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Gogna S, Zangbar B, Rafieezadeh A, Hanna K, Shnaydman I, Con J, Bronstein M, Klein J, Prabhakaran K. Fragmentation of Care After Geriatric Trauma: A Nationwide Analysis of outcomes and Predictors. Am Surg 2024; 90:1007-1014. [PMID: 38062751 DOI: 10.1177/00031348231220569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
The health care system for the elderly is fragmented, that is worsened when readmission occurs to different hospitals. There is limited investigation into the impact of fragmentation on geriatric trauma patient outcomes. The aim of this study was to compare the outcomes following readmissions after geriatric trauma. The Nationwide Readmissions Database (2016-2017) was queried for elderly trauma patients (aged ≥65 years) readmitted due to any cause. Patients were divided into 2 groups according to readmission: index vs non-index hospital. Outcomes were 30 and 180-day complications, mortality, and the number of subsequent readmissions. Multivariable logistic regression was performed to analyze the independent predictors of fragmentation of care. A total of 36,176 trauma patients were readmitted, of which 3856 elderly patients (aged ≥65 years) were readmitted: index hospital (3420; 89%) vs non-index hospital (436; 11%). Following 1:2 propensity matching, elderly with non-index hospital readmission had higher rates of death and MI within 180 days (P = .01 and .02, respectively). They had statistically higher 30 and 180-day pneumonia (P < .01), CHF (P < .01), arrhythmias (P < .01), MI (P < .01), sepsis (P < .01), and UTI (P < .01). On multivariable binary logistic regression analysis, pneumonia (OR 1.70, P = .03), congestive heart failure (CHF) (OR 1.80, P = .03), female gender (OR .72, P = .04), and severe Head and Neck trauma (AIS≥3) (OR 1.50, P < .01) on index admission were independent predictors of fragmentation of care. While the increase in time to readmission (OR 1.01, P < .01) was also associated independently with non-index hospital admission. Fragmented care after geriatric trauma could be associated with higher mortality and complications.
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Affiliation(s)
- Shekhar Gogna
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Bardiya Zangbar
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Aryan Rafieezadeh
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Kamil Hanna
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ilya Shnaydman
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jorge Con
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Matthew Bronstein
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Joshua Klein
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
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Hanna K, Zangbar B, Kirsch J, Bronstein M, Okumura K, Gogna S, Shnaydman I, Prabhakaran K, Con J. Non-operative management of cirrhotic patients with acute calculous cholecystitis: How effective is it? Am J Surg 2023; 226:668-674. [PMID: 37482476 DOI: 10.1016/j.amjsurg.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM. METHODS We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only. PRIMARY OUTCOMES complications, failure of NOM. SECONDARY OUTCOMES mortality, length of stay (LOS), and charges. RESULTS 3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality. CONCLUSION ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure. LEVEL OF EVIDENCE Level III, prognostic.
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Affiliation(s)
- Kamil Hanna
- Department of Surgery, Westchester Medical Center, New York, USA.
| | - Bardiya Zangbar
- Department of Surgery, Westchester Medical Center, New York, USA.
| | - Jordan Kirsch
- Department of Surgery, Westchester Medical Center, New York, USA.
| | | | - Kenji Okumura
- Department of Surgery, Westchester Medical Center, New York, USA.
| | - Shekhar Gogna
- Department of Surgery, Medstar Health, Washington, USA.
| | - Ilya Shnaydman
- Department of Surgery, Westchester Medical Center, New York, USA.
| | | | - Jorge Con
- Department of Surgery, Westchester Medical Center, New York, USA.
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Castaldi MT, Palmer M, Con J, Bergamaschi R. Robotic-Assisted Surgery Training (RAST): Assessment of Surgeon Console Ergonomic Skills. J Surg Educ 2023; 80:1723-1735. [PMID: 37770293 DOI: 10.1016/j.jsurg.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/27/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the responsiveness of postgraduate year (PGY) general surgery residents (GSRs) to surgeon console ergonomics within the robotic-assisted surgery training (RAST) program. DESIGN This was a prospective educational study. GSRs were prepared with a pretraining educational video. Faculty provided one-on-one resident hands-on training and testing. Nine proficiency criteria (emergency stop & recover; left side pod adjustments; touchpad controls; footswitch panel; energy control pedals; camera control & focus; arm swap; master & finger clutch; dual console settings control) were assessed with a 5-point Likert-scale. Responsiveness was defined as change in performance over time. The robotic platform was Da Vinci Xi (Intuitive Surgical, Sunnyvale, CA). The Dundee ready educational environment measure (DREEM) inventory was used by GSRs to assess the educational environment. SETTING Tertiary care academic teaching institution. PARTICIPANTS A total of 22 GSRs: 4 PGY 1, 4 PGY 2, 4 PGY 3, 5 PGY 4, 5 PGY 5. RESULTS From June 2022 to March 2023 the hands-on console time decreased at testing when compared to baseline: median 39.0 (range 37-41) vs 20.1 (range 19-22) minutes, respectively. There was no difference in mean hands-on testing scores stratified by PGY: 4.85±0.4 PGY1; 4.98 ± 0.3 PGY2; 4.86 ± 0.4 PGY3, 4.88 ± 0.2 PGY4, and 4.91 ± 0.1 PGY5 (ANOVA test; p = 0.095). The overall DREEM score was 167.1 ± 16.9 with CAC = 0.908 (excellent internal consistency). CONCLUSIONS Training in ergonomics on the surgeon console impacted the responsiveness of the GSRs with 51% console time reduction. There were no differences in hands-on testing scores among PGYs. Perception of the educational environment by the GSRs was high.
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Affiliation(s)
- M T Castaldi
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York
| | - M Palmer
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York
| | - J Con
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York
| | - R Bergamaschi
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York.
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Shah S, Con J, Mercado L, Smiley A, Weber G, Abramowicz AE. Predictors of Matching into Anesthesiology and Surgery: Analysis of One Program's Results. J Surg Educ 2023; 80:1231-1241. [PMID: 37455190 DOI: 10.1016/j.jsurg.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/18/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The objectives of this study were to use a multivariable regression model to determine what application factors made anesthesiology and surgery applicants more or less likely to match into an anesthesiology or surgery residency program. METHODS Surgery and Anesthesiology applicants listed on the final National Resident Matching Program (NRMP) Rank Order Lists from WMC in the 2020-2021 application cycle were included in analysis. All applicant data were collected through the Electronic Residency Application Service (ERAS). All ERAS and letters of recommendation (LOR) data were deidentified and LOR were subsequently inputted into a linguistics software to analyze the language use in LOR. Descriptive analyses were conducted to compare variables between applicants that matched to a specific residency program and those who matched elsewhere. A multivariable regression model was then used to determine characteristics of anesthesiology and surgery applicants that were indicative of matching to a specific rank of residency program. RESULTS A total of 116 anesthesiology and 78 surgery applicants were included in final analysis. Analysis of anesthesiology applicants yielded four significant application characteristics that influenced matching to a higher or lower ranked residency program: USMLE Step 2 CK scores, medical school attended, insight category words in LOR, and anger category words in LOR. Similarly, analysis of surgery applicants yielded four significant characteristics: Race, USMLE Step 1 scores, insight category words, and see category words. CONCLUSION Our results demonstrated that specialties of anesthesiology and surgery considered different metrics regarding the residency application process. Among the many factors that were analyzed, USMLE scores and language in LOR were considered significant in both specialties. As the application process continues to evolve, we may see a shift in what application factors are considered more important than others.
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Affiliation(s)
- Sonali Shah
- School of Medicine, New York Medical College, Valhalla, New York.
| | - Jorge Con
- Department of Surgery, New York Medical College, Valhalla, New York
| | - Lori Mercado
- Department of Anesthesiology, New York Medical College, Valhalla, New York
| | - Abbas Smiley
- Department of Surgery, New York Medical College, Valhalla, New York
| | - Garret Weber
- Department of Anesthesiology, New York Medical College, Valhalla, New York
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Castaldi MT, Palmer M, Felsenreich DM, Con J, Bergamaschi R. Robotic-assisted surgery training (RAST) program: module 1 of a three-module program. Assessment of patient cart docking skills and educational environment. Updates Surg 2023:10.1007/s13304-023-01485-9. [PMID: 36862353 DOI: 10.1007/s13304-023-01485-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/23/2023] [Indexed: 03/03/2023]
Abstract
There is currently no standardized robotic surgery training program in General Surgery Residency. RAST involves three modules: ergonomics, psychomotor, and procedural. This study aimed to report the results of module 1, which assessed the responsiveness of 27 PGY (postgraduate year) 1-5 general surgery residents (GSRs) to simulated patient cart docking, and to evaluate the residents' perception of the educational environment from 2021 to 2022. GSRs prepared with pre-training educational video and multiple-choice questions test (MCQs). Faculty provided one-on-one resident hands-on training and testing. Nine proficiency criteria (deploy cart; boom control; driving cart; docking camera port; targeting anatomy; flex joints; clearance joints; port nozzles; emergency undocking) were assessed with five-point Likert scale. A validated 50-item Dundee Ready Educational Environment Measure (DREEM) inventory was used by GSRs to assess the educational environment. Mean MCQ scores: (90.6 ± 16.1 PGY1), (80.2 ± 18.1PGY2), (91.7 ± 16.5 PGY3) and (PGY4, 86.8 ± 18.1 PGY5) (ANOVA test; p = 0.885). Hands-on docking time decreased at testing when compared to base line: median 17.5 (range 15-20) min vs. 9.5 (range 8-11). Mean hands-on testing score was 4.75 ± 0.29 PGY1; 5.0 ± 0 PGY2 and PGY3, 4.78 ± 0.13 PGY4, and 4.93 ± 0.1 PGY5 (ANOVA test; p = 0.095). No correlation was found between pre-course MCQ score and hands-on training score (Pearson correlation coefficient = - 0.359; p = 0.066). There was no difference in the hands-on scores stratified by PGY. The overall DREEM score was 167.1 ± 16.9 with CAC = 0.908 (excellent internal consistency). Patient cart training impacted the responsiveness of GSRs with 54% docking time reduction and no differences in hands-on testing scores among PGYs with a highly positive perception.
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Affiliation(s)
- Maria Teresa Castaldi
- Department of Surgery, Westchester Medical Center, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA
- Department of Surgery, New York Medical College, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Mathias Palmer
- Department of Surgery, New York Medical College, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Daniel Moritz Felsenreich
- Department of Surgery, New York Medical College, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Jorge Con
- Department of Surgery, Westchester Medical Center, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA
- Department of Surgery, New York Medical College, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Roberto Bergamaschi
- Department of Surgery, Westchester Medical Center, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA.
- Department of Surgery, New York Medical College, Taylor Pavilion, Suite D-361, 100 Woods Road, Valhalla, NY, 10595, USA.
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Okumura K, Latifi R, Smiley A, Lee JS, Shnaydman I, Zangbar B, Bronstein M, Con J, Prabhakaran K, Rhee P, Klein J, Shivaraj K, Klein MD, Miller DM. Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients. Surg Technol Int 2022; 41:sti41/1620. [PMID: 36041078 DOI: 10.52198/22.sti.41.gs1620] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation. MATERIALS AND METHODS We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated. RESULTS 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home. CONCLUSION DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Abbas Smiley
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Joon Sub Lee
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ilya Shnaydman
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Bardiya Zangbar
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Matthew Bronstein
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jorge Con
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kartik Prabhakaran
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Peter Rhee
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Joshua Klein
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kiran Shivaraj
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Michael D Klein
- Division of Nephrology, Westchester Medical Center, Valhalla, New York
| | - Daniel M Miller
- Critical Care Medicine, Department of Medicine, Westchester Medical Center, New York, Medical College, Valhalla, New York
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Hanna K, Con J, Gogna S, Bronstein M, Choi JK, Zeeshan M, Shnaydman I, Prabhakaran K, Latifi R, Rhee P. Occult Traumatic Pneumomediastinum on CT Scan Is Not of Concern for Aerodigestive Injury. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gogna S, Latifi R, Choi J, Con J, Prabhakaran K, Anderson PL, Policastro AJ, Klein J, Samson DJ, Smiley A, Rhee P. Early versus delayed complex abdominal wall reconstruction with biologic mesh following damage-control surgery. J Trauma Acute Care Surg 2021; 90:527-534. [PMID: 33507024 DOI: 10.1097/ta.0000000000003011] [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: 12/21/2022]
Abstract
BACKGROUND Damage-control surgery for trauma and intra-abdominal catastrophe is associated with a high rate of morbidities and postoperative complications. This study aimed to compare the outcomes of patients undergoing early complex abdominal wall reconstruction (e-CAWR) in acute settings versus those undergoing delayed complex abdominal wall reconstruction (d-CAWR). METHOD This study was a pooled analysis derived from the retrospective and prospective database between the years 2013 and 2019. The outcomes were compared for differences in demographics, presentation, intraoperative variables, Ventral Hernia Working Grade (VHWG), US Centers for Disease Control and Prevention wound class, American Society of Anesthesiologists (ASA) scores, postoperative complications, hospital length of stay, and readmission rates. We performed Student's t test, χ2 test, and Fisher's exact test to compare variables of interest. Multivariable linear regression model was built to evaluate the association of hospital length of stay and all other variables including the timing of complex abdominal wall reconstruction (CAWR). A p value of <0.05 was considered significant. RESULTS Of the 236 patients who underwent CAWR with biological mesh, 79 (33.5%) had e-CAWR. There were 45 males (57%) and 34 females (43%) in the e-CAWR group. The ASA scores of IV and V, and VHWG grades III and IV were significantly more frequent in the e-CAWR group compared with the d-CAWR one. Postoperatively, the incidence of surgical site occurrence, Clavien-Dindo complications, comprehensive complication index, unplanned reoperations, and mortality were similar between the two groups. Backward linear regression model showed that the timing of CAWR (β = -11.29, p < 0.0001), ASA (β = 3.98, p = 0.006), VHWG classification (β = 3.62, p = 0.015), drug abuse (β = 13.47, p = 0.009), and two comorbidities of cirrhosis (β = 12.34, p = 0.001) and malignancy (β = 7.91, p = 0.008) were the significant predictors of the hospital length of stay left in the model. CONCLUSION Early CAWR led to shorter hospital length of stay compared with d-CAWR in multivariable regression model. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Shekhar Gogna
- From the Department of Surgery, Westchester Medical Center and New York Medical College (S.G., R.L., J.C., J.C., K.P., P.L.A., A.J.P., J.K., D.J.S., A.S., P.R.)
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Gogna S, Samson D, Choi J, Con J, Prabhakaran K, Rhee P, Latifi R. The Role of Nutritional Access in Malnourished Elderly Undergoing Major Surgery for Acute Abdomen: A Propensity Score-Matched Analysis. Am Surg 2020; 87:1252-1258. [PMID: 33345560 DOI: 10.1177/0003134820973719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND About 50% of the elderly undergoing emergency abdominal surgery are malnourished. The role of timely surgical nutritional access in this group of patients is unknown. METHODS We analyzed the National Inpatient Sample database from 2009 through the first three-quarters of 2015 of patients aged ≥65 years who were malnourished and underwent major abdominal surgery for the acute abdomen within the first 2 days of hospital admission. RESULTS Of 3 246 721 patients analyzed, 4311 patients met inclusion criteria. Of these, only 507 (11.8%) patients had surgical nutritional access (gastrostomy or jejunostomy) (group I), while 3804 patients (88.2%) did not (group II). In the propensity score-matched population, there were 482 patients in each group. The patients in group I had lower odds of mortality and postoperative gastrointestinal complications (paralytic ileus, anastomotic dehiscence, and intestinal fistulae) (P-value <.01, respectively). DISCUSSION Elderly who receive surgical nutritional access have lower rates of gastrointestinal complications and mortality.
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Affiliation(s)
- Shekhar Gogna
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - David Samson
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - James Choi
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Jorge Con
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Kartik Prabhakaran
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Peter Rhee
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Rifat Latifi
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
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Asmar S, Zeeshan M, Khurrum M, Con J, Chehab M, Bible L, Latifi R, Joseph B. Delta Shock Index Predicts Outcomes in Pediatric Trauma Patients Regardless of Age. J Surg Res 2020; 259:182-191. [PMID: 33290893 DOI: 10.1016/j.jss.2020.10.026] [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: 04/10/2020] [Revised: 10/01/2020] [Accepted: 10/31/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients. METHODS We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed. RESULTS We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01). CONCLUSIONS Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients. LEVEL OF EVIDENCE Level III Prognostic.
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Affiliation(s)
- Samer Asmar
- Division of Trauma, Critical Care, Department of Surgery, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Zeeshan
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Muhammad Khurrum
- Division of Trauma, Critical Care, Department of Surgery, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, Arizona
| | - Jorge Con
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Mohamad Chehab
- Division of Trauma, Critical Care, Department of Surgery, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, Arizona
| | - Letitia Bible
- Division of Trauma, Critical Care, Department of Surgery, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, Arizona
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Bellal Joseph
- Division of Trauma, Critical Care, Department of Surgery, Emergency Surgery, and Burns, College of Medicine, University of Arizona, Tucson, Arizona.
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Choi J, Smiley A, Latifi R, Gogna S, Prabhakaran K, Con J, Anderson P, Policastro A, Beydoun M, Rhee P. Body Mass Index and Mortality in Blunt Trauma: The Right BMI can be Protective. Am J Surg 2020; 220:1475-1479. [PMID: 33109335 DOI: 10.1016/j.amjsurg.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/14/2020] [Accepted: 10/10/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND There are limited studies examining the role of BMI on mortality in the trauma population. The aim of this study was to analyze whether the "obesity paradox" exists in non-elderly patients with blunt trauma. METHODS A retrospective study was performed on the Trauma Quality Improvement Program (TQIP) database for 2016. All non-elderly patients aged 18-64, with blunt traumatic injuries were identified. A generalized additive model (GAM) was built to assess the association of mortality and BMI adjusted for age, gender, race, and injury severity score (ISS). RESULTS 28,475 patients (mean age = 42.5, SD = 14.3) were identified. 20,328 (71.4%) were male. Age (p < 0.0001), gender (p < 0.0001), and ISS (p < 0.0001) had significant associations with mortality. After GAM, BMI showed a significant U-shaped association with mortality (EDF = 3.2, p = 0.003). A BMI range of 31.5 ± 0.9 kg/m2 was associated with the lowest mortality. CONCLUSION High BMI can be a protective factor in mortality within non-elderly patients with blunt trauma. However, underweight or morbid obesity suggest a higher risk of mortality.
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Affiliation(s)
- James Choi
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Abbas Smiley
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Rifat Latifi
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Shekhar Gogna
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Kartik Prabhakaran
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Jorge Con
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Patrice Anderson
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Anthony Policastro
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Malk Beydoun
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Peter Rhee
- New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
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Affiliation(s)
- Aditya Safaya
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
| | - Alessandra Piscina
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
| | - Jorge Con
- Department of Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
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13
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Gogna S, Latifi R, Choi J, Con J, Prabhakaran K, Smiley A, Anderson PL. Predictors of 30- and 90-Day Readmissions After Complex Abdominal Wall Reconstruction With Biological Mesh: A Longitudinal Study of 232 Patients. World J Surg 2020; 44:3720-3728. [PMID: 32734453 DOI: 10.1007/s00268-020-05714-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hospital readmissions are recognized as indicators of poor healthcare services which further increase patient morbidity. The aim of this study is to analyze predicting factors for the 30-day and 90-day readmissions after a complex abdominal wall reconstruction (CAWR). METHODS A pooled analysis of the prospective study and retrospective database patients undergoing CAWR with acellular porcine dermis from 2012 to 2019 was carried out. Independent t test for continuous variables and Chi-square and Fischer's exact tests for categorical variables were used. A multivariable logistic regression model and linear regression analysis were used to analyze the independent predictors of 30-day and 90-day readmissions. RESULTS A total of 232 patients underwent CAWR, and the readmission rate (RR) was 16.8% (n = 40). The 30-day and 90-day RR was 11.3% (n = 23) and 13.3% (n = 33), respectively. There were no statistical differences in age, frailty, and gender distribution between the two groups. There was no difference in ASA score, type of component separation, ventral hernia working group class, size of the biological mesh, placement of mesh, and intestinal resection rate. The Clavien-Dindo complications and mean comprehensive complication index (CCI) were higher in the readmission group as compared to no readmission group (p < 0.01). Readmitted patients had higher surgical site infections (p < 0.01) and wound necrosis (p = 0.01). Higher CCI, past or concomitant pelvic surgery, and the presence of enterocutaneous fistula were independent predictors of earlier days to readmission. CONCLUSION Surgical site occurrences were associated with 30-day and 90-day readmissions after CAWR, while the presence of ascites and dialysis was associated with 90-day readmissions.
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Affiliation(s)
- Shekhar Gogna
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, Office Suite #353, Valhalla, NY, 10595, USA
| | - Rifat Latifi
- Department of Surgery, School of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
| | - James Choi
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, Office Suite #353, Valhalla, NY, 10595, USA
| | - Jorge Con
- Trauma and Critical Care, Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion E-131, Valhalla, NY, 10595, USA
| | - Kartik Prabhakaran
- Trauma and Critical Care, Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E150, Valhalla, NY, 10595, USA
| | - Abbas Smiley
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Patrice L Anderson
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-145, Valhalla, NY, 10595, USA
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14
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Gogna S, Latifi R, Policastro A, Prabhakaran K, Anderson P, Con J, Choi J, Samson DJ, Butler J. Complex abdominal wall hernia repair with biologic mesh in elderly: a propensity matched analysis. Hernia 2020; 24:495-502. [PMID: 31981009 PMCID: PMC7223233 DOI: 10.1007/s10029-019-02068-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/04/2019] [Indexed: 12/18/2022]
Abstract
Background Complex abdominal wall reconstruction (CAWR) has become a common surgical procedure both in non-elderly and elderly patients. Objective The aim of this study is to analyze the outcomes of the elderly compared to nonelderly undergoing CAWR using propensity score matching. Methods All patients who underwent CAWR using porcine-derived, non-crosslinked acellular dermal matrix (ADM) (Strattice™) between January 2014 and July 2017 were studied retrospectively. Propensity matched analysis was performed for risk adjustment in multivariable analysis and for one-to-one matching. The outcomes were analyzed for differences in postoperative complications, reoperations, mortality, hospital length of stay and adverse discharge disposition. Results One hundred-thirty-six patients were identified during the study period. Non-elderly (aged 18–64 years) constituted 70% (n = 95) and elderly (aged ≥ 65 years) comprised 30% of the overall patient population (n = 41). Seventy-three (56.7%) were females. After adjustment through the propensity score, which included 35 pairs, the surgical site infection (p = 1.000), wound necrosis (p = 1.000), the need for mechanical ventilation (p = 0.259), mortality (p = 0.083), reoperation rate (p = 0.141), hospital length of stay (p = 0.206), and discharge disposition (p = 0.795) were similar. Conclusion Elderly patients undergoing CAWR with biological mesh have comparable outcomes with non-elderly patients when using propensity matching score.
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Affiliation(s)
- S Gogna
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, E-348, Valhalla, NY, 10595, USA
| | - R Latifi
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY, 10595, USA.
| | - A Policastro
- Medical Director SICU, PCU, Trauma and Critical Care, Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-136, Valhalla, NY, 10595, USA
| | - K Prabhakaran
- Division of Trauma, Acute Care Surgery and Burns, Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-150, Valhalla, NY, 10595, USA
| | - P Anderson
- Trauma Intensive Care Unit, Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, Office E-145, Valhalla, NY, 10595, USA
| | - J Con
- Department of Surgery, Westchester Medical center, School of Medicine, New York Medical College, 100 Woods Road, Taylor Pavilion, E-131, Office #E145, Valhalla, NY, 10595, USA
| | - J Choi
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, E-348, Valhalla, NY, 10595, USA
| | - D J Samson
- Department of Surgery, Clinical Research Unit, Westchester Medical Center, 100 Woods Road, Taylor Pavilion, Office E-348, Valhalla, NY, 10595, USA
| | - J Butler
- Clinical Research Unit, Westchester Medical Center, 100 Woods Road, Taylor Pavilion, Office E-348, Valhalla, NY, 10595, USA
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Jehan F, Con J, McIntyre M, Khan M, Azim A, Prabhakaran K, Latifi R. Pre-hospital shock index correlates with transfusion, resource utilization and mortality; The role of patient first vitals. Am J Surg 2019; 218:1169-1174. [DOI: 10.1016/j.amjsurg.2019.08.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022]
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16
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Khan MN, Jehan FS, Feeney JM, Lombardo GG, Con J, Latifi R, Prabhakaran K. Early Tracheostomy in Patients with Cervical Spine Injuries: A Potential Method to Reduce Morbidity. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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17
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Azim A, Khan MN, Jehan FS, Con J. In-Hospital Outcomes after Operative Fixation of Multiple Rib Fractures with Non-Flail Chest: A Propensity Matched Analysis. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Jehan F, Zeeshan M, Con J, Hanna K, Tang A, Hamidi M, Latifi R, Joseph B. Metabolic Syndrome Exponentially Increases the Risk of Adverse Outcomes in Operative Diverticulitis. J Surg Res 2019; 245:544-551. [PMID: 31470335 DOI: 10.1016/j.jss.2019.07.075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/20/2019] [Accepted: 07/19/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Metabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients. METHODS We analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m2, hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed. RESULTS A total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m2. 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (β = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone. CONCLUSIONS Adverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality. LEVEL OF EVIDENCE Level III Prognostic.
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Affiliation(s)
- Faisal Jehan
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Jorge Con
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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19
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Gogna S, Latifi R, Lombardo G, Prabhakaran K, Anderson P, Con J. Gastrointestinal Stromal Tumor of Small Bowel Presenting with Hemorrhagic Shock after Blunt Trauma to the Abdomen. Am Surg 2019. [DOI: 10.1177/000313481908500824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Shekhar Gogna
- Department of Surgery Westchester Medical Center New York Medical College Valhalla, New York
| | - Rifat Latifi
- Department of Surgery Westchester Medical Center New York Medical College Valhalla, New York
| | - Gary Lombardo
- Department of Surgery Westchester Medical Center New York Medical College Valhalla, New York
| | - Kartik Prabhakaran
- Department of Surgery Westchester Medical Center New York Medical College Valhalla, New York
| | - Patrice Anderson
- Department of Surgery Westchester Medical Center New York Medical College Valhalla, New York
| | - Jorge Con
- Department of Surgery Westchester Medical Center New York Medical College Valhalla, New York
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20
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Gogna S, Latifi R, Lombardo G, Prabhakaran K, Anderson P, Con J. Gastrointestinal Stromal Tumor of Small Bowel Presenting with Hemorrhagic Shock after Blunt Trauma to the Abdomen. Am Surg 2019; 85:e428-e429. [PMID: 31560338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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21
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Harmon L, Bilow R, Shanmuganathan K, Lauerman M, Todd SR, Cardenas J, Haugen CE, Albrecht R, Pittman S, Cohen M, Kaups K, Dirks R, Burlew CC, Fox CJ, Con J, Inaba K, Harrison PB, Berg GM, Waller CJ, Kallies KJ, Kozar RA. Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study. Am J Surg 2019; 218:579-583. [PMID: 31284948 DOI: 10.1016/j.amjsurg.2019.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/17/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. METHODS Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. RESULTS Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. CONCLUSION This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.
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Affiliation(s)
- Laura Harmon
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Ronald Bilow
- Department of Radiology, UTHealth McGovern Medical School, Houston, TX, USA.
| | - Kathirkama Shanmuganathan
- Shock Trauma and Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Margret Lauerman
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA.
| | - S Rob Todd
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Cardenas
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | | | | | | | - Mitchell Cohen
- University of Colorado, Denver Health Medical Center, Denver CO, USA.
| | | | | | | | - Charles J Fox
- University of Colorado, Denver Health Medical Center, Denver CO, USA.
| | - Jorge Con
- Department of Surgery, New York Medical College-Westchester, Valhalla, NY, USA.
| | - Kenji Inaba
- University of Southern California, Los Angeles County, Los Angeles, CA, USA.
| | | | - Gina M Berg
- Wesley Medical Center Trauma Services, Wichita, KS, USA.
| | | | | | - Rosemary Ann Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA.
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22
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Haider A, Con J, Prabhakaran K, Anderson P, Policastro A, Feeney J, Latifi R. Developing a Simple Clinical Score for Predicting Mortality and Need for ICU in Trauma Patients. Am Surg 2019; 85:733-737. [PMID: 31405418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Several models exist to predict trauma center need in the prehospital setting; however, there is lack of simple clinical tools to predict the need for ICU admission and mortality in trauma patients. The aim of our study was to develop a simple clinical tool that can be used with ease in the prehospital or emergency setting and can reliably predict the need for ICU admission and mortality in trauma patients. We abstracted one year of National Trauma Data Bank for all patients aged ≥ 18 years. Transferred patients and those dead on arrival were excluded. Patient demographics, injury parameters, vital signs, and Glasgow Coma Scale (GCS) were recorded. Our primary outcome measures were mortality and ICU admission. Logistic regression analysis was performed using three variables (age > 55 years, shock index (SI) > 1, and GCS score) to determine the appropriate weights for predicting mortality. Appropriate weights derived from regression analysis were used to construct a simple SI, age, and GCS (SAG) score, and associated mortality and ICU admissions were calculated for three different risk groups (low, intermediate, and high). A total of 281,522 patients were included. The mean age was 47 ± 20 years, and 65 per cent were male. The overall mortality rate was 2.9 per cent, and the rate of ICU admission was 28.7 per cent. The SAG score was constructed using weights derived from regression analysis for age ≤ 55 years (4 points), SI < 1 (3 points), and GCS (3-15 points). The median [IQR] SAG score was 21 [18-22]. The area under the receiver operating curve [95% Confidence Interval (CI)] of the SAG score for predicting mortality and ICU admission was 0.873 [0.870-0.877] and 0.644 [0.642-0.647], respectively. Each 1-point increase in the SAG score was associated with 18 per cent lower odds of mortality (odds ratio [95% CI]: 0.822 [0.820-0.825]) and 10 per cent lower odds of ICU admission (odds ratio [95% CI]: 0.901 [0.899-0.902]). The SAG score is a simple clinical tool derived from variables that can be assessed with ease during the initial evaluation of trauma patients. It provides a rapid assessment and can reliably predict mortality and need for ICU admission in trauma patients. This simple tool may allow early resource mobilization possibly even before the arrival of the patient.
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Haider A, Con J, Prabhakaran K, Anderson P, Policastro A, Feeney J, Latifi R. Developing a Simple Clinical Score for Predicting Mortality and Need for ICU in Trauma Patients. Am Surg 2019. [DOI: 10.1177/000313481908500733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several models exist to predict trauma center need in the prehospital setting; however, there is lack of simple clinical tools to predict the need for ICU admission and mortality in trauma patients. The aim of our study was to develop a simple clinical tool that can be used with ease in the prehospital or emergency setting and can reliably predict the need for ICU admission and mortality in trauma patients. We abstracted one year of National Trauma Data Bank for all patients aged ≥ 18 years. Transferred patients and those dead on arrival were excluded. Patient demographics, injury parameters, vital signs, and Glasgow Coma Scale (GCS) were recorded. Our primary outcome measures were mortality and ICU admission. Logistic regression analysis was performed using three variables (age > 55 years, shock index (SI) > 1, and GCS score) to determine the appropriate weights for predicting mortality. Appropriate weights derived from regression analysis were used to construct a simple SI, age, and GCS (SAG) score, and associated mortality and ICU admissions were calculated for three different risk groups (low, intermediate, and high). A total of 281,522 patients were included. The mean age was 47 ± 20 years, and 65 per cent were male. The overall mortality rate was 2.9 per cent, and the rate of ICU admission was 28.7 per cent. The SAG score was constructed using weights derived from regression analysis for age ≤ 55 years (4 points), SI< 1 (3 points), and GCS (3-15 points). The median [IQR] SAG score was 21 [18–22]. The area under the receiver operating curve [95% Confidence Interval (CI)] of the SAG score for predicting mortality and ICU admission was 0.873 [0.870–0.877] and 0.644 [0.642–0.647], respectively. Each 1-point increase in the SAG score was associated with 18 per cent lower odds of mortality (odds ratio [95% CI]: 0.822 [0.820–0.825]) and 10 per cent lower odds of ICU admission (odds ratio [95% CI]: 0.901 [0.899–0.902]). The SAG score is a simple clinical tool derived from variables that can be assessed with ease during the initial evaluation of trauma patients. It provides a rapid assessment and can reliably predict mortality and need for ICU admission in trauma patients. This simple tool may allow early resource mobilization possibly even before the arrival of the patient.
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Affiliation(s)
- Ansab Haider
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jorge Con
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kartik Prabhakaran
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Patrice Anderson
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Anthony Policastro
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - James Feeney
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Rifat Latifi
- Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
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Xu JL, Con J, Hou J, Parikh SB, Junge JM, Dotzauer B. Ultrasound-Guided Erector Spinae Plane Block Using Long-Range Multi-Orifice Catheter for Chest Wall Pain Management in Patients with Multiple Rib Fractures. Am Surg 2019; 85:e6-e8. [PMID: 30760358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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25
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Xu JL, Con J, Hou J, Parikh SB, Junge JM, Dotzauer B. Ultrasound-Guided Erector Spinae Plane Block Using Long-Range Multi-Orifice Catheter for Chest Wall Pain Management in Patients with Multiple Rib Fractures. Am Surg 2019. [DOI: 10.1177/000313481908500103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jeff L. Xu
- Division of Regional Anesthesia and Acute Pain Management Department of Anesthesiology Westchester Medical Center/New York Medical College Valhalla, New York
| | - Jorge Con
- Department of Surgery Westchester Medical Center/New York Medical College Valhalla, New York
| | - Jian Hou
- Division of Regional Anesthesia and Acute Pain Management Department of Anesthesiology Westchester Medical Center/New York Medical College Valhalla, New York
| | - Shalvi B. Parikh
- Department of Surgery Westchester Medical Center/New York Medical College Valhalla, New York
| | | | - Bernd Dotzauer
- Division of Regional Anesthesia and Acute Pain Management Department of Anesthesiology Westchester Medical Center/New York Medical College Valhalla, New York
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Angeles C, Lombardo G, Prabhakaran K, Con J. Retained Piece of Glass in Pleural Cavity: Is Chest X-ray Enough? Am Surg 2018; 84:e448-e450. [PMID: 30747647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Angeles C, Lombardo G, Prabhakaran K, Con J. Retained Piece of Glass in Pleural Cavity: Is Chest X-ray Enough? Am Surg 2018. [DOI: 10.1177/000313481808401104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Clara Angeles
- Department of Surgery New York Medical College at Westchester Medical Center Valhalla, New York
| | - Gary Lombardo
- Department of Surgery New York Medical College at Westchester Medical Center Valhalla, New York
| | - Karthik Prabhakaran
- Department of Surgery New York Medical College at Westchester Medical Center Valhalla, New York
| | - Jorge Con
- Department of Surgery New York Medical College at Westchester Medical Center Valhalla, New York
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Samson DJ, Prabhakaran K, Patel AS, Pee S, Con J, Alamgir H, Latifi R. Predictors of Repeat Falls and Outcomes in the Elderly. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Prabhakaran K, Tilley EH, Samson DJ, Con J, Anderson PL, Alamgir H, Latifi R. Should all Elderly Trauma Patients be Admitted Directly to a Level I Trauma Center? J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Safaya A, Elzaine A, Xu ML, Con J, Prabhakaran K, Lombardo G. Delayed Acute Subdural Hematoma in a Young Patient in the Setting of Trauma with No Head Injury. Am Surg 2018; 84:e120-e122. [PMID: 30454431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Aditya Safaya
- Division of Trauma and Acute Care Surgery, New York Medical College, Westchester Medical, Center, Valhalla, New York, USA
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Safaya A, Elzaine A, Xu ML, Con J, Prabhakaran K, Lombardo G. Delayed Acute Subdural Hematoma in a Young Patient in the Setting of Trauma with No Head Injury. Am Surg 2018. [DOI: 10.1177/000313481808400402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Aditya Safaya
- Division of Trauma and Acute Care Surgery New York Medical College, Westchester Medical Center Valhalla, New York
| | - Ashraf Elzaine
- Division of Trauma and Acute Care Surgery New York Medical College, Westchester Medical Center Valhalla, New York
| | - Min Li Xu
- Division of Trauma and Acute Care Surgery New York Medical College, Westchester Medical Center Valhalla, New York
| | - Jorge Con
- Division of Trauma and Acute Care Surgery New York Medical College, Westchester Medical Center Valhalla, New York
| | - Kartik Prabhakaran
- Division of Trauma and Acute Care Surgery New York Medical College, Westchester Medical Center Valhalla, New York
| | - Gary Lombardo
- Division of Trauma and Acute Care Surgery New York Medical College, Westchester Medical Center Valhalla, New York
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Bardes JM, Palmer A, Con J, Wilson A, Schaefer G. Antifibrinolytics in a rural trauma state: assessing the opportunities. Trauma Surg Acute Care Open 2017; 2:e000107. [PMID: 29766102 PMCID: PMC5877915 DOI: 10.1136/tsaco-2017-000107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 12/03/2022] Open
Abstract
Background Tranexamic acid (TXA) has demonstrated improved mortality among trauma patients. However, recent evidence from urban US trauma centers has failed to show a benefit among the civilian population. TXA in rural states has not been evaluated. This study aimed to evaluate the current use of TXA in the rural trauma population. Methods A retrospective observational review at a level 1 trauma center based in a rural environment. Records were reviewed for TXA indications. TXA indication was defined as: systolic blood pressure <90 mm Hg, blood transfusion, or with a clinical concern for ongoing bleeding. Patients were ineligible if the time since injury was >3 hours. Results 400 patients were evaluated. 54% of patients met indications for TXA. 14% of these received TXA. 30.4% with an indication for TXA were ineligible due to arrival beyond 3 hours from time of injury. 135 patients arrived as transfers, 265 from the scene. There was no difference in TXA indications between scene and transfers (73 vs 144, p=1). Transfers were more likely to arrive beyond the 3-hour window (59 vs 7, p=0.001). Mortality for patients treated with TXA was 12.5%. This was not significantly different from patients not treated with TXA (19%). Discussion In a rural system, long transfers exclude most patients from treatment with TXA. A multicenter rural trauma center study will be needed to better define the optimal use of TXA in rural populations. Level of evidence Level IV data: therapeutic/care management.
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Affiliation(s)
- James M Bardes
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Amanda Palmer
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Jorge Con
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Alison Wilson
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Gregory Schaefer
- Division of Trauma, Acute Care Surgery and Critical Care, Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
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Latifi R, Samson D, Haider A, Azim A, Iftikhar H, Joseph B, Tilley E, Con J, Gashi S, El-Menyar A. Risk-adjusted adverse outcomes in complex abdominal wall hernia repair with biologic mesh: A case series of 140 patients. Int J Surg 2017; 43:26-32. [PMID: 28526657 DOI: 10.1016/j.ijsu.2017.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 04/13/2017] [Revised: 04/17/2017] [Accepted: 05/14/2017] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Biologic mesh is preferred for repair of complex abdominal wall hernias (CAWHs) in patients at high risk of wound infection. We aimed to identify predictors of adverse outcomes after complex abdominal wall hernia repair (CAWR) using biologic mesh with different placement techniques and under different surgical settings. METHODS A retrospective case series study was conducted on all patients who underwent CAWR with biologic mesh between 2010 and 2015 at a tertiary medical center. RESULTS the study population included 140 patients with a mean age of 54 ± 14 years and a median follow up period 8.8 months. Mesh size ranged from 50 to 1225 cm2. Ninety percent of patients had undergone previous surgery. Type of surgery was classified as elective in 50.7%, urgent in 24.3% and emergent in 25.0% and a porcine mesh was implanted in 82.9%. The most common mesh placement technique was underlay (70.7%), followed by onlay (16.4%) and bridge (12.9%). Complications included wound complications (30.7%), reoperation (25.9%), hernia recurrence (20.7%), and mesh removal (10.0%). Thirty-two patients (23.0%) were admitted to the ICU and the mean hospital length of stay was 10.8 ± 17.5 days. Age-sex adjusted predictors of recurrence were COPD (OR 4.2; 95%CI 1.003-17.867) and urgent surgery (OR 10.5; 95%CI 1.856-59.469), whereas for reoperation, mesh size (OR 6.8; 95%CI 1.344-34.495) and urgent surgery (OR 5.2; 95%CI 1.353-19.723) were the predictors. CONCLUSIONS Using biologic mesh, one-quarter and one-fifth of CAWR patients are complicated with reoperation or recurrence, respectively. The operation settings and comorbidity may play a role in these outcomes regardless of the mesh placement techniques.
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Affiliation(s)
- Rifat Latifi
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA; Department of Surgery, The University of Arizona, Tucson, AZ, USA.
| | - David Samson
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ansab Haider
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Asad Azim
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Hajira Iftikhar
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Bellal Joseph
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Elizabeth Tilley
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Jorge Con
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Saranda Gashi
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ayman El-Menyar
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Leung A, Bonasso P, Lynch K, Long D, Vaughan R, Wilson A, Con J. Pediatric Secondary Overtriage in a Statewide Trauma System. Am Surg 2016; 82:763-767. [PMID: 27670555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Secondary overtriage is a term that describes patients who are discharged home shortly after being transferred, an indication that transfer and hospitalization were unnecessary. The study goal was to identify factors associated with secondary triage. A statewide trauma registry was used to identify trauma patients aged less than 18 years during a 6-year period (2007-2012) who were discharged within 48 hours from arrival and did not undergo a surgical procedure. We compared those that were treated at initial facility and those transferred to a second facility using clinical indices including patterns of injury pattern using multivariate logistic regression. Of the 4441 patients who fit our inclusion criteria, 801 (18%) were transferred. Younger age groups were more likely to be transferred. Factors associated with being transferred included head, spinal, and facial injuries, and patient arrival during the nighttime work shifts. In conclusion, young patients who have signs of possible neurological or spinal injuries and those who arrive during nondaytime shifts during the workday are more likely to be transferred to another trauma center. These may reflect the comfort level and resources of the local facility.
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Affiliation(s)
- Alexander Leung
- Department of Surgery, West Virginia University, Morgantown, West Virginia, USA
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Abstract
Secondary overtriage is a term that describes patients who are discharged home shortly after being transferred, an indication that transfer and hospitalization were unnecessary. The study goal was to identify factors associated with secondary triage. A statewide trauma registry was used to identify trauma patients aged less than 18 years during a 6-year period (2007–2012) who were discharged within 48 hours from arrival and did not undergo a surgical procedure. We compared those that were treated at initial facility and those transferred to a second facility using clinical indices including patterns of injury pattern using multivariate logistic regression. Of the 4441 patients who fit our inclusion criteria, 801 (18%) were transferred. Younger age groups were more likely to be transferred. Factors associated with being transferred included head, spinal, and facial injuries, and patient arrival during the nighttime work shifts. In conclusion, young patients who have signs of possible neurological or spinal injuries and those who arrive during nondaytime shifts during the workday are more likely to be transferred to another trauma center. These may reflect the comfort level and resources of the local facility.
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Affiliation(s)
- Alexander Leung
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Patrick Bonasso
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Kevin Lynch
- School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Dustin Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Richard Vaughan
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia
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Lynch K, Cho S, Andres R, Knight J, Con J. Pre-operative Identification and Surgical Management of the Appendiceal Mucocele: A Case Report. W V Med J 2016; 112:28-30. [PMID: 27491099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
An appendiceal mucocele (AM) is an uncommon differential in the patient being evaluated for acute appendicitis. Although often asymptomatic, AMs can clinically mimic acute appendicitis, and preoperative distinction between these processes facilitates optimal management. We report the case of a 60-year-old male with an AM presenting with nausea and periumbilical pain radiating to the right lower quadrant. Literature relevant to the diagnosis and treatment of AMs is reviewed, with emphasis on diagnosis through radiographic imaging and surgical management. Abdominal CT scan or ultrasound are useful in identifying AMs preoperatively. A decision to perform a right hemicolectomy should be influenced by the criteria reported by Gonzalez-Moreno. The safety of the laparoscopic resection relative to an open appendectomy is debated.
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Lynch KT, Essig RM, Long DM, Wilson A, Con J. Nationwide secondary overtriage in level 3 and level 4 trauma centers: are these transfers necessary? J Surg Res 2016; 204:460-466. [PMID: 27565083 DOI: 10.1016/j.jss.2016.05.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/29/2016] [Accepted: 05/18/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Secondary overtriage (SO) refers to the interfacility transfer of trauma patients who are rapidly discharged home without surgical intervention by the receiving institution. SO imposes a financial hardship on patients and strains trauma center resources. Most studies on SO have been conducted from the perspective of the receiving hospital, which is usually a level 1 trauma center. Having previously studied SO from the referring rural hospital's perspective, we sought to identify variables contributing to SO at the national level. METHODS Using data from the 2008-2012 National Trauma Data Bank, we isolated patients transferred to level 1 trauma centers who were: (1) discharged home within 48 h and (2) did not undergo any surgical procedure. This population was subsequently compared with similar patients treated at and discharged directly from level 3 and 4 centers. Multivariate logistic regression analysis was used to isolate variables that independently influenced a patient's risk of undergoing SO. Injury patterns were characterized by use of subspecialty consultants. RESULTS A total of 99,114 patients met inclusion criteria, of which 13.2% were discharged directly from level 3 or 4 trauma centers, and 86.8% of them were transferred to a level 1 trauma center before discharge. The mean Injury Severity Score of the nontransfer and transfer groups was 5.4 ± 4.5 and 7.3 ± 5.7, respectively. Multivariate regression analysis showed that Injury Severity Score > 15, alcoholism, smoking, drug use, and certain injury patterns involving the head, vertebra, and face were associated with being transferred. In this minimally injured population, factors protective against transfers were: age > 65 y, female gender, systolic blood pressure <80, a head computed tomography scan and orthopedic injuries. CONCLUSIONS SO results from the complex interplay of variables including patient demographics, facility characteristics, and injury type. The inability to exclude a potentially devastating neurologic injury seems to drive SO.
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Affiliation(s)
- Kevin T Lynch
- School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Rachael M Essig
- School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Dustin M Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia.
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Con J, Long D, Sasala E, Khan U, Knight J, Schaefer G, Wilson A. Secondary overtriage in a statewide rural trauma system. J Surg Res 2015; 198:462-7. [PMID: 25959835 DOI: 10.1016/j.jss.2015.03.077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 01/01/2015] [Revised: 03/10/2015] [Accepted: 03/25/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in resources and operational goals. "Secondary overtriage" refers to the patient who is discharged home shortly after being transferred from another hospital. An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole. MATERIALS AND METHODS Data were extracted from a statewide trauma registry from 2007-2012 to include those who were (1) discharged home within 48 h of arrival and (2) did not undergo a surgical procedure. We then identified those who arrived as a transfer before being discharged (secondary overtriage) from those who arrived from the scene. Factors associated with transfers were analyzed using a logistic regression. Injuries were classified based on the need of a specific consultant. Time of arrival to the emergency department was analyzed using 8-h blocks, with the 7 AM-3 PM block as reference. RESULTS A total of 19,319 patients fit our inclusion criteria of which 1897 (9.8%) arrived as transfers. Descriptive analysis showed a number of differences between transfers and nontransfers because of our large sample size. Thus, we examined variables that had more clinical significance using logistic regression controlling for age, injury severity score, the type of injury, blood products given, the time of arrival to initial emergency room, and whether a computed tomography scan was obtained initially. Factors associated with being transferred were injury severity score >15, transfusion of packed-red-blood-cells, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries. Patients having a computed tomography scan were less likely to be transferred. CONCLUSIONS Secondary overtriage may result from the hospital's limited resources. Some of these limitations are the availability of surgical specialists, blood products, and overall coverage during the "graveyard-shift." However, some of these transfers may be appropriate even though patients are ultimately discharged shortly after transfer.
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Affiliation(s)
- Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia.
| | - Dustin Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Emily Sasala
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Uzer Khan
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jennifer Knight
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Greg Schaefer
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- Department of Surgery, West Virginia University, Morgantown, West Virginia
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Con J, Friese RS, Long DM, Zangbar B, O'Keeffe T, Joseph B, Rhee P, Tang AL. Falls from ladders: age matters more than height. J Surg Res 2014; 191:262-7. [PMID: 25066188 PMCID: PMC4419695 DOI: 10.1016/j.jss.2014.05.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/16/2014] [Accepted: 05/23/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Falls from ladders account for a significant number of hospital visits. However, the epidemiology, injury pattern, and how age affects such falls are poorly described in the literature. MATERIALS AND METHODS Patients ≥18 y who suffered falls from ladders over a 5½-y period were identified in our trauma registry. Dividing patients into three age groups (18-45, 46-65, and >66 y), we compared demographic characteristics, clinical data, and outcomes including injury pattern and mortality. The odds ratios (ORs) were calculated with the group 18-45 y as reference; group means were compared with one-way analysis of variance. RESULTS Of 27,155 trauma patients, 340 (1.3%) had suffered falls from ladders. The average age was 55 y, with a male predominance of 89.3%. Average fall height was 9.8 ft, and mean Injury Severity Score was 10.6. Increasing age was associated with a decrease in the mean fall height (P < 0.001), an increase in the mean Injury Severity Score (P < 0.05), and higher likelihood of admission (>66 y: OR, 5.3; confidence interval [CI], 2.5-11.5). In univariate analysis, patients in the >66-y age group were more likely to sustain traumatic brain injuries (OR, 3.4; CI, 1.5-7.8) and truncal injuries (OR, 3.6; CI, 1.9-7.0) and less likely to sustain hand and/or forearm fractures (OR, 0.3; CI, 0.1-0.9). CONCLUSIONS Older people are particularly vulnerable after falling from ladders. Although they fell from lower heights, the elderly sustained different and more severe injury patterns. Ladder safety education should be particularly tailored at the elderly.
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Affiliation(s)
- Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia.
| | | | - Dustin M Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Bardiya Zangbar
- Department of Surgery, University of Arizona, Tucson, Arizona
| | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew L Tang
- Department of Surgery, University of Arizona, Tucson, Arizona
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Con J, Tang A, O'Keeffe T, Wynne J, Kulvatunyou N, Joseph B, Gries L, Green D, Rhee P, Friese R. Fall from a Ladder: Age Matters More Than Height. J Surg Res 2012. [DOI: 10.1016/j.jss.2011.11.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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