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Tenorio A, Brandel MG, McCann CP, Doucet JJ, Costantini TW, Khalessi AA, Ciacci JD. Traumatic Brain Injuries After Falls From Height vs Falls at the US-Mexico Border Wall. JAMA Surg 2024:2817240. [PMID: 38598245 PMCID: PMC11007647 DOI: 10.1001/jamasurg.2024.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/06/2024] [Indexed: 04/11/2024]
Abstract
This cohort study examines the incidence, severity, and mortality of fall-related injuries among migrants at the US-Mexico border in San Diego, California.
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Affiliation(s)
- Alexander Tenorio
- Department of Neurosurgery, University of California, San Diego, San Diego
| | - Michael G. Brandel
- Department of Neurosurgery, University of California, San Diego, San Diego
| | - Carson P. McCann
- School of Medicine, University of California, San Diego, San Diego
| | - Jay J. Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Todd W. Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | | | - Joseph D. Ciacci
- Department of Neurosurgery, University of California, San Diego, San Diego
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2
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Tenorio A, Hill LL, Doucet JJ. A border health crisis at the United States-Mexico border: an urgent call to action. Lancet Reg Health Am 2024; 31:100676. [PMID: 38304757 PMCID: PMC10827580 DOI: 10.1016/j.lana.2024.100676] [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] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
In this Viewpoint, we provide an overview of the worsening trend of traumatic injuries across the United States-Mexico border after its recent fortification and height extension to 30-feet. We further characterize the international factors driving migration and the current U.S. policies and political climate that will allow this public health crisis to progress. Finally, we provide recommendations involving prevention efforts, effective resource allocation, and advocacy that will start addressing the humanitarian and economic consequences of current U.S. border policies and infrastructure.
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Affiliation(s)
- Alexander Tenorio
- Department of Neurosurgery, University of California, San Diego, San Diego, CA, USA
| | - Linda L. Hill
- School of Public Health, University of California, San Diego, San Diego, CA, USA
| | - Jay J. Doucet
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
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3
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Ilfeld BM, Abramson WB, Alexander B, Sztain JF, Said ET, Broderick RC, Sandler BJ, Doucet JJ, Adams LM, Abdullah B, Cha BJ, Finneran JJ. Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following cholecystectomy and hernia repair: a randomized, double-masked, sham-controlled pilot study. Reg Anesth Pain Med 2024:rapm-2024-105283. [PMID: 38388014 DOI: 10.1136/rapm-2024-105283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Percutaneous auricular nerve stimulation (neuromodulation) involves implanting electrodes around the ear and administering an electric current. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial; and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following two ambulatory surgical procedures. METHODS Within the recovery room following cholecystectomy or hernia repair, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied. Participants were randomized to 5 days of either electrical stimulation or sham in a double-blinded fashion. RESULTS In the first 5 days, the median (IQR) pain level for active stimulation (n=15) was 0.6 (0.3-2.4) vs 2.6 (1.1-3.7) for the sham group (n=15) (p=0.041). Concurrently, the median oxycodone use for the active stimulation group was 0 mg (0-1), compared with 0 mg (0-3) for the sham group (p=0.524). Regarding the highest pain level experienced over the entire 8-day study period, only one participant (7%) who received active stimulation experienced severe pain, versus seven (47%) in those given sham (p=0.031). CONCLUSIONS Percutaneous auricular neuromodulation reduced pain scores but not opioid requirements during the initial week after cholecystectomy and hernia repair. Given the ease of application as well as a lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER NCT05521516.
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Affiliation(s)
- Brian M Ilfeld
- Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wendy B Abramson
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Brenton Alexander
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Jacklynn F Sztain
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Ryan C Broderick
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Bryan J Sandler
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Jay J Doucet
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Laura M Adams
- Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Baharin Abdullah
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Brannon J Cha
- Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - John J Finneran
- Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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4
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Tenorio A, Brandel MG, Produturi GR, McCann CP, Wali AR, Bravo J, Godat LN, Doucet JJ, Costantini TW, Santiago-Dieppa DR, Ciacci JD. Characterizing the frequency, morbidity, and types of traumatic brain injuries after the Mexico-San Diego border wall extension: a retrospective cohort review. J Neurosurg 2023; 139:848-853. [PMID: 36806495 DOI: 10.3171/2023.1.jns221859] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/12/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the impact of the US-Mexico border wall height extension on traumatic brain injuries (TBIs) and related costs. METHODS In this retrospective cohort study, patients who presented to the UC San Diego Health Trauma Center for injuries from falling at the border wall between 2016 and 2021 were considered. Patients in the pre-height extension period (January 2016-May 2018) were compared with those in the post-height extension period (January 2020-December 2021). Demographic characteristics, clinical data, and hospital charges were analyzed. RESULTS A total of 383 patients were identified: 51 (0 TBIs, 68.6% male) in the pre-height extension cohort and 332 (14 TBIs, 77.1% male) in the post-height extension cohort, with mean ages of 33.5 and 31.5 years, respectively. There was an increase in the average number of TBIs per month (0.0 to 0.34) and operative TBIs per month (0.0 to 0.12). TBIs were associated with increased Injury Severity Score (8.8 vs 24.2, p < 0.001), median (IQR) hospital length of stay (5.0 [2-11] vs 8.5 [4-45] days, p = 0.03), and median (IQR) hospital charges ($163,490 [$86,369-$277,918] vs $243,658 [$136,769-$1,127,920], p = 0.04). TBIs were normalized for changing migration rates on the basis of Customs and Border Protection apprehensions. CONCLUSIONS This heightened risk of intracranial injury among vulnerable immigrant populations poses ethical and economic concerns to be addressed regarding border wall infrastructure.
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Affiliation(s)
| | | | | | - Carson P McCann
- 2School of Medicine, University of California, San Diego; and
| | - Arvin R Wali
- 1Department of Neurosurgery, University of California, San Diego
| | - Javier Bravo
- 3Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, California
| | - Laura N Godat
- 3Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, California
| | - Jay J Doucet
- 3Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, California
| | - Todd W Costantini
- 3Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, California
| | | | - Joseph D Ciacci
- 1Department of Neurosurgery, University of California, San Diego
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5
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Williams EE, Haaland CB, Haines LN, Dwight KD, Gonzalez AGV, Doucet JJ, Schwartz AK, Kent WT, Costantini TW. Falling from new heights: Traumatic fracture burden and resource utilization after border wall height increase. Surgery 2023; 174:337-342. [PMID: 37183129 DOI: 10.1016/j.surg.2023.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND San Diego County hospitals commonly care for patients injured by falls from the United States-Mexico border. From 2018 to 2019, the height of >400 miles of an existing border wall was raised. Prior work has demonstrated a 5-fold increase in traumatic border wall fall injuries after barrier expansion. We aimed to examine the impact of a barrier height increase on fracture burden and resource use. METHODS We performed a retrospective review of patients admitted to a level 1 trauma center from 2016 to 2021 with lower extremity or pelvic fractures sustained from a border wall fall. We defined the pre-wall group as patients admitted from 2016 to 2018 and the post-wall group as those admitted from 2019 to 2021. We collected demographic and treatment data, hospital charges, weight-bearing status at discharge, and follow-up. RESULTS A total of 320 patients (pre-wall: 45; post-wall: 275) were admitted with 951 lower extremity fractures (pre-wall: 101; post-wall: 850) due to border wall fall. Hospital resources were utilized to a greater extent post-wall: a 537% increase in hospital days, a 776% increase in intensive care unit days, and a 468% increase in operative procedures. Overall, 86% of patients were non-weight-bearing on at least 1 lower extremity at discharge; 82% were lost to follow-up. CONCLUSION Traumatic lower extremity fractures sustained from border wall fall rapidly rose after the wall height increase. Hospital resources were used to a greater extent. Patients were frequently discharged with weight-bearing limitations and rarely received scheduled follow-up care. Policymakers should consider the costs of caring for border fall patients, and access to follow-up should be expanded.
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Affiliation(s)
| | | | - Laura N Haines
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA
| | - Kathryn D Dwight
- Department of Orthopaedic Surgery, University of California, San Diego, CA
| | | | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA
| | | | - William T Kent
- Department of Orthopaedic Surgery, University of California, San Diego, CA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA.
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6
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Marshall WA, Bansal V, Krzyzaniak A, Haines LN, Berndtson AE, Ignacio R, Keller BA, Doucet JJ, Costantini TW. Up and over: Consequences of raising the United States-Mexico border wall height. J Trauma Acute Care Surg 2023; 95:220-225. [PMID: 36972427 DOI: 10.1097/ta.0000000000003970] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES San Diego County's geographic location lends a unique demographic of migrant patients injured by falls at the United States-Mexico border. To prevent migrant crossings, a 2017 Executive Order allocated funds to increase the southern California border wall height from 10 ft to 30 ft, which was completed in December 2019. We hypothesized that the elevated border wall height is associated with increased major trauma, resource utilization, and health care costs. METHODS Retrospective trauma registry review of border wall falls was performed by the two Level I trauma centers that admit border fall patients from the southern California border from January 2016 to June 2022. Patients were assigned to either "pre-2020" or "post-2020" subgroups based upon timing of completion of the heightened border wall. Total number of admissions, operating room utilization, hospital charges, and hospital costs were compared. RESULTS Injuries from border wall falls grew 967% from 2016 to 2021 (39 vs. 377 admissions); this percentage is expected to be supplanted in 2022. When comparing the two subgroups, operating room utilization (175 vs. 734 total operations) and median hospital charges per patient ($95,229 vs. $168,795) have risen dramatically over the same time period. Hospital costs increased 636% in the post-2020 subgroup ($11,351,216 versus $72,172,123). The majority (97%) of these patients are uninsured at admission, with costs largely subsidized by federal government entities (57%) or through state Medicaid enrollment postadmission (31%). CONCLUSION The increased height of the United States-Mexico border wall has resulted in record numbers of injured migrant patients, placing novel financial and resource burdens on already stressed trauma systems. To address this public health crisis, legislators and health care providers must conduct collaborative, apolitical discussions regarding the border wall's efficacy as a means of deterrence and its impact on traumatic injury and disability. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- William A Marshall
- From the Department of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Medical Center (W.A.M., L.N.H., A.E.B., J.J.D., T.W.C.); Department of Surgery, Scripps Mercy Hospital (V.B., A.K.); and Department of Pediatric Surgery, Rady Children's Hospital (R.I., B.A.K.), San Diego, California
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7
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Tenorio A, Brandel MG, Produturi GR, McCann CP, Wali AR, Bravo Quintana J, Doucet JJ, Costantini TW, Ciacci JD. Novel association of blunt cerebrovascular injuries with the San Diego-Mexico border wall height extension. World Neurosurg 2023:S1878-8750(23)00908-7. [PMID: 37419313 DOI: 10.1016/j.wneu.2023.06.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND The San Diego-Mexico border wall height extension is associated with increased traumatic injuries and related costs after wall falls. We report previous trends and a neurological injury type not previously associated with border falls: blunt cerebrovascular injuries (BCVIs). METHODS In this retrospective cohort study, patients who presented to the UC San Diego Health Trauma Center for injuries from border wall falls from 2016-2021 were considered. Patients were included if they were admitted in the pre-height extension period (January 2016-May 2018) or post-height extension period (June 2018-December 2021). Demographics, clinical data, and hospital stay data were compared. RESULTS We identified 383 patients, 51 (68.6% male; mean age 33.5 years) in the pre-height extension cohort and 332 (77.1% male; mean age 31.5 years) in the post-height extension cohort. There were 0 and 5 BCVIs in the pre-height and post-height extension groups respectively. BCVIs were associated with increased injury severity scores (9.16 vs 31.33; p<0.001), median ICU length of stay (0 [IQR 0-3] vs 5 [IQR 2-21]; p=0.022), and total hospital charges ($163,490 [IQR $86,578, $282,036] vs $835,260 [IQR $171,049, $1,933,996]; p=0.048). Poisson modeling found BCVI admissions were 0.21 (95%CI 0.07-0.41; p=0.042) per month higher post-height extension. CONCLUSIONS We review the injuries correlated with the border wall extension and reveal an association with rare, potentially devastating BCVIs that were not seen before the border wall modifications. These BCVIs and associated morbidity shed light on the trauma increasingly found at the southern US border, which may be informative for future infrastructure policy decisions.
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Affiliation(s)
- Alexander Tenorio
- Department of Neurosurgery, University of California, San Diego, San Diego, CA.
| | - Michael G Brandel
- Department of Neurosurgery, University of California, San Diego, San Diego, CA
| | | | - Carson P McCann
- School of Medicine, University of California, San Diego, San Diego, CA
| | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego, San Diego, CA
| | - Javier Bravo Quintana
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Joseph D Ciacci
- Department of Neurosurgery, University of California, San Diego, San Diego, CA
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8
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Ventro GJ, Adams LM, Doucet JJ, Costantini TW, Weaver JL. Post-traumatic Liver Pseudoaneurysms: Rare but Serious Sequela. J Surg Res 2023; 285:85-89. [PMID: 36652772 DOI: 10.1016/j.jss.2022.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/18/2022] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The liver is the most commonly injured organ after blunt abdominal trauma. Nonoperative management is the standard of care in stable individuals. Liver injuries, particularly high-grade injuries, can develop pseudoaneurysms (PSAs), which can rupture and cause life-threatening bleeding, even after hospital discharge. There is no consensus on whether patients should receive predischarge contrast computed tomography (CT) screening, or at what time interval after injury, nor which patients are at the highest risk for PSA. The purpose of this study was to identify the rates of PSA in our population and potential risk factors for their formation. METHODS The trauma registry at our Level 1 urban trauma center was queried for patients admitted with liver injuries between 2015 and 2021. Demographic information was collected from the registry. Individual charts were then reviewed for timing of CT scans, CT findings, interventions, and complications. Liver injury grade was assessed using radiology reports or operative findings. The frequency of PSAs was then analyzed using descriptive statistics using Microsoft Excel and SPSS for odds ratio. RESULTS A total of 172 patients were admitted with liver injuries during the study period. 130 patients received a CT scan diagnosing liver injury, 42 were diagnosed with liver injury intraoperatively. Of the 130 patients (59.9%) which received follow-up CT scans, six (6.5%) developed PSA, four of which being from penetrating injuries (odds ratio, 6.95). CONCLUSIONS This study demonstrated a low incidence of PSA consistent with the known literature. We found the majority of the PSA developed following penetrating injury. This may represent a significant indication for follow-up imaging regardless of grade. A larger study will be necessary to identify those most at risk for PSA formation and determine the best PSA screening algorithm.
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Affiliation(s)
- George J Ventro
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California.
| | - Laura M Adams
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
| | - Jessica L Weaver
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
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Dunbar C, Santorelli JE, Marshall WA, Haines LN, Box K, Lee JG, Strait E, Costantini TW, Smith AM, Doucet JJ, Berndtson AE. Cross-Border Antibiotic Resistance Patterns in Burn Patients. Surg Infect (Larchmt) 2023; 24:327-334. [PMID: 37036781 DOI: 10.1089/sur.2022.313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Background: Antimicrobial resistance (AMR) is a growing problem worldwide, with differences in regional resistance patterns partially driven by local variance in antibiotic stewardship. Trauma patients transferring from Mexico have more AMR than those injured in the United States; we hypothesized a similar pattern would be present for burn patients. Patients and Methods: The registry of an American Burn Association (ABA)-verified burn center was queried for all admissions for burn injury January 2015 through December 2019 with hospital length-of-stay (LOS) longer than seven days. Patients were divided into two groups based upon burn location: United States (USA) or Mexico (MEX). All bacterial infections were analyzed. Results: A total of 73 MEX and 826 USA patients were included. Patients had a similar mean age (40.4 years MEX vs. 42.2 USA) and gender distribution (69.6% male vs. 64.4%). The MEX patients had larger median percent total body surface area burned (%TBSA; 11.1% vs. 4.3%; p ≤ 0.001) and longer hospital LOS (18.0 vs. 13.0 days; p = 0.028). The MEX patients more often had respiratory infections (16.4% vs. 7.4%; p = 0.046), whereas rates of other infections were similar. The MEX patients had higher rates of any resistant organism (47.2% of organisms MEX vs. 28.1% USA; p = 0.013), and were more likely to have resistant infections on univariable analysis; however, on multivariable analysis country of burn was no longer significant. Conclusions: Antimicrobial resistance is more common in burn patients initially burned in Mexico than those burned in the United States, but location was not a predictor of resistance compared to other traditional burn-related factors. Continuing to monitor for AMR regardless of country of burn remains critical.
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Affiliation(s)
- Chance Dunbar
- School of Medicine, UC San Diego, San Diego, California, USA
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - William A Marshall
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Laura N Haines
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Kevin Box
- Department of Pharmacology, UC San Diego, San Diego, California, USA
| | - Jeanne G Lee
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Eli Strait
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Alan M Smith
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
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10
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Liepert AE, Ventro G, Weaver JL, Berndtson AE, Godat LN, Adams LM, Santorelli J, Costantini TW, Doucet JJ. Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality. World J Emerg Surg 2022; 17:60. [PMID: 36503680 PMCID: PMC9743619 DOI: 10.1186/s13017-022-00462-8] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach. METHODS The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses. RESULTS There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001). CONCLUSION SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.
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Affiliation(s)
- Amy E. Liepert
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - George Ventro
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Jessica L. Weaver
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Allison E. Berndtson
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Laura N. Godat
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Laura M. Adams
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Jarrett Santorelli
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Todd W. Costantini
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
| | - Jay J. Doucet
- grid.266100.30000 0001 2107 4242Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, USA
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11
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Tenorio A, Brandel MG, Produturi GR, McCann CP, Doucet JJ, Costantini TW, Ciacci JD. The impact of the Mexico-San Diego border wall extension on spine injuries: a retrospective cohort review. J Travel Med 2022; 29:6722606. [PMID: 36165623 DOI: 10.1093/jtm/taac112] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND The recent San Diego-Mexico border wall height extension has resulted in an increased injury risk for unauthorized immigrants falling from greater heights. However, the effects of the border wall extension on frequency and morbidity of spinal injuries and related economic costs have yet to be highlighted. METHODS We retrospectively compared two cohorts who presented to the UC San Diego Health Trauma Center for border wall falls: pre-height extension (12 patients; January 2016-May 2018), and post-height extension (102 patients; January 2020-December 2021). Patients presented during border wall construction (June 2018-December 2019) were excluded. Demographics, clinical data and hospital costs were collected. Spinal injuries were normalized using Customs and Border Protection apprehensions. Costs were adjusted for inflation using the 2021 medical care price index. RESULTS The increase in spine injuries per month (0.8-4.25) and operative spine injuries per month (0.3- 1.7) was statistically significant (P < 0.001). Increase in median length of stay from 6 [interquartile range (IQR) 2-7] to 9 days (IQR 6-13) was statistically significant (P = 0.006). Median total hospital charges increased from $174 660 to $294 421 and was also significant (P < 0.001). CONCLUSION The data support that the recent San Diego-Mexico border wall extension is correlated with more frequent, severe and costly spinal injuries. This current infrastructure should be re-evaluated as border-related injuries represent a humanitarian and public health crisis.
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Affiliation(s)
- Alexander Tenorio
- Department of Neurosurgery, University of California, San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California, San Diego, San Diego, CA, USA
| | - Gautam R Produturi
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Carson P McCann
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Joseph D Ciacci
- Department of Neurosurgery, University of California, San Diego, San Diego, CA, USA
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12
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Kirchberg TN, Costantini TW, Santorelli J, Doucet JJ, Godat LN. Predictors of Readmission Following Treatment for Traumatic Hemothorax. J Surg Res 2022; 277:365-371. [DOI: 10.1016/j.jss.2022.04.031] [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] [Received: 01/16/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
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13
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Berndtson AE, Costantini TW, Smith AM, Edwards SB, Kobayashi L, Doucet JJ, Godat LN. Management of choledocholithiasis in the elderly: Same-admission cholecystectomy remains the standard of care. Surgery 2022; 172:1057-1064. [PMID: 35989133 DOI: 10.1016/j.surg.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy. METHODS The Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions. RESULTS A total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death. CONCLUSION Index admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.
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Affiliation(s)
- Allison E Berndtson
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA.
| | - Todd W Costantini
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA. https://twitter.com/TWCostantini
| | - Alan M Smith
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA
| | - Sara B Edwards
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA
| | - Leslie Kobayashi
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA
| | - Jay J Doucet
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA. https://twitter.com/jaydoucet
| | - Laura N Godat
- Department of Surgery; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, CA. https://twitter.com/godat_l
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14
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Mou Z, Sitapati AM, Ramachandran M, Doucet JJ, Liepert AE. Development and implementation of an automated electronic health record-linked registry for emergency general surgery. J Trauma Acute Care Surg 2022; 93:273-279. [PMID: 35195091 PMCID: PMC9329176 DOI: 10.1097/ta.0000000000003582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite adoption of the emergency general surgery (EGS) service by hospitals nationally, quality improvement (QI) and research for this patient population are challenging because of the lack of population-specific registries. Past efforts have been limited by difficulties in identifying EGS patients within institutions and labor-intensive approaches to data capture. Thus, we created an automated electronic health record (EHR)-linked registry for EGS. METHODS We built a registry within the Epic EHR at University of California San Diego for the EGS service. Existing EHR labels that identified patients seen by the EGS team were used to create our automated inclusion rules. Registry validation was performed using a retrospective cohort of EGS patients in a 30-month period and a 1-month prospective cohort. We created quality metrics that are updated and reported back to clinical teams in real time and obtained aggregate data to identify QI and research opportunities. A key metric tracked is clinic schedule rate, as we care that discontinuity postdischarge for the EGS population remains a challenge. RESULTS Our registry captured 1,992 patient encounters with 1,717 unique patients in the 30-month period. It had a false-positive EGS detection rate of 1.8%. In our 1-month prospective cohort, it had a false-positive EGS detection rate of 0% and sensitivity of 85%. For quality metrics analysis, we found that EGS patients who were seen as consults had significantly lower clinic schedule rates on discharge compared with those who were admitted to the EGS service (85% vs. 60.7%, p < 0.001). CONCLUSION An EHR-linked EGS registry can reliably conduct capture data automatically and support QI and research. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Zongyang Mou
- Department of Surgery, UC San Diego, San Diego, California
| | | | | | - Jay J. Doucet
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, San Diego, California
| | - Amy E. Liepert
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, San Diego, California
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Liepert AE, Berndtson AE, Hill LL, Weaver JL, Godat LN, Costantini TW, Doucet JJ. Association of 30-ft US-Mexico Border Wall in San Diego With Increased Migrant Deaths, Trauma Center Admissions, and Injury Severity. JAMA Surg 2022; 157:633-635. [PMID: 35486395 PMCID: PMC9055512 DOI: 10.1001/jamasurg.2022.1885] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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)
- Amy E Liepert
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Linda L Hill
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego.,Department of Family Medicine and Public Health, University of California, San Diego, San Diego
| | - Jessica L Weaver
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego
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16
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Abstract
BACKGROUND Ultrasonography for trauma is a widely used tool in the initial evaluation of trauma patients with complete ultrasonography of trauma (CUST) demonstrating equivalence to computed tomography (CT) for detecting clinically significant abdominal hemorrhage. Initial reports demonstrated high sensitivity of CUST for the bedside diagnosis of pneumothorax. We hypothesized that the sensitivity of CUST would be greater than initial supine chest radiograph (CXR) for detecting pneumothorax. METHODS A retrospective analysis of patients diagnosed with pneumothorax from 2018 through 2020 at a Level I trauma center was performed. Patients included had routine supine CXR and CUST performed prior to intervention as well as confirmatory CT imaging. All CUST were performed during the initial evaluation in the trauma bay by a registered sonographer. All imaging was evaluated by an attending radiologist. Subgroup analysis was performed after excluding occult pneumothorax. Immediate tube thoracostomy was defined as tube placement with confirmatory CXR within 8 hours of admission. RESULTS There were 568 patients screened with a diagnosis of pneumothorax, identifying 362 patients with a confirmed pneumothorax in addition to CXR, CUST, and confirmatory CT imaging. The population was 83% male, had a mean age of 45 years, with 85% presenting due to blunt trauma. Sensitivity of CXR for detecting pneumothorax was 43%, while the sensitivity of CUST was 35%. After removal of occult pneumothorax (n = 171), CXR was 78% sensitive, while CUST was 65% sensitive (p < 0.01). In this subgroup, CUST had a false-negative rate of 36% (n = 62). Of those patients with a false-negative CUST, 50% (n = 31) underwent tube thoracostomy, with 85% requiring immediate placement. CONCLUSION Complete ultrasonography of trauma performed on initial trauma evaluation had lower sensitivity than CXR for identification of pneumothorax including clinically significant pneumothorax requiring tube thoracostomy. Using CUST as the primary imaging modality in the initial evaluation of chest trauma should be considered with caution. LEVEL OF EVIDENCE Diagnostic Test study, Level IV.
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Affiliation(s)
- Jarrett E Santorelli
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, California
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17
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Mou Z, Godat LN, El-Kareh R, Berndtson AE, Doucet JJ, Costantini TW. Electronic health record machine learning model predicts trauma inpatient mortality in real time: A validation study. J Trauma Acute Care Surg 2022; 92:74-80. [PMID: 34932043 PMCID: PMC9032917 DOI: 10.1097/ta.0000000000003431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Patient outcome prediction models are underused in clinical practice because of lack of integration with real-time patient data. The electronic health record (EHR) has the ability to use machine learning (ML) to develop predictive models. While an EHR ML model has been developed to predict clinical deterioration, it has yet to be validated for use in trauma. We hypothesized that the Epic Deterioration Index (EDI) would predict mortality and unplanned intensive care unit (ICU) admission in trauma patients. METHODS A retrospective analysis of a trauma registry was used to identify patients admitted to a level 1 trauma center for >24 hours from October 2019 to July 2020. We evaluated the performance of the EDI, which is constructed from 125 objective patient measures within the EHR, in predicting mortality and unplanned ICU admissions. We performed a 5 to 1 match on age because it is a major component of EDI, then examined the area under the receiver operating characteristic curve (AUROC), and benchmarked it against Injury Severity Score (ISS) and new injury severity score (NISS). RESULTS The study cohort consisted of 1,325 patients admitted with a mean age of 52.5 years and 91% following blunt injury. The in-hospital mortality rate was 2%, and unplanned ICU admission rate was 2.6%. In predicting mortality, the maximum EDI within 24 hours of admission had an AUROC of 0.98 compared with 0.89 of ISS and 0.91 of NISS. For unplanned ICU admission, the EDI slope within 24 hours of ICU admission had a modest performance with an AUROC of 0.66. CONCLUSION Epic Deterioration Index appears to perform strongly in predicting in-patient mortality similarly to ISS and NISS. In addition, it can be used to predict unplanned ICU admissions. This study helps validate the use of this real-time EHR ML-based tool, suggesting that EDI should be incorporated into the daily care of trauma patients. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Zongyang Mou
- Department of Surgery, UC San Diego, San Diego, California
| | - Laura N. Godat
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, San Diego, California
| | - Robert El-Kareh
- Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Allison E. Berndtson
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, San Diego, California
| | - Jay J. Doucet
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, San Diego, California
| | - Todd W. Costantini
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego, San Diego, California
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18
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Santorelli JE, Costantini TW, Berndtson AE, Kobayashi L, Doucet JJ, Godat LN. Readmission after splenic salvage: How real is the risk? Surgery 2021; 171:1417-1421. [PMID: 34857387 DOI: 10.1016/j.surg.2021.10.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/23/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage due to delayed splenic rupture is a potentially fatal complication of nonoperative management of splenic injuries. Suboptimal postdischarge follow-up has made measuring the incidence of failed splenic salvage challenging. We hypothesized that readmission after splenic salvage is rare; however, readmissions for splenic conditions would be associated with a high rate of splenectomy. METHODS The National Readmission Database for 2016 and 2017 was queried for trauma admissions with the International Classification of Diseases 10th revision codes for splenic injury. Patients with missing discharge disposition, discharge to a short-term hospital, death during index admission, or admitted in December were excluded. The primary endpoint was nonelective 30-day readmission for splenic diagnoses after nonoperative management during the index admission. Outcomes collected included transfusions, complications, interventions at readmission, and mortality. RESULTS There were 22,736 patients admitted for a traumatic splenic injury; 15,596 (68.6%) underwent no intervention, 2,261 (9.9%) were treated with embolization only, and 4,509 (19.8%) underwent splenectomy. The overall 30-day readmission rate was 8.4%, whereas the spleen-related readmission rate was 2.0%. For those treated with embolization or no intervention, the spleen-related 30-day readmission rate was 2.4%, with the majority (69.4%) occurring within 7 days of discharge. The most common complications were pleural effusion (23.0%), sepsis (4.4%), splenic abscess (3.9%), and splenic infarct (3.0%). Those patients readmitted for spleen-related diagnoses after undergoing splenic salvage during the index admission had a 22.3% rate of splenectomy and mortality of 1.6%. CONCLUSION Readmission after splenic salvage is rare, with the majority presenting within 1 week of discharge. However, of those readmitted for spleen injury-related diagnoses there was a high rate of splenectomy. Patients managed with splenic salvage should be counseled on the risk of potential failure and need for readmission and operation after discharge.
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Affiliation(s)
- Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/JE_Santorelli
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/TWCostantini
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/ABerndtson
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/jaydoucet
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA.
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Doucet JJ, Godat LN, Kobayashi L, Berndtson AE, Liepert AE, Raschke E, Denny JW, Weaver J, Smith A, Costantini T. Enhancing trauma registries by integrating traffic records and geospatial analysis to improve bicyclist safety. J Trauma Acute Care Surg 2021; 90:631-640. [PMID: 33443983 DOI: 10.1097/ta.0000000000003075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma registries are used to identify modifiable injury risk factors for trauma prevention efforts. However, these may miss factors useful for prevention of bicycle-automobile collisions, such as vehicle speeds, driver intoxication, street conditions, and neighborhood characteristics. We hypothesize that (GIS) analysis of trauma registry data matched with a traffic accident database could identify risk factors for bicycle-automobile injuries and better inform injury prevention efforts. METHODS The trauma registry of a US Level I trauma center was used retrospectively to identify bicycle-motor vehicle collision admissions from January 1, 2010, to December 31, 2018. Data collected included demographics, vitals, injury severity scores, toxicology, helmet use, and mortality.Matching with the Statewide Integrated Traffic Records System was done to provide collision, victim and GIS information. The GIS mapping of collisions was done with census tract data including poverty level scoring. Incident hot spot analysis to identify statistically significant incident clusters was done using the Getis Ord Gi* statistic. RESULTS Of 25,535 registry admissions, 531 (2.1%) were bicyclists struck by automobiles, 425 (80.0%) were matched to Statewide Integrated Traffic Records System. Younger age (odds ratio [OR], 1.026; 95% confidence interval [CI], 1.013-1.040, p < 0.001), higher census tract poverty level percentage (OR, 0.976; 95% CI, 0.959-0.993, p = 0.007), and high school or less education (OR, 0.60; 95 CI, 0.381-0.968; p = 0.036) were predictive of not wearing a helmet. Higher census tract poverty level percentage (OR, 1.019; 95% CI, 1.004-1.034; p = 0.012) but not educational level was predictive of toxicology positive-bicyclists in automobile collisions. Geographic information systems analysis identified hot spots in the catchment area for toxicology-positive bicyclists and lack of helmet use. CONCLUSION Combining trauma registry data and matched traffic accident records data with GIS analysis identifies additional risk factors for bicyclist injury. Trauma centers should champion efforts to prospectively link public traffic accident data to their trauma registries. LEVEL OF EVIDENCE Prognostic and Epidemiological, level III.
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Affiliation(s)
- Jay J Doucet
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (J.J.D., L.N.G., L.K., A.E.B., A.E.L., M.A.J.E.R., J.W., A.S., T.C.), University of California San Diego Health, San Diego, California; and Lloyd L. Gregory School of Pharmacy (J.W.D.), Palm Beach Atlantic University, West Palm Beach, Florida
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20
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Borst J, Godat LN, Berndtson AE, Kobayashi L, Doucet JJ, Costantini TW. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery 2021; 170:623-627. [PMID: 33781587 DOI: 10.1016/j.surg.2021.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/17/2021] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients on antithrombotic medications presenting with blunt trauma are at risk for delayed intracranial hemorrhage. We hypothesized that clinically significant delayed intracranial hemorrhage is rare in patients presenting on antithrombotic medications and therefore routine, repeat head computed tomography imaging is not a cost-effective practice to monitor for delayed intracranial hemorrhage. METHODS Patients presenting to our institution on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period from January 2014 through March 2019 who underwent a head computed tomography for blunt trauma were identified in our trauma registry. Patients with an initial negative head computed tomography underwent repeat imaging 6 h after their initial head computed tomography. Patient demographics, antithrombotic medication, international normalized ratio, Glasgow Coma Score, clinical change in neurologic status, and need for neurosurgical intervention were collected. RESULTS Our institution evaluated 1,676 patients on antithrombotic therapy with blunt trauma. The initial head computed tomography was negative in 1,377 patients (82.0%). Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography. Delayed intracranial hemorrhage included 6 patients with intraventricular hemorrhage, 3 with subdural hematoma, 2 with subarachnoid hemorrhage, and 1 with an intraparenchymal hemorrhage. None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention. The estimated total direct cost of the negative head computed tomography scans was $926,247. CONCLUSION Clinically significant delayed intracranial hemorrhage is rare in trauma patients on antithrombotic therapy, with an initial negative head computed tomography. Routine repeat head computed tomography imaging in patients with a negative scan on admission is not cost-effective.
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Affiliation(s)
- Johanna Borst
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/BorstJohanna
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/godat_l
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/ABerndtson
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA. https://twitter.com/jaydoucet
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, CA.
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21
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Godat LN, Costantini TW, Doucet JJ. Emergency General Surgery and the Gallbladder: The Affordable Care Act's Impact on Practice Patterns. J Surg Res 2020; 257:356-362. [PMID: 32892131 DOI: 10.1016/j.jss.2020.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/17/2020] [Accepted: 08/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gallbladder disease frequently requires emergency general surgery (EGS). The Affordable Care Act (ACA) mandated health insurance coverage for all with the intent to improve access to care and decrease morbidity, mortality, and costs. We hypothesize that after the ACA open-enrollment in 2014 the number of EGS cholecystectomies decreased as access to care improved with a shift in EGS cholecystectomies to teaching institutions. METHODS A retrospective review of the National Inpatient Sample Database from 2012 to quarter 3 of 2015 was performed. Patients age 18-64, with a nonelective admission for gallbladder disease based on ICD-9 codes, were collected. Outcomes measured included cholecystectomy, complications, mortality, and wage index-adjusted costs. The effect of the ACA was determined by comparing preACA to postACA years. RESULTS 189,023 patients were identified. In the postACA period the payer distribution for admissions decreased for Self-pay (19.3% to 13.6%, P < 0.001), Medicaid increased (26.3% to 34.0%, P < 0.001) and Private insurance was unchanged (48.6% to 48.7%, P = 0.946). PostACA, admissions to teaching hospitals increased across all payer types, EGS cholecystectomies decreased, while complications increased, and mortality was unchanged. Median costs increased significantly for Medicaid and Private insurance while Self-pay was unchanged. Based on adjusted DID analyses for Insured compared to Self-pay patients, EGS cholecystectomies decreased (-2.7% versus -1.21%, P = 0.033) and median cost increased more rapidly (+$625 versus +$166, P = 0.017). CONCLUSIONS The ACA has changed EGS, shifting the majority of patients to teaching institutions despite insurance type and decreasing the need for EGS cholecystectomy. The trend toward higher complication rate with increased overall cost requires attention.
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Affiliation(s)
- Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego School of Medicine.
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego School of Medicine
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego School of Medicine
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Albini PT, Cochran-Yu MR, Godat LN, Costantini TW, Doucet JJ. Who's being left behind? Uninsured emergency general surgery admissions after the ACA. Am J Surg 2019; 218:1102-1109. [PMID: 31607385 DOI: 10.1016/j.amjsurg.2019.10.005] [Citation(s) in RCA: 2] [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: 03/16/2019] [Revised: 09/27/2019] [Accepted: 10/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) increased Medicaid coverage of Emergency General Surgery (EGS). We hypothesized that despite the ACA, racial and geographic disparities persisted for EGS admissions. METHODS The Nationwide Inpatient Sample was queried from 2012 through Q3 of 2015 for Non-Medicare patient EGS admissions. Difference-in-Differences analyses (DID) compared payors, complications, mortality and costs in pre-ACA years (2012-2013) and post-ACA years (2014-2015Q3). RESULTS EGS cases fell 9.1% from 1,711,940 to 1,555,033 NIS-weighted cases. Hispanics were still most likely to be uninsured but had improved coverage (OR 0.92, 95% CI: 0.88-0.96, p < 0.001). Risk of uninsured EGS admissions from the South region persisted (OR 1.52, 95% CI: 1.46-1.58, p < 0.001). Uninsured EGS patients had higher DID increased mortality than insured patients (0.31% higher, P = 0.003). Insured group DID costs increased more rapidly than in self-pay Patients (6.0% higher, P = 0.008) CONCLUSIONS: Post ACA, risk of uninsured EGS admissions remained highest in the South, in males, and Hispanics.
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Affiliation(s)
- Paul T Albini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, 92103, USA.
| | - Megan R Cochran-Yu
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, 92103, USA.
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, 92103, USA.
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, 92103, USA.
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, San Diego, CA, 92103, USA.
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Brito A, Costantini TW, Berndtson AE, Smith A, Doucet JJ, Godat LN. Readmissions After Acute Hospitalization for Traumatic Brain Injury. J Surg Res 2019; 244:332-337. [PMID: 31306890 DOI: 10.1016/j.jss.2019.06.071] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/02/2019] [Accepted: 06/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is associated with functional deficits, impaired cognition, and medical complications that continue well after the initial injury. Many patients seek medical care at other health care facilities after discharge, rather than returning to the admitting trauma center, making assessment of readmission rates and readmission diagnoses difficult to determine. The objective of this study was to determine the incidence and factors associated with readmission to any acute care hospital after an index admission for TBI. MATERIALS AND METHODS The Nationwide Readmission Database was queried for all patients admitted with a TBI during the first 3 mo of 2015. Nonelective readmissions for this population were then collected for the remainder of 2015. Patients who died during the index admission were excluded. Demographic data, injury mechanism, type of TBI, the number of readmissions, days from discharge to readmission, readmission diagnosis, and mortality were studied. RESULTS Of the 15,277 patients with an index admission for TBI, 5296 patients (35%) required at least 1 readmission. Forty percent of readmissions occurred within the first 30 d after discharge from the index trauma admission. The most common primary diagnosis on readmission was SDH, followed by septicemia, urinary tract infection, and aspiration. Readmission rates increased with age, with 75% of readmissions occurring in patients aged >65 y. Initial discharge to a skilled nursing facility (Relative Risk [RR], 1.60) or leaving the hospital against medical advice (RR, 1.59) increased the risk of readmission. Patients with fall as their mechanism of injury and a subdural hematoma were more likely to require readmission compared with other types of mechanisms with TBI (RR, 1.59 and RR, 1.21, respectively; P < 0.001). Notably, the first readmission was to a different hospital for 39.5% of patients and 46.9% of patients had admissions to at least one facility outside that of their original presentation. CONCLUSIONS Hospital readmission is common for patients discharged after TBI. Elderly patients who fall with resultant subdural hematoma are at especially high risk for complications and readmission. Understanding potentially preventable causes for readmission can be used to guide discharge planning pathways to decrease morbidity in this patient population.
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Affiliation(s)
- Alex Brito
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego Health, San Diego, California
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego Health, San Diego, California
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego Health, San Diego, California
| | - Alan Smith
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego Health, San Diego, California
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego Health, San Diego, California
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego Health, San Diego, California.
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Jenkins I, Doucet JJ, Clay B, Kopko P, Fipps D, Hemmen E, Paulson D. Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices. Jt Comm J Qual Patient Saf 2017; 43:389-395. [DOI: 10.1016/j.jcjq.2017.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Eng AJ, Namba JM, Box KW, Lane JR, Kim DY, Davis DP, Doucet JJ, Coimbra R. High-fidelity simulation training in advanced resuscitation for pharmacy residents. Am J Pharm Educ 2014; 78:59. [PMID: 24761020 PMCID: PMC3996391 DOI: 10.5688/ajpe78359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 10/28/2013] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To assess the impact of high-fidelity patient simulation on pharmacy resident knowledge, confidence, and competency with advanced resuscitation algorithms and interventions. DESIGN An overview of the institutional cardiopulmonary arrest algorithm and a review of pertinent medications and calculations were presented to postgraduate year 1 (PGY1) pharmacy residents, followed by participation in 3 simulated clinical scenarios using a high-fidelity mannequin. ASSESSMENT An improvement of pharmacy resident knowledge, confidence, and competency with advanced resuscitation skills was observed. In addition, pharmacy residents demonstrated high performance levels with skills requiring advanced competency and proactive interactions with the cardiac arrest team. CONCLUSION Incorporating high-fidelity patient simulation into an advanced resuscitation training program can help pharmacy residents achieve competency through the active learning of practical skills.
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Affiliation(s)
- Amy J Eng
- University of California San Diego Medical Center, San Diego, California
| | - Jennifer M Namba
- University of California San Diego Medical Center, San Diego, California
| | - Kevin W Box
- University of California San Diego Medical Center, San Diego, California
| | - James R Lane
- University of California San Diego Medical Center, San Diego, California
| | - Dennis Y Kim
- University of California San Diego Medical Center, San Diego, California
| | - Daniel P Davis
- University of California San Diego Medical Center, San Diego, California
| | - Jay J Doucet
- University of California San Diego Medical Center, San Diego, California
| | - Raul Coimbra
- University of California San Diego Medical Center, San Diego, California
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26
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Doucet JJ, Galarneau MR, Potenza BM, Bansal V, Lee JG, Schwartz AK, Dougherty AL, Dye J, Hollingsworth-Fridlund P, Fortlage D, Coimbra R. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma 2011; 70:1241-1247. [PMID: 21610438 DOI: 10.1097/ta.0b013e3182095b52] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates. METHODS Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality. RESULTS The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted. CONCLUSION Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.
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Affiliation(s)
- Jay J Doucet
- University of California San Diego, San Diego, California 92103-8896, USA.
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27
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Doucet JJ, Hill L, Stout P, Bansal V, Lee J, Fortlage D, Potenza B, Workman P, Coimbra R. The unrecognized danger of a new transportation mechanism of injury--pedicabs. J Safety Res 2011; 42:131-135. [PMID: 21569895 DOI: 10.1016/j.jsr.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 12/30/2010] [Accepted: 03/01/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Pedicabs are a new and controversial transportation innovation for tourists in congested areas in several U.S. cities. Scant literature on this trauma mechanism exists. The purpose of this study is to identify the incidence, demographics, morbidity, mortality, and potential for injury prevention of pedicab incidents amongst major trauma admissions at an urban, academic Level I Trauma Center. PATIENTS & METHODS Researchers conducted a retrospective review of the Trauma Registry from 2000 to 2009. All patients identified as being injured in a pedicab incident were reviewed. Demographics, diagnoses, toxicology, treatments, and injury severity scale (ISS) were collected. Outcomes included mortality, ICU, and hospital length of stay (LOS), discharge disposition, and hospital charges. A photographic survey of 50 local pedicabs was examined for the presence and use of safety equipment. RESULTS During the period of January 2000 to July 2009 there were 15 major trauma victims from identified pedicab incidents. Falling from the pedicab was the mechanism of injury in 14 of 15 cases. There were two fatalities in victims following severe traumatic brain injury. Traumatic brain injury, skull fracture, or loss of consciousness was seen in 11/15 victims. Ethanol ingestion was detected in blood tests of 10 of the 14 adult victims. Median charges of hospitalization due to a pedicab related injury was US$29,956 ± 77,482. A photographic survey of 50 local pedicabs reveals very limited use of safety belts by passengers despite existing city ordinances. CONCLUSIONS Major trauma victims of pedicab incidents in the United States suffer significant injuries and death. Most cases occurred in passengers falling from the pedicab at night after alcohol ingestion. There is an opportunity for implementation of strategies toward improved injury prevention with this new form of transport.
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Affiliation(s)
- Jay J Doucet
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California Medical Center, 200 W Arbor Drive, San Diego, CA 92103-8896, USA.
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Tien HC, Battad A, Bryce EA, Fuller J, Mulvey M, Bernard K, Brisebois R, Doucet JJ, Rizoli SB, Fowler R, Simor A. Multi-drug resistant Acinetobacter infections in critically injured Canadian forces soldiers. BMC Infect Dis 2007; 7:95. [PMID: 17697345 PMCID: PMC1988813 DOI: 10.1186/1471-2334-7-95] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 08/14/2007] [Indexed: 11/16/2022] Open
Abstract
Background Military members, injured in Afghanistan or Iraq, have returned home with multi-drug resistant Acinetobacter baumannii infections. The source of these infections is unknown. Methods Retrospective study of all Canadian soldiers who were injured in Afghanistan and who required mechanical ventilation from January 1 2006 to September 1 2006. Patients who developed A. baumannii ventilator associated pneumonia (VAP) were identified. All A. baumannii isolates were retrieved for study patients and compared with A. baumannii isolates from environmental sources from the Kandahar military hospital using pulsed-field gel electrophoresis (PFGE). Results During the study period, six Canadian Forces (CF) soldiers were injured in Afghanistan, required mechanical ventilation and were repatriated to Canadian hospitals. Four of these patients developed A. baumannii VAP. A. baumannii was also isolated from one environmental source in Kandahar – a ventilator air intake filter. Patient isolates were genetically indistinguishable from each other and from the isolates cultured from the ventilator filter. These isolates were resistant to numerous classes of antimicrobials including the carbapenems. Conclusion These results suggest that the source of A. baumannii infection for these four patients was an environmental source in the military field hospital in Kandahar. A causal linkage, however, was not established with the ventilator. This study suggests that infection control efforts and further research should be focused on the military field hospital environment to prevent further multi-drug resistant A. baumannii infections in injured soldiers.
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Affiliation(s)
- Homer C Tien
- The Trauma Program, and the Department of Surgery, Sunnybrook Health Sciences Centre, H186-2075 Bayview Avenue, Toronto, Canada, M4N 3M5
- 1st Canadian Field Hospital, CFB Petawawa, Petawawa, Ontario, Canada
| | - Anthony Battad
- 1st Canadian Field Hospital, CFB Petawawa, Petawawa, Ontario, Canada
| | - Elizabeth A Bryce
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Jeffrey Fuller
- Department of Laboratory Medicine and Pathology, University of Alberta Hospital, Edmonton, Canada
| | - Michael Mulvey
- Nosocomial Infections and Antimicrobial Resistance Laboratory, National Microbiology Laboratory, Winnipeg, Canada
| | - Kathy Bernard
- Nosocomial Infections and Antimicrobial Resistance Laboratory, National Microbiology Laboratory, Winnipeg, Canada
| | - Ronald Brisebois
- 1st Canadian Field Hospital, CFB Petawawa, Petawawa, Ontario, Canada
- Departments of Surgery and Critical Care Medicine, University of Alberta Hospital, Edmonton, Canada
| | - Jay J Doucet
- 1st Canadian Field Hospital, CFB Petawawa, Petawawa, Ontario, Canada
- Department of Surgery, Vancouver General Hospital, Vancouver, Canada
| | - Sandro B Rizoli
- The Trauma Program, and the Department of Surgery, Sunnybrook Health Sciences Centre, H186-2075 Bayview Avenue, Toronto, Canada, M4N 3M5
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrew Simor
- Department of Microbiology, Sunnybrook Health Sciences Centre, Toronto, Canada
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Abstract
BACKGROUND This review covers the pathogenesis and treatment of the disease along with the reexamination of the current recommendations for prophylaxis against tetanus in the United States. Although tetanus is still a major problem worldwide, the incidence in North America has become almost negligible because of the highly effective primary immunization program. Recently, there have been no deaths reported attributable to tetanus in the United States in trauma patients who had received the primary childhood immunization. However, tetanus immunization and prophylaxis in the acute injury setting is frequently misused and misunderstood. METHODS A review of the literature regarding tetanus. RESULTS After review, the authors recommend tetanus toxoid in adults only if it has been more than 10 years since their last immunization. There is no urgency for the administration of tetanus toxoid in the acute setting, as it provides protection against the next injury and not the current injury. Tetanus-diphtheria toxoid is not required unless there are plans for the injured patient to travel to diphtheria-prone countries in the future, as the incidence of diphtheria is negligible in the United States. CONCLUSION The review of reported cases of tetanus demonstrates that it is not possible to clinically determine which wounds are tetanus prone, as tetanus can occur after minor, seemingly innocuous injuries, yet is rare after severely contaminated wounds. Tetanus immunoglobulin should be reserved for patients with wounds who had never received primary immunization against tetanus.
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Affiliation(s)
- Peter Rhee
- Navy Trauma Training Center at Los Angeles County Medical Center, California 90033, USA.
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Doucet JJ, Hoyt DB, Coimbra R, Schmid-Schönbein GW, Junger WG, Paul L W, Loomis WH, Hugli TE. Inhibition of enteral enzymes by enteroclysis with nafamostat mesilate reduces neutrophil activation and transfusion requirements after hemorrhagic shock. ACTA ACUST UNITED AC 2004; 56:501-10; discussion 510-1. [PMID: 15128119 DOI: 10.1097/01.ta.0000114536.98447.f7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The gut origin of the inflammatory response in trauma patients has been difficult to define. "In vivo" generation of neutrophil-activating factors by gut proteases may be a cause of multiorgan failure after hemorrhagic shock, and can be prevented with the serine protease inhibitor nafamostat mesilate (Futhan). The objective of this study was to determine the effect of nafamostat mesilate given by enteroclysis on enteric serine protease activity, neutrophil activation, and transfusion requirements during hemorrhagic shock. METHODS Sixteen pigs weighing 21 to 26 kg were divided into control and treatment groups. A laparotomy was performed under anesthesia, and catheters were placed in the duodenum, midjejunum, and terminal ileum. Pigs were bled 30 mL/kg over 30 minutes and maintained at a mean arterial pressure of 30 mm Hg for 60 minutes. Shed blood was then used to maintain a mean arterial pressure of 45 mm Hg for another 3 hours. Treated animals received 100 mL/kg of 0.37 mmol/L nafamostat mesilate in GoLYTELY through the duodenal catheter at 1 L/h. Control animals received GoLYTELY only. Samples of enteral content and blood were taken at baseline, after shock, and at 30-minute intervals during resuscitation. Animals were killed after 3 hours of resuscitation. Enteral trypsin-like activity at the three gut sites was measured by spectrophotometry. Activation of naive human neutrophils by pig plasma was measured by the percentage of cells having pseudopods larger than 1 microm on microscopy. Lung, liver, and small bowel were analyzed by histology and myeloperoxidase assay. RESULTS Both control and nafamostat mesilate-treated groups had significant reductions in protein and protease levels in the duodenum during enteroclysis; however, only nafamostat mesilate-treated animals had persistent suppression of protease activity throughout the experiment. Nafamostat mesilate-treated animals had a lower transfusion requirement of shed blood, 18.1 +/- 4.5 mL/kg versus 30 +/- 0.43 mL/kg (p = 0.002). Nafamostat mesilate-treated animals had significantly less neutrophil activation than controls at 150 minutes after resuscitation (33.7 +/- 6.48% vs. 42.4 +/- 4.57%,p = 0.01) and 180 minutes after resuscitation (31.1 +/- 3.31% vs. 46.9 +/- 4.53%, p = 0.0002). Lung myeloperoxidase activity was lower in nafamostat mesilate-treated animals (0.31 +/- 0.14) than in control animals (0.16 +/- 0.04, p = 0.04). Histology of liver and small intestine showed less injury in nafamostat mesilate-treated animals. CONCLUSION Nafamostat mesilate given by means of enteroclysis with GoLYTELY significantly reduces enteral protease levels, leukocyte activation, and transfusion requirements during resuscitation from hemorrhagic shock. This strategy may have clinical promise.
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Affiliation(s)
- Jay J Doucet
- Department of Surgery University of California San Diego 92103-8899, USA
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Watson DB, Gray GW, Doucet JJ. Exercise rhabdomyolysis in military aircrew: two cases and a review of aeromedical disposition. Aviat Space Environ Med 2000; 71:1137-41. [PMID: 11086669] [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] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Exercise rhabdomyolysis (ER) is a rare, sometimes catastrophic condition where muscle fibers breakdown in response to exertion and release their breakdown products into the circulation. While ER was brought to the medical community's attention largely through reports from military training establishments we are unaware of ER having resulted from the activities of military aircrew. This paper reports two cases of ER in military aircrew and discusses the condition and the approaches taken in determining their future aeromedical disposition. CASE REPORTS Rhabdomyolysis occurred in two military pilots as a result of their aircrew duties. One, an experienced pilot, suffered rhabdomyolysis as a result of centrifuge based G-training, while the other, a cadet in training, suffered rhabdomyolysis precipitated by exertion during moderately warm weather. Further investigation revealed the second case to also have the Malignant Hyperthermia Trait. AEROMEDICAL DISPOSTION After wide consultation and lengthy deliberations both of these aircrew were returned to their full previous flying status. No further complications or recurrences have occurred.
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Affiliation(s)
- D B Watson
- Institute of Aviation Medicine, RAAF Base Edinburgh, SA, Australia.
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Doucet JJ, Hall RI. Limited resuscitation with hypertonic saline, hypertonic sodium acetate, and lactated Ringer's solutions in a model of uncontrolled hemorrhage from a vascular injury. J Trauma 1999; 47:956-63. [PMID: 10568730 DOI: 10.1097/00005373-199911000-00027] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypertonic sodium acetate-dextran solution (HAD) causes vasodilatation and buffers metabolic acidosis. In controlled hemorrhage models, HAD in small volumes increases cardiac output without increasing blood pressure, thus creating a "high flow-low pressure" state. The objective of this study was to determine whether limited resuscitation of uncontrolled hemorrhage with HAD solution improves gut perfusion as measured by intestinal mucosal tonometry. METHODS Three groups of 10 swine were bled 25 mL/kg by means of a femoral artery catheter to produce a mean blood pressure of 30 mm Hg. A 4-mm abdominal aortic laceration was then produced by pulling out a preimplanted wire loop. Groups were then randomly assigned to be resuscitated with either lactated Ringer's solution, a hypertonic saline-dextran solution or HAD solution sufficient to maintain a mean blood pressure of 45 mm Hg for 5 hours or until death. Outcomes were measured by survival, intraperitoneal blood loss, hemodynamic monitoring, and ileal mucosal tonometry. RESULTS HAD infusions caused transient worsening of hypotension and were associated with increased mortality (p = 0.038). Blood loss and volumes required for resuscitation were significantly increased in the lactated Ringer's solution group. HAD showed significant buffering effect against metabolic acidosis in arterial blood only, but intestinal ileal mucosal tonometry was not different among the groups. CONCLUSION HAD did not improve gut perfusion despite buffering the systemic acidosis of shock and caused increased mortality. Limited resuscitation with any of these solutions is associated with significant mucosal acidosis.
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Affiliation(s)
- J J Doucet
- Department of Surgery, Dalhousie University, and the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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Cook SD, Paveloff MJ, Doucet JJ, Cottingham AJ, Sedarati F, Hill JM. Ocular herpes simplex virus reactivation in mice latently infected with latency-associated transcript mutants. Invest Ophthalmol Vis Sci 1991; 32:1558-61. [PMID: 1849874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A mouse model for ocular reactivation of herpes simplex virus type 1 (HSV-1) was modified and used to study the effect of strain difference on the frequency of ocular HSV reactivation. Outbred male NIH white mice were immunized with 1.0 ml of anti-HSV serum with a neutralizing titer of 1:400 24 hr before infection and bilaterally infected at 10(5) plaque-forming units/eye with one of three HSV-1 strains: 17 Syn+, LAT+ (XC-20), or LAT- (X10-13). Latency-associated transcripts (LAT) are produced by strain 17 Syn+ and LAT+ but not by LAT-. The primary infection was monitored by ocular swabbing for HSV. Reactivation was induced by intravenous (i.v.) injection of cyclophosphamide (5 mg) followed 24 hr later by i.v. dexamethasone (0.2 mg). These drugs significantly reduced the white cell count between 0 and 6 days post-administration. The eyes were swabbed for 7 consecutive days to monitor reactivation, and HSV-1 reactivation was induced at the following frequencies in individual eyes: 17 Syn+ (32.5%), LAT+ (18.5%), and LAT- (2.5%) (P less than or equal to 0.002). Co-culture of trigeminal ganglia was done, and random isolates were checked to ascertain their identity. The HSV was recovered from individual trigeminal ganglia at the following frequencies: 17 Syn+ (83%), LAT+ (100%), and LAT- (67%) (P less than or equal to 0.091). These results confirm that the mouse can be used as a reactivation model for ocular HSV infection and that the presence of LAT facilitates reactivation in vivo in the mouse.
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Affiliation(s)
- S D Cook
- Lions Eye Research Laboratories, LSU Eye Center, New Orleans 70112-2234
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