, 2014. We also analyzed the National Trauma Data Bank (NTDB) research data set for the years 2012-2014 using the same metrics. During this study period, our center admitted 575 children with skull fractures, 197 of which were isolated (no associated intracranial lesions (ICLs)). Of the 197 patients with isolated SFs, 155 had a normal neurological examination at presentation. In these patients, there were no fatalities and only three (1.9%) required surgery, all for the elevation of the depressed skull fracture. Analyzing the NTDB yielded similar results. In 5,194 children with isolated SFs and a normal neurological examination on presentation, there were no fatalities and 249 (4.8%) required neurosurgical intervention, almost all involving craniotomy/craniectomy and/or elevation of the SF segments. In conclusion, children with non-depressed isolated skull fractures and a normal Glasgow coma scale (GCS) at the time of initial presentation are at extremely low risk of death or needing neurosurgical intervention.
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Affiliation(s)
- Saif Hassan
- Surgery, St. Luke's the Woodlands Hospital, Woodland, USA
| | | | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
| | | | - Mitchell R Price
- Pediatric Surgery, Northwell Health at Staten Island University Hospital, Staten Island, USA
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21
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Abstract
Background: Physicians are required to assume a leadership role as part of their career. For most, this is not an innate characteristic and must be developed throughout their medical training. There are few residency courses designed to assist in the enhancement of these leadership skills. We created and implemented a novel course on leadership, utilizing weekly presentations designed to stimulate discussions and improve the leadership qualities of trainees. Methods: Senior residents provided leadership lectures stimulated by assigned readings from the book "The Founding Fathers on Leadership." The traits and characteristics demonstrated throughout course readings and discussions were subsequently incorporated into everyday resident activities. Baseline and post-course survey responses were evaluated to assess changes in leadership qualities. Results: Seven senior (postgraduate year (PGY) 3-5) participated as course leaders. All seven filled out pre- and post-course surveys. Seventeen junior residents (PGY 1-2) were involved as audience members. Significant pre- and post-course differences were noted in the following areas: feelings of increased encouragement of personal development (4.86 vs. 5.43, p=0.03); increased team participation in decision-making (4.00 vs. 4.57, p=0.03); increased ease of obtaining answers to difficult questions (4.57 vs. 5.23, p=0.047); increased team member work (4.86 vs. 5.71, p=0.047), and a sense of leading a more balanced life (3.86 vs. 4.43, p=0.03). Conclusion: The initiation of a novel leadership course for senior surgical residents led to an enjoyable experience, resulting in enhanced leadership skills for all participants. We believe this process resulted in a more cohesive, efficient, communicative, and supportive residency program.
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Affiliation(s)
- David A Hill
- Plastic and Reconstructive Surgery, Houston Methodist Hospital, Houston, USA
| | - Jean-Carlos Jimenez
- Surgery, Northwell Health at Staten Island University Hospital, Staten Island, USA
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
| | - Mitchell R Price
- Pediatric Surgery, Northwell Health at Staten Island University Hospital, Staten Island, USA
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22
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Hill DA, Jimenez JC, Price MR, Cohn SM. Improving Oratory Skills: An "American Idol" Presentation Competition for Residents. Cureus 2018; 10:e3049. [PMID: 30271695 PMCID: PMC6157649 DOI: 10.7759/cureus.3049] [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] [Indexed: 11/20/2022] Open
Abstract
Background It is essential for physicians to master the ability to deliver high-quality oral presentations. Despite this, little time is dedicated throughout residency for training and refining this important skill. In order to solve this issue, we set out to design and implement a course which will improve the oratory skills of the resident physicians. Methods Senior surgical residents (postgraduate years three and four) were involved in a single-elimination tournament with the audience voting for the top presenters. Faculty provided feedback on oration, slide layout and overall presentation format throughout the course. Baseline and post-course survey responses were evaluated to assess a change in presentation skills after the “oratory course”. Results Seven senior residents participated as competitors. Seventeen other junior and chief residents (postgraduate years 1, 2 and 5) were involved as audience members along with several attending physicians, physician assistants and medical students. Both the presenters and audience appreciated a statistically significant improvement in communication skills and slide layout (p < 0.01). Conclusion The use of a structured course in public speaking and presentation skills proved to be effective in developing oratory skills in surgical residents when used in conjunction with an entertaining format.
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Affiliation(s)
- David A Hill
- Plastic and Reconstructive Surgery, Houston Methodist Hospital, Houston, USA
| | - Jean-Carlos Jimenez
- Surgery, Northwell Health at Staten Island University Hospital, Staten Island, USA
| | - Mitchell R Price
- Pediatric Surgery, Northwell Health at Staten Island University Hospital, Staten Island, USA
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
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23
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Abstract
OBJECTIVE Upper gastrointestinal (GI) bleeding occurs at a rate of 40-150 episodes per 100,000 persons per year and is associated with a mortality rate of 6%-10%. We sought to determine the need for therapeutic endoscopy or surgical interventions in patients with hematemesis and the association with blood transfusion requirements. METHODS We queried the database of our large teaching facility for adult patients presenting with obvious upper GI hemorrhage (hematemesis) between 2014 and 2017. We evaluated the amount of blood transfusions administered and the need for operative, endoscopic or angiographic interventions. RESULTS Eighty-one patients were admitted with hematemesis: mean age was 63 years old (range 21-103), 60% were male, and mean hemoglobin was 11.3 g/dL (range 3.6-15.6). Forty-one percent received blood transfusions with a mean of one unit transfused per patient (range 0-10); 9% received ≥ 3 units of packed red blood cells. Bleeding stopped spontaneously in 88% of patients and nine died. Forty-seven percent underwent inpatient endoscopy but only 6% underwent a therapeutic endoscopic intervention. No patient had a surgical or interventional radiologic procedure related to their GI bleed. CONCLUSION Upper GI bleeding rarely requires operative or interventional radiologic intervention. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6% of patients.
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Affiliation(s)
- Leen Khoury
- Research/surgery, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - David A Hill
- Plastic and Reconstructive Surgery, Houston Methodist Hospital, Houston, USA
| | - Melissa Panzo
- Research, Staten Island University Hospital/Northwell Health, New York, USA
| | - Melissa Chiappetta
- Surgery, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Sachin Tekade
- Surgery, Staten Island University Hospital/Northwell Health, Staten Island, USA
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
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24
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Kumar A, Holloway T, Cohn SM, Goodwiler G, Admire JR. The Clinical Evaluation of Alcohol Intoxication Is Inaccurate in Trauma Patients. Cureus 2018; 10:e2190. [PMID: 29662729 PMCID: PMC5898838 DOI: 10.7759/cureus.2190] [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] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Discharging patients from emergency centers based on the clinical features of intoxication alone may be dangerous, as these may poorly correlate with ethanol measurements. OBJECTIVE We determined the feasibility of utilizing a hand-held breath alcohol analyzer to aid in the disposition of intoxicated trauma patients by comparing serial breathalyzer (Intoximeter, Alco-Sensor FST, St. Louis, Missouri, USA] data with clinical assessments in determining the readiness of trauma patients for discharge. METHODS A total of 20 legally intoxicated (LI) patients (blood alcohol concentration (BAC) >80 mg/dL) brought to our trauma center were prospectively investigated. Serial breath samples were obtained using a breathalyzer as a surrogate measure of repeated BAC. A clinical exam (nystagmus, one-leg balance, heel-toe walk) was performed prior to each breath sampling. RESULTS The enrollees were 85% male, age 30±10 (range 19-51), with a body mass index (BMI) of 29±7. The average initial body alcohol level (BAL) was 245±61 (range 162-370) mg/dL. Based on breath samples, the alcohol elimination rates varied from 21.5 mg/dL/hr to 45.7 mg/dL/hr (mean 28.5 mg/dL/hr). There were no significant differences in alcohol elimination rates by gender, age, or BMI. The clinical exam also varied widely among patients; only seven of 16 (44%) LI patients demonstrated horizontal nystagmus (suggesting sobriety when actually LI) and the majority of the LI patients (66%) were able to complete the balance tasks (suggesting sobriety). CONCLUSION Intoxicated trauma patients have an unreliable clinical sobriety exam and a wide range of alcohol elimination rates. The portable alcohol breath analyzer represents a potential option to easily and inexpensively establish legal sobriety in this population.
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Affiliation(s)
- Ashwini Kumar
- Surgery, University of Texas Health Science Center at San Antonio
| | - Travis Holloway
- Surgery, University of Texas Health Science Center at San Antonio
| | | | | | - John R Admire
- Surgery, University of Texas Health Science Center at San Antonio
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25
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Pal A, Mahmood E, Dinitto T, Li Z, Cohn SM. Thirty-Day Readmission Rates for Nonoperative Management of Acute Appendicitis in 4,219 Patients. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Alarhayem AQ, Cohn SM, Muir MT, Myers JG, Fuqua J, Eastridge BJ. Organ Donation, an Unexpected Benefit of Aggressive Resuscitation of Trauma Patients Presenting Dead on Arrival. J Am Coll Surg 2017; 224:926-932. [PMID: 28263857 DOI: 10.1016/j.jamcollsurg.2017.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND We sought to determine whether aggressive resuscitation in trauma patients presenting without vital signs, or "dead on arrival," was futile. We also sought to determine whether organ donation was an unexpected benefit of aggressive resuscitation. STUDY DESIGN We conducted a review of adults presenting to our Level I trauma center with no signs of life (pulse = 0 beats/min; systolic blood pressure = 0 mmHg; and no evidence of neurologic activity, Glasgow Coma Scale score = 3). Primary end point was survival to hospital discharge or major organ donation (ie heart, lung, kidney, liver, or pancreas were harvested). We compared our survival rates with those of the National Trauma Data Bank in 2012. Patient demographics, emergency department vital signs, and outcomes were analyzed. RESULTS Three hundred and forty patients presented with no signs of life to our emergency department after injury (median Injury Severity Score = 40). There were 7 survivors to discharge, but only 5 (1.5%) were functionally independent (4 were victims of penetrating trauma). Of the 333 nonsurvivors, 12 patients (3.6%) donated major organs (16 kidneys, 2 hearts, 4 livers, and 2 lungs). An analysis of the National Trauma Data Bank yielded a comparable survival rate for those presenting dead on arrival, with an overall survival rate of 1.8% (100 of 5,384); 2.3% for blunt trauma and 1.4% for penetrating trauma. CONCLUSIONS Trauma patients presenting dead on arrival rarely (1.5%) achieve functional independence. However, organ donation appears to be an under-recognized outcomes benefit (3.6%) of the resuscitation of injury victims arriving without vital signs.
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Affiliation(s)
- Abdul Q Alarhayem
- University of Texas Health Science Center at San Antonio, San Antonio, TX.
| | | | - Mark T Muir
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - John G Myers
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - James Fuqua
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Brian J Eastridge
- University of Texas Health Science Center at San Antonio, San Antonio, TX
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Rowan MP, Beckman DJ, Rizzo JA, Isbell CL, White CE, Cohn SM, Chung KK. Elevations in growth hormone and glucagon-like peptide-2 levels on admission are associated with increased mortality in trauma patients. Scand J Trauma Resusc Emerg Med 2016; 24:119. [PMID: 27716276 PMCID: PMC5050752 DOI: 10.1186/s13049-016-0310-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 05/11/2016] [Accepted: 09/27/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients. METHODS To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013. RESULTS Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors. DISCUSSION This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured. CONCLUSIONS GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.
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Affiliation(s)
- Matthew P Rowan
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Darrick J Beckman
- Brooke Army Medical Center, 3855 Roger Brooke Drive, JBSA, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Julie A Rizzo
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA, Fort Sam Houston, San Antonio, TX, 78234, USA. .,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd # A3007, Bethesda, MD, 20814, USA.
| | - Claire L Isbell
- Baylor Scott and White Memorial Hospital, 2401 S. 31st St, Temple, TX, 76502, USA
| | - Christopher E White
- Brooke Army Medical Center, 3855 Roger Brooke Drive, JBSA, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Stephen M Cohn
- Staten Island University Hospital, 475 Seaview Ave, Staten Island, NY, 10305, USA
| | - Kevin K Chung
- United States Army Institute of Surgical Research, 3698 Chambers Pass, JBSA, Fort Sam Houston, San Antonio, TX, 78234, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd # A3007, Bethesda, MD, 20814, USA
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Cohn SM, Moller BA, Feinstein AJ, Burns GA, Ginzburg E, Hammers, LW. Prospective Trial of Low-Molecular-Weight Heparin Versus Unfractionated Heparin in Moderately Injured Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449903300219] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The safety and efficacy of low-molecular-weight heparin (LMWH) was compared with those of conventional unfractionated heparin (UH) in preventing deep venous thrombosis (DVT) in trauma patients with moderate injuries in a prospective double-blind, randomized trial at a level I trauma center. After informed consent, trauma patients meeting inclusion criteria (age > 45 or requiring > 2 days' bedrest) received LMWH or UH twice daily in a double-blind, randomized trial. Patients were excluded if they had severe brain injuries or bleeding injuries not accessible to hemostatic control (eg, severe visceral contusions). Clinical examination and weekly venous duplex ultrasound evaluations were performed to identify DVT. One hundred four patients were randomized, 53 to receive UH and 51 to receive LMWH; 32 UH and 34 LMWH patients completed the study (mean injury severity score [ISS] = 12). There were no significant differences between groups with regard to age, sex, ISS, mechanism of injury, or doses of drug given. Outcome measures such as length of stay in the surgical intensive care unit and hospital days were similar. There were two patients with DVT in the UH group, none in the LMWH group (p = 0.493 by Fisher's exact test). This was not a statistically significant difference. There were five major bleeding complications in each group. The incidence of DVT in injured patients receiving prophylaxis appears to be quite low if individuals such as those with severe head injury or visceral contusions are excluded. LMWH is not clearly beneficial when compared with UH in this moderate-risk trauma population.
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Affiliation(s)
- Stephen M. Cohn
- Department of Surgery, University of Miami School of Medicine, Miami, Florida
| | - Beth A. Moller
- Departments of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Ara J. Feinstein
- Department of Surgery, University of Miami School of Medicine, Miami, Florida
| | - Gerard A. Burns
- Departments of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Enrique Ginzburg
- Department of Surgery, University of Miami School of Medicine, Miami, Florida
| | - Lynn W. Hammers,
- Departments of Radiology, Yale University School of Medicine, New Haven, Connecticut
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Alarhayem AQ, Cohn SM, Eastridge BJ, Rubalcava NS, Myers JG. Natural History of Trauma Patients Presenting “Dead on Arrival”: Should We Resuscitate? J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.394] [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: 10/23/2022]
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30
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Hassan S, Alarhayem AQ, Cohn SM, Wiersch JC. Natural history of isolated skull fractures in children. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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de Moya MA, Sideris AC, Choy G, Chang Y, Landman WB, Cropano CM, Cohn SM. Appendectomy and Pregnancy: Gestational Age Does Not Affect the Position of the Incision. Am Surg 2015. [DOI: 10.1177/000313481508100331] [Citation(s) in RCA: 3] [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: 11/15/2022]
Abstract
The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.
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Affiliation(s)
| | | | | | | | - Wendy B. Landman
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; and the
| | | | - Stephen M. Cohn
- Department of Surgery, University of Texas Health Science Center, San Antonio, Texas
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de Moya MA, Sideris AC, Choy G, Chang Y, Landman WB, Cropano CM, Cohn SM. Appendectomy and pregnancy: gestational age does not affect the position of the incision. Am Surg 2015; 81:282-288. [PMID: 25760205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.
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Affiliation(s)
- Marc A de Moya
- Department of Surgery, Division of Trauma, Massachusetts General Hospital, Boston, Massachusetts, USA
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Hutchison TN, Krueger CA, Berry JS, Aden JK, Cohn SM, White CE. Venous thromboembolism during combat operations: a 10-y review. J Surg Res 2013; 187:625-30. [PMID: 24405609 DOI: 10.1016/j.jss.2013.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 10/22/2013] [Accepted: 11/07/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND This article examines the incidence of venous thromboembolism (VTE) in combat wounded, identifies risk factors for pulmonary embolism (PE), and compares the rate of PE in combat with previously reported civilian data. METHODS A retrospective review was performed of all U.S. military combat casualties in Operation Enduring Freedom and Operation Iraqi Freedom with a VTE recorded in the Department of Defense Trauma Registry from September 2001 to July 2011. The Military Amputation Database of all U.S. military amputations during the same 10-y period was also reviewed. Demographic data, injury characteristics, and outcomes were evaluated. RESULTS Among 26,634 subjects, 587 (2.2%) had a VTE. This number included 270 subjects (1.0%) with deep venous thrombosis (DVT), 223 (0.8%) with PE, and 94 (0.4%) with both DVT and PE. Lower extremity amputation was independently associated with PE (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.07-2.69). A total of 1003 subjects suffered a lower extremity amputation, with 174 (17%) having a VTE. Of these, 75 subjects (7.5%) were having DVT, 70 (7.0%) were having PE, and 29 (2.9%) were found to have both a DVT and a PE. Risk factors found to be independently associated with VTE in amputees were multiple amputations (OR, 2; 95% CI, 1.35-3.42) and above the knee amputation (OR, 2.11; 95% CI, 1.3-3.32). CONCLUSIONS Combat wounded are at a high risk for thromboembolic complications with the highest risk associated with multiple or above the knee amputations.
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Affiliation(s)
| | | | - John S Berry
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, Texas
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Cohn SM. Please pack open your dirty wounds! JAMA Surg 2013; 148:786-7. [PMID: 23803953 DOI: 10.1001/jamasurg.2013.2343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stephen M Cohn
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio
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Van Sickle KR, Nanda Kumar HR, Parikh A, Ayon AA, Cohn SM. Development of an animal model to investigate optimal laparoscopic trocar site fascial closure. J Surg Res 2013; 184:126-31. [PMID: 23764309 DOI: 10.1016/j.jss.2013.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/28/2013] [Accepted: 05/07/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rate of hernia formation after closure of 10-12 mm laparoscopic trocar sites is grossly under-reported. Using an animal model, we have developed a method to assess trocar site fascial dehiscence and the strength of different methods of fascial closure. MATERIALS AND METHODS Pigs (n = 9; 17 ± 2.5 lbs) underwent placement of 12 mm Hasson trocars with pneumoperitoneum maintained for 1 h. Three closure techniques (Figure-of-eight; simple interrupted; pulley) were compared with no fascial closure and to native fascia at five randomly allocated abdominal wall midline locations. Necropsy was performed on the fourth postoperative d. Statistical comparisons of tensile strength and breaking strength based on closure type and trocar location were made using ANOVA with Tukey's tests. RESULTS The mean (SD) force (Newtons) required for fascial disruption varied significantly with closure type [Native Fascia 170 (39), Figure-of-eight 169 (31), Pulley 167 (59), Simple Interrupted 151 (27), No Closure 108 (28)]; P = 0.007. The mean force required for fascial disruption was significantly increased for Native Fascia, Figure-of-eight, and Pulley relative to No Closure (P = 0.013, P = 0.015, P = 0.023, respectively). The mean (SD) force (in Newtons) required for fascial disruption also varied significantly with location of trocar [subxiphoid 181 (43), supraumbilical 151 (23), Umbilical 146 (23), infraumbilical 168 (62), suprapubic 120 (38)]; P = 0.03. The mean force for subxiphoid location was significantly increased relative to the suprapubic location (P = 0.021). CONCLUSIONS We have developed a novel assessment model that reliably detects differences in fascial integrity after laparoscopic trocar placement and closure. This model will allow for further testing of various trocars and closure techniques, and facilitate hernia prevention strategies.
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Affiliation(s)
- Kent R Van Sickle
- Department of Surgery, University of Texas Health Science Center San Antonio (UTHSCSA), San Antonio, Texas 78229, USA
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Ivey KM, White CE, Wallum TE, Aden JK, Cannon JW, Chung KK, McNeil JD, Cohn SM, Blackbourne LH. Thoracic injuries in US combat casualties. J Trauma Acute Care Surg 2012. [DOI: 10.1097/ta.0b013e3182754654] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ivey KM, White CE, Wallum TE, Cannon JW, Chung KK, McNeil JD, Cohn SM, Blackbourne LH. Thoracic injuries in U.S. combat casualties: A review of Operation Enduring Freedom and Operation Iraqi Freedom. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hotz G, Cohn SM, Russ WB. Re: Annual pediatric pedestrian education does not improve pedestrian behavior. J Trauma Acute Care Surg 2012; 72:1118-120. [PMID: 22491641 DOI: 10.1097/ta.0b013e31823f6c9a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Muir MT, Inaba K, Ong A, Barmparas G, Branco BC, Zubowicz EA, Salhanick M, Cohn SM. The need for early angiography in patients with penetrating renal injuries. Eur J Trauma Emerg Surg 2011; 38:275-80. [PMID: 26815959 DOI: 10.1007/s00068-011-0155-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 08/25/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Renal injuries occur in as many as 10% of penetrating abdominal wounds. Today, these wounds are often managed selectively, but there is little contemporary information on the natural history of kidney injuries after penetrating trauma. The purpose of this study was to examine the clinical outcomes of penetrating injuries to the kidney, and to determine if these patients may benefit from routine early angiography. METHODS All trauma patients admitted to three Level I Trauma Centers with penetrating renal injuries over a 10 year study period were retrospectively reviewed. RESULTS We identified 237 patients with a penetrating renal injury, of whom 39 died within the first 24 h and were excluded from analysis. Among the remaining 198 individuals, 130 (66%) underwent immediate exploratory laparotomy. Of the 68 subjects not undergoing immediate surgery, seven had early angiography. The remaining 61 patients (31%) were observed, with 12 (20%) ultimately requiring an intervention to treat the renal injury. Those subjects who failed nonoperative management had significantly fewer hospital-free days compared to those who did not need a procedure (19.2 ± 8.1 vs. 25.7 ± 4.5, p = 0.002). CONCLUSIONS Nearly one in three patients with penetrating renal injuries are currently managed with serial observation, although one in five of these subjects ultimately require either angiographic or surgical treatment. We feel that routine use of early angiography may reduce the failure rate and improve outcomes for patients whose penetrating renal injuries are managed nonoperatively.
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Affiliation(s)
- M T Muir
- Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - K Inaba
- Department of Surgery, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - A Ong
- Department of Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - G Barmparas
- Department of Surgery, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - B C Branco
- Department of Surgery, University of Southern California School of Medicine, Los Angeles, CA, USA
| | - E A Zubowicz
- Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - M Salhanick
- Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - S M Cohn
- Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
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Cohn SM, McCarthy J, Stewart RM, Jonas RB, Dent DL, Michalek JE. Impact of Low-dose Vasopressin on Trauma Outcome: Prospective Randomized Study. World J Surg 2010; 35:430-9. [DOI: 10.1007/s00268-010-0875-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cohn SM, Pearl RG, Acosta SM, Nowlin MU, Hernandez A, Guta C, Michalek JE. A Prospective Randomized Pilot Study of Near-Infrared Spectroscopy-Directed Restricted Fluid Therapy versus Standard Fluid Therapy in Patients Undergoing Elective Colorectal Surgery. Am Surg 2010. [DOI: 10.1177/000313481007601224] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [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
There are substantial data supporting the concept that algorithms that effectively limit fluid volumes to patients undergoing elective surgery, particularly intraoperatively, significantly reduce perioperative morbidity. We hypothesized that intraoperative fluid limitation could be safely accomplished when guided by near-infrared spectroscopy (NIRS) monitoring, and that this fluid restriction regimen would result in a reduction in postoperative morbidity when compared with standard monitoring and fluid therapy. The intent of this pilot study was to demonstrate the feasibility and ease of conduct of this study protocol before expanding to the multicenter pivotal trial. We performed a prospective, (2:1) randomized, pilot study at two centers. A total enrollment of 24 fully evaluable patients undergoing elective open colorectal surgery (16 restricted, 8 standard) was planned. After providing informed consent, patients were randomized to standard fluid resuscitation (500 LR induction bolus, then LR 7 mL/kg/h X 1 h, then 5 mL/kg/h) or restricted fluid resuscitation (no induction bolus, then LR 2 mL/kg/h). Subsequent fluid bolus infusions were guided by physiologic parameters (systolic blood pressure < 90 mm Hg, heart rate > 100 bpm, or oliguria) in the standard group, and by tissue oxygen saturation from NIRS (tissue oxygen saturation (StO2) < 75%, or 20% below baseline; or the same physiologic parameters) in the restricted group. Primary endpoints were major postoperative complications. A total of 27 patients were randomized (18 restricted, 9 standard). Age, gender, ethnicity, past medical history, and body mass index were similar. American Society of Anesthesiologists class was somewhat higher in the restricted group (American Society of Anesthesiologists class 3 in 77% of restricted vs 44% of standard patients; P = 0.194). Median total intraoperative fluids were less in the restricted group (1300 mL) when compared with the standard group (3014 mL) ( P = 0.021). Total fluids for the hospitalization were also statistically significantly decreased in the restricted group. Complications occurred in about two-thirds of patients, and complication rates were not statistically different between groups (1.6/restricted patient vs 2.1/standard patient; P = 0.333). Primary indications for boluses (n = 93) given to study patients were: hypotension (69%); oliguria (15%); and tachycardia (14%), with multiple indications per bolus. In only two instances did the StO2 drop to less than 75 per cent, or decrease by 20 per cent from baseline in the 3 minutes before bolus as an indication for fluid administration. Patients undergoing elective colorectal surgery with a fluid restricted strategy had only rare episodes of decreased StO2, suggesting that adequate tissue perfusion was maintained in this group. As a result, NIRS monitoring did not significantly influence intraoperative fluid management of patients undergoing colorectal surgery.
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Affiliation(s)
- Stephen M. Cohn
- Department of Surgery, University of Texas Health Science Center, San Antonio, Texas
| | | | - Shirley M. Acosta
- Department of Surgery, University of Texas Health Science Center, San Antonio, Texas
| | | | - Antonio Hernandez
- Department of Surgery, University of Texas Health Science Center, San Antonio, Texas
| | | | - Joel E. Michalek
- Department of Surgery, University of Texas Health Science Center, San Antonio, Texas
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Cohn SM, Pearl RG, Acosta SM, Nowlin MU, Hernandez A, Guta C, Michalek JE. A prospective randomized pilot study of near-infrared spectroscopy-directed restricted fluid therapy versus standard fluid therapy in patients undergoing elective colorectal surgery. Am Surg 2010; 76:1384-1392. [PMID: 21265353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
There are substantial data supporting the concept that algorithms that effectively limit fluid volumes to patients undergoing elective surgery, particularly intraoperatively, significantly reduce perioperative morbidity. We hypothesized that intraoperative fluid limitation could be safely accomplished when guided by near-infrared spectroscopy (NIRS) monitoring, and that this fluid restriction regimen would result in a reduction in postoperative morbidity when compared with standard monitoring and fluid therapy. The intent of this pilot study was to demonstrate the feasibility and ease of conduct of this study protocol before expanding to the multicenter pivotal trial. We performed a prospective, (2:1) randomized, pilot study at two centers. A total enrollment of 24 fully evaluable patients undergoing elective open colorectal surgery (16 restricted, 8 standard) was planned. After providing informed consent, patients were randomized to standard fluid resuscitation (500 LR induction bolus, then LR 7 mL/kg/h x 1 h, then 5 mL/kg/h) or restricted fluid resuscitation (no induction bolus, then LR 2 mL/kg/h). Subsequent fluid bolus infusions were guided by physiologic parameters (systolic blood pressure < 90 mm Hg, heart rate > 100 bpm, or oliguria) in the standard group, and by tissue oxygen saturation from NIRS (tissue oxygen saturation (StO2) < 75%, or 20% below baseline; or the same physiologic parameters) in the restricted group. Primary endpoints were major postoperative complications. A total of 27 patients were randomized (18 restricted, 9 standard). Age, gender, ethnicity, past medical history, and body mass index were similar. American Society of Anesthesiologists class was somewhat higher in the restricted group (American Society of Anesthesiologists class 3 in 77% of restricted vs 44% of standard patients; P = 0.194). Median total intraoperative fluids were less in the restricted group (1300 mL) when compared with the standard group (3014 mL) (P = 0.021). Total fluids for the hospitalization were also statistically significantly decreased in the restricted group. Complications occurred in about two-thirds of patients, and complication rates were not statistically different between groups (1.6/restricted patient vs 2.1/standard patient; P = 0.333). Primary indications for boluses (n = 93) given to study patients were: hypotension (69%); oliguria (15%); and tachycardia (14%), with multiple indications per bolus. In only two instances did the StO2 drop to less than 75 per cent, or decrease by 20 per cent from baseline in the 3 minutes before bolus as an indication for fluid administration. Patients undergoing elective colorectal surgery with a fluid restricted strategy had only rare episodes of decreased StO2, suggesting that adequate tissue perfusion was maintained in this group. As a result, NIRS monitoring did not significantly influence intraoperative fluid management of patients undergoing colorectal surgery.
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Affiliation(s)
- Stephen M Cohn
- Department of Surgery, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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Cohn SM, Blackbourne LH, Landry DW, Proctor KG, Walley KR, Wenzel V. San Antonio Vasopressin in Shock Symposium Report. Resuscitation 2010; 81:1473-5. [DOI: 10.1016/j.resuscitation.2010.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 06/03/2010] [Indexed: 10/19/2022]
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Abstract
Pulmonary contusion is a common finding after blunt chest trauma. The physiologic consequences of alveolar hemorrhage and pulmonary parenchymal destruction typically manifest themselves within hours of injury and usually resolve within approximately 7 days. Clinical symptoms, including respiratory distress with hypoxemia and hypercarbia, peak at about 72 h after injury. The timely diagnosis of pulmonary contusion requires a high degree of clinical suspicion when a patient presents with trauma caused by an appropriate mechanism of injury. The clinical diagnosis of acute parenchymal lung injury is usually confirmed by thoracic computed tomography, which is both highly sensitive in identifying pulmonary contusion and highly predictive of the need for subsequent mechanical ventilation. Management of pulmonary contusion is primarily supportive. Associated complications such as pneumonia, acute respiratory distress syndrome, and long-term pulmonary disability, however, are frequent sequelae of these injuries.
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Affiliation(s)
- Stephen M Cohn
- Department of Surgery, University of Texas Health Sciences Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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Lopez PP, Cohn SM. CT scanning in the management of acute appendicitis. J Am Coll Surg 2010; 211:567; author reply 567. [PMID: 20868979 DOI: 10.1016/j.jamcollsurg.2010.06.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 06/29/2010] [Indexed: 11/19/2022]
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Muir MT, Cohn SM, Louden C, Kannan TR, Baseman JB. Novel toxin assays implicate Mycoplasma pneumoniae in prolonged ventilator course and hypoxemia. Chest 2010; 139:305-310. [PMID: 20884727 DOI: 10.1378/chest.10-1222] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Community-acquired respiratory distress syndrome (CARDS) toxin is a unique Mycoplasma pneumoniae virulence factor. Molecular assays targeting this toxin are more sensitive than existing diagnostics, but these assays have not been used to investigate the role of M pneumoniae as a nosocomial infection in critical illness. We sought to determine the incidence of M pneumoniae among mechanically ventilated subjects using these novel assays and to investigate the impact of this pathogen on pulmonary outcomes. METHODS We conducted a prospective observational study enrolling subjects with suspected ventilator-associated pneumonia (VAP) undergoing BAL in the surgical trauma ICU at a level I trauma center. Lavage fluid and serum samples were tested for M pneumoniae using assays to detect CARDS toxin gene sequences, protein, or antitoxin antibodies. RESULTS We collected samples from 37 subjects, with 41% (15 of 37) testing positive using these assays. The positive and negative groups did not differ significantly in baseline demographic characteristics, including age, sex, injury severity, or number of ventilator days before bronchoscopy. The positive group had significantly fewer ventilator-free days (P = .04) and lower average oxygenation (P = .02). These differences were most pronounced among subjects with ARDS. CONCLUSIONS Evidence is provided that M pneumoniae is present in a substantial number of subjects with suspected VAP. Subjects testing positive experience a significantly longer ventilator course and worse oxygenation compared with subjects testing negative.
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Affiliation(s)
- Mark T Muir
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Stephen M Cohn
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX.
| | - Christopher Louden
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Thirumalai R Kannan
- Department of Microbiology and Immunology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Joel B Baseman
- Department of Microbiology and Immunology, University of Texas Health Science Center at San Antonio, San Antonio, TX
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Hardin M, Oh JS, White CE, Cohn SM. Effect of stitch length on complications. Arch Surg 2010; 145:600-601. [PMID: 20566986 DOI: 10.1001/archsurg.2010.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Abstract
Traumatic diaphragmatic injuries are uncommon events but are associated with a high mortality. We hypothesize that injury pattern has changed over time with increasing prevalence of blunt injuries. A retrospective chart review was performed of 124 patients who sustained traumatic diaphragmatic injuries over the 20-year period between January 1,1986 and December 31, 2005. Penetrating trauma accounted for 65 per cent (80/124) of all diaphragm injuries, and blunt trauma for 35 per cent (44/124). Mean Injury Severity Scores of 19 ± 9 and 34 ± 13 were observed for the penetrating and blunt trauma groups, respectively ( P = 0.001). Blunt traumatic diaphragm injuries increased from 13 per cent in the first 10-year period to 66 per cent in the second 10-year period ( P = 0.001). The overall mortality was 9 per cent (11/124) with 10 deaths resulting from blunt trauma and one resulting from penetrating trauma ( P < 0.001). The mortality rate increased from 3 to 17 per cent over the two decades ( P = 0.007). Our data suggests that over the last 20 years, the increase in mortality associated with traumatic diaphragmatic injury is primarily related to an increase in the proportion of patients with blunt trauma as a cause of their diaphragmatic injury and associated injuries.
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Affiliation(s)
- Peter P. Lopez
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - Jorge Arango
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - Theresa M. Gallup
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - Stephen M. Cohn
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - John Myers
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - Michael Corneille
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - Ronald Stewart
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
| | - Daniel L. Dent
- Department of Trauma, Emergency Surgery, and Surgical Critical Care, University of Texas Health Science Center, San Antonio, Texas
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