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Anandalwar SP, O'Meara L, Vesselinov R, Zhang A, Baum JN, Cooper A, Decker C, Schroeppel T, Cai J, Cullinane D, Catalano RD, Bugaev N, LeClair M, Feather C, McBride K, Sams V, Leung PS, Olafson S, Callahan DS, Posluszny J, Moradian S, Estroff J, Hochman B, Coleman N, Goldenberg-Sandau A, Nahmias J, Rosenbaum K, Pasley J, Boll L, Hustad L, Reynolds J, Truitt M, Ghneim M. Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study. J Trauma Acute Care Surg 2024:01586154-990000000-00691. [PMID: 38595274 DOI: 10.1097/ta.0000000000004278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
INTRODUCTION To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.
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Affiliation(s)
- Seema P Anandalwar
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Lindsay O'Meara
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Roumen Vesselinov
- Department of Epidemiology & Public Health, University of Maryland Medical Center, Baltimore Maryland
| | - Ashling Zhang
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Amanda Cooper
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Cassandra Decker
- Department of Surgery, UCHealth Memorial Hospital, Colorado Springs
| | | | - Jenny Cai
- Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | | | - Nikolay Bugaev
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Madison LeClair
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | | | - Valerie Sams
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Pak Shan Leung
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samantha Olafson
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Devon S Callahan
- Department of Surgery, Allina Health/Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Joseph Posluszny
- Separtment of Surgery, Northwestern University, Evanston, Illinois
| | - Simon Moradian
- Separtment of Surgery, Northwestern University, Evanston, Illinois
| | - Jordan Estroff
- Department of Surgery, George Washington University, Washington D.C
| | - Beth Hochman
- Columbia University Irving Medical Center, New York, New York
| | - Natasha Coleman
- Columbia University Irving Medical Center, New York, New York
| | | | - Jeffry Nahmias
- University of California Irvine Medical Center, Irvine, California
| | | | | | | | | | | | | | - Mira Ghneim
- Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Bhattacharya B, Kodadek L, Nichiporenko I, Morrissey S, Kirsch J, Choi J, Ladhani H, Kasotakis G, Mukherjee K, Narsule C, Sharma R, Ruangvoravat L, Grushka J, Rattan R, Bugaev N. Role of Vena Cava Filter in the Prophylaxis and Treatment of Venous Thromboembolism in Injured Adult Patients: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2024:01586154-990000000-00653. [PMID: 38454308 DOI: 10.1097/ta.0000000000004289] [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] [Indexed: 03/09/2024]
Abstract
BACKGROUND Injured patients are at an increased risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). Inferior vena cava (IVC) filters have been used in injured patients to prevent venous thromboembolism (VTE), but current evidence-based guidelines are lacking. METHODS Questions regarding IVC filter use in injured patients with clearly defined Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes (PICO) were formulated. The study sought to understand the evidence behind use of ultra short term IVC filters and use of IVC filters in injured patients with and without known VTE who are unable to receive therapeutic anticoagulation and chemoprophylaxis, respectively. A literature search and review was conducted, followed by meta-analysis. The quality of evidence was assessed per Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS There were twenty-one studies that were analyzed. Three studies were randomized controlled trials (RCTs), three were observational studies, and fifteen studies were retrospective studies. In injured patients without known acute VTE who cannot receive chemoprophylaxis, we recommend against placement of an IVC filter due to associated higher rate of mortality, DVT, PE, and length of stay. The quality of evidence was assessed to be low. In injured patients with known DVT who cannot receive chemoprophylaxis we conditionally recommend against placement of an IVC filter. The quality of evidence was assessed to be very low. No recommendations can be made with respect to placement of ultra short term IVC filters based upon available data. CONCLUSION IVC filters should not be placed routinely for prophylaxis in injured adult patients without known VTE who cannot receive chemoprophylaxis. The taskforce conditionally recommends against the placement of IVC filter in injured adult patients with known DVT who cannot receive chemoprophylaxis. LEVEL OF EVIDENCE Guideline; Systematic review/meta-analysis, level IV.
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Affiliation(s)
| | - Lisa Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | | | - Jordan Kirsch
- Section of Trauma and Acute Care Surgery, Westchester Medical Center, Valhalla, NY
| | - Jeff Choi
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Husayn Ladhani
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - George Kasotakis
- Division of Trauma & Acute Care Surgery, Inova Fairfax Medical Campus, Falls Church, VA, University of Virginia
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Health, Loma Linda, CA
| | - Chaitan Narsule
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Rahul Sharma
- Section of Trauma and Acute Care Surgery, Mercy Hospital - St. Louis, St. Louis, MO
| | | | | | - Rishi Rattan
- Department of Surgery, Legacy Emanuel Medical Center, Portland, OR
| | - Nikolay Bugaev
- Associate Professor of Surgery, Emergency Surgical Services, Executive Director of Research, Department of Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington st, #4488, Boston, MA, 02111
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Spoor K, Cull JD, Otaibi BW, Hazelton JP, Chipko J, Reynolds J, Fugate S, Pederson C, Zier LB, Jacobson LE, Williams JM, Easterday TS, Byerly S, Mentzer C, Hawke E, Cullinane DC, Ontengco JB, Bugaev N, LeClair M, Udekwu P, Josephs C, Noorbaksh M, Babowice J, Velopulos CG, Urban S, Goldenberg A, Ghobrial G, Pickering JM, Quarfordt SD, Aunchman AF, LaRiccia AK, Spalding C, Catalano RD, Basham JE, Edmundson PM, Nahmias J, Tay E, Norwood SH, Meadows K, Wong Y, Hardman C. Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study. Trauma Surg Acute Care Open 2024; 9:e001159. [PMID: 38464553 PMCID: PMC10921525 DOI: 10.1136/tsaco-2023-001159] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/25/2023] [Indexed: 03/12/2024] Open
Abstract
Objectives There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence IV.
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Affiliation(s)
- Kristen Spoor
- Prisma Health Upstate, Greenville, South Carolina, USA
| | - John David Cull
- Surgery, Prisma Health Upstate, Greenville, South Carolina, USA
| | - Banan W Otaibi
- Pennsylvania State University, Hershey, Pennsylvania, USA
| | | | - John Chipko
- Research Medical Center, Kansas City, Missouri, USA
| | | | - Sam Fugate
- University of Kentucky HealthCare, Lexington, Kentucky, USA
| | | | - Linda B Zier
- Medical Center of the Rockies, Loveland, Colorado, USA
| | - Lewis E Jacobson
- Trauma Department, St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | - Jamie M Williams
- Trauma Department, St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | | | | | - Caleb Mentzer
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Edward Hawke
- Spartanburg Regional Health System, Spartanburg, South Carolina, USA
| | | | | | | | | | - Pascal Udekwu
- Surgery, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | | | | | | | | | - Shane Urban
- Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Anna Goldenberg
- Trauma, Acute Care Surgery, and Surgical Critical Care, Cooper University Hospital Regional Trauma Center, Camden, New Jersey, USA
| | | | | | | | - Alia F Aunchman
- University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Chance Spalding
- Trauma and Acute Care Surgery, Grant Medical Center, Columbus, Ohio, USA
| | - Richard D Catalano
- Loma Linda University Adventist Health Sciences Center, Loma Linda, California, USA
| | | | | | | | - Erika Tay
- Texas Health Presbyterian Hospital, Dallas, Texas, USA
| | | | | | - Yee Wong
- Premier Health Partners Inc, Dayton, Ohio, USA
| | - Claire Hardman
- Wright State Physicians, Department of Surgery, Dayton, Ohio, USA
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Wuopio A, Baker BM, Koethe B, Goodman MD, Shin R, Bugaev N, Nepomnayshy D, Kim WC, Schnelldorfer T. Can Surgeons Reliably Identify Non-cirrhotic Liver Disease During Laparoscopic Bariatric Surgery? Obes Surg 2024; 34:769-777. [PMID: 38280161 DOI: 10.1007/s11695-024-07070-2] [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: 09/17/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 01/29/2024]
Abstract
INTRODUCTION Identification of liver disease during bariatric operations is an important task given the patients risk for occult fatty liver disease. Surgeon's accuracy of assessing for liver disease during an operation is poorly understood. The objective was to measure surgeons' performance on intra-operative visual assessment of the liver in a simulated environment. METHODS Liver images from 100 patients who underwent laparoscopic bariatric surgery and pre-operative ultrasound elastography between July 2020 and July 2021 were retrospectively evaluated. The perception of 15 surgeons regarding the degree of hepatic steatosis and fibrosis was collected in a simulated clinical environment by survey and compared to results determined by ultrasonographic exam. RESULTS The surgeons' ability to correctly identify the class of steatosis and fibrosis was poor (accuracy 61% and 59%, respectively) with a very weak correlation between the surgeon's predicted class and its true class (r = 0.17 and r = 0.12, respectively). When liver disease was present, surgeons completely missed its presence in 26% and 51% of steatosis and fibrosis, respectively. Digital image processing demonstrated that surgeons subjectively classified steatosis based on the "yellowness" of the liver and fibrosis based on texture of the liver, despite neither correlating with the true degree of liver disease. CONCLUSION Laparoscopic visual assessment of the liver surface for identification of non-cirrhotic liver disease was found to be an inaccurate method during laparoscopic bariatric surgery. While validation studies are needed, the results suggest the clinical need for alternative approaches.
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Affiliation(s)
- Alexandra Wuopio
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, 01805, USA
| | | | - Benjamin Koethe
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, 02111, USA
| | - Martin D Goodman
- Department of Surgery, Tufts Medical Center, Boston, MA, 02111, USA
| | - Reuben Shin
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, 01805, USA
| | - Nikolay Bugaev
- Department of Surgery, Tufts Medical Center, Boston, MA, 02111, USA
| | - Dmitry Nepomnayshy
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, 01805, USA
| | - Woon Cho Kim
- Department of Surgery, Tufts Medical Center, Boston, MA, 02111, USA
| | - Thomas Schnelldorfer
- Department of Surgery, Tufts Medical Center, Boston, MA, 02111, USA.
- Department of Translational Research, Lahey Hospital and Medical Center, Burlington, MA, 01805, USA.
- Surgical Imaging Lab, Tufts Medical Center, Boston, MA, 02111, USA.
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Bugaev N, Como JJ. Early control of non-compressible abdominal hemorrhage when resources are scarce: where do we stand and where should we go? Trauma Surg Acute Care Open 2024; 9:e001393. [PMID: 38375025 PMCID: PMC10875471 DOI: 10.1136/tsaco-2024-001393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Affiliation(s)
- Nikolay Bugaev
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - John J Como
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
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Abosena W, Tedesco A, Han SM, Bugaev N, Hojman HM, Johnson BP, Kim WC, Bawazeer M, Bloom JA. A Cost-Effectiveness Analysis of Wittmann Patch-Assisted Abdominal Closure Compared to Planned Ventral Hernia in Management of the Open Abdomen. Am Surg 2024:31348241227214. [PMID: 38195166 DOI: 10.1177/00031348241227214] [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: 01/11/2024]
Abstract
BACKGROUND Inability to achieve primary fascial closure after damage control laparotomy is a frequently encountered problem by acute care and trauma surgeons. This study aims to compare the cost-effectiveness of Wittmann patch-assisted closure to the planned ventral hernia closure. METHODS A literature review was performed to determine the probabilities and outcomes for Wittmann patch-assisted primary closure and planned ventral hernia closure techniques. Average utility scores were obtained by a patient-administered survey for the following: rate of successful surgeries (uncomplicated abdominal wall closure), surgical site infection, wound dehiscence, abdominal hernia and enterocutaneous fistula. A visual analogue scale (VAS) was utilized to assess the survey responses and then converted to quality-adjusted life years (QALYs). Total cost for each strategy was calculated using Medicare billing codes. A decision tree was generated with rollback and incremental cost-utility ratio (ICUR) analyses. Sensitivity analyses were performed to account for uncertainty. RESULTS Wittmann patch-assisted closure was associated with higher clinical effectiveness of 19.43 QALYs compared to planned ventral hernia repair (19.38), with a relative cost reduction of US$7777. Rollback analysis supported Wittmann patch-assisted closure as the more cost-effective strategy. The resulting negative ICUR of -156,679.77 favored Wittmann patch-assisted closure. Monte Carlo analysis demonstrated a confidence of 96.8% that Wittmann patch-assisted closure was cost-effective. CONCLUSIONS This study demonstrates using the Wittmann patch-assisted closure strategy as a more cost-efficient management of the open abdomen compared to the planned ventral hernia approach.
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Affiliation(s)
- Wael Abosena
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Sam M Han
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Nikolay Bugaev
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | | | - Woon C Kim
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Joshua A Bloom
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
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Mahoney EJ, Bugaev N, Appelbaum R, Goldenberg-Sandau A, Baltazar GA, Posluszny J, Dultz L, Kartiko S, Kasotakis G, Como J, Klein E. Response to letter to the editor regarding article: Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2023; 95:e62-e63. [PMID: 37683253 DOI: 10.1097/ta.0000000000004111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
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Bottom-Tanzer SF, Poyant JO, Louzada MT, Abela D, Boudouvas A, Poon E, Power L, Kim WC, Hojman HM, Bugaev N, Johnson BP, Bawazeer MA, Mahoney EJ. Longitudinal study evaluating post-ICU syndrome differences between acute care surgery and trauma SICU survivors. J Trauma Acute Care Surg 2023; 95:893-898. [PMID: 37314426 DOI: 10.1097/ta.0000000000003977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Post-intensive care unit (ICU) syndrome (PICS) occurs at an exorbitant rate in surgical ICU (SICU) survivors. It remains unknown if critical illness due to trauma versus acute care surgery (ACS) may represent different pathophysiologic entities. In this longitudinal study, we determined if admission criteria in a cohort of trauma and ACS patients were associated with differences in the occurrence of PICS. METHODS Patients were 18 years or older, admitted to a Level I trauma center to the trauma or ACS services, remained in the SICU for ≥72 hours, and were seen in an ICU Recovery Center at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. Post-ICU syndrome sequelae were diagnosed by dedicated specialist staffing using clinical criteria and screening questionnaires. The PICS symptoms were distilled into physical, cognitive, and psychiatric categories. Preadmission histories, hospital courses, and recovery data were collected via retrospective chart review. RESULTS One hundred twenty-six patients were included: 74 (57.3%) trauma patients and 55 (42.6%) ACS patients. Prehospital psychosocial histories were similar between groups. Acute care surgery patients had a significantly longer hospital course, higher APACHE II and III scores, were intubated for longer, and had higher rates of sepsis, acute renal failure, open abdomen, and hospital readmissions. At the 2-week follow-up visit, ACS patients had higher rates of PICS sequelae (ACS, 97.8% vs. trauma 85.3%; p = 0.03), particularly in the physical (ACS, 95.6% vs. trauma 82.0%, p = 0.04), and psychiatric domains (ACS, 55.6% vs. trauma 35.0%, p = 0.04). At the 12-week and 24-week visits, rates of PICS symptoms were comparable between groups. CONCLUSION The occurrence of PICS is extraordinarily high in both trauma and ACS SICU survivors. Despite entering the SICU with similar psychosocial histories, the two cohorts have different pathophysiologic experiences, which are associated with a higher rate of impairment in the ACS patients during early follow-up. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Samantha F Bottom-Tanzer
- From the Tufts University School of Medicine & Tufts Graduate School of Biomedical Sciences (S.F.B.-T., D.A., L.P.); Department of Pharmacy (J.O.P.), Tufts Medical Center; Department of General Surgery, Tufts Medical Center (M.T.L.), Tufts University School of Medicine,; Department of Physical and Occupational Therapy (A.B., E.P.), Tufts Medical Center; Division of Trauma & Acute Care Surgery (W.C.K., H.M.H., N.B., B.P.J., M.A.B.), Tufts Medical Center, Tufts University School of Medicine, Boston; and Division of Surgical Critical Care (E.J.M.), Lahey Hospital & Medical Center, Burlington, Massachusetts
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Ardeshna S, Esposito E, Spalding C, Dunn J, Nahmias J, Grigorian A, Harmon L, Gergen A, Young A, Pascual J, Murry J, Ong A, Appelbaum R, Bugaev N, Tatar A, Zreik K, Scalea TM, Stein D, Lauerman M. Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury. Am Surg 2023; 89:5183-5190. [PMID: 36417771 DOI: 10.1177/00031348221138083] [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
BACKGROUND Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.
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Affiliation(s)
| | | | | | - Julie Dunn
- University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Anna Gergen
- University of Colorado Denver, Denver, CO, USA
| | - Andrew Young
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jose Pascual
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Rachel Appelbaum
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Deborah Stein
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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O'Meara L, Zhang A, Baum JN, Cooper A, Decker C, Schroeppel T, Cai J, Cullinane DC, Catalano RD, Bugaev N, LeClair MJ, Feather C, McBride K, Sams V, Leung PS, Olafson S, Callahan DS, Posluszny J, Moradian S, Estroff J, Hochman B, Coleman NL, Goldenberg-Sandau A, Nahmias J, Rosenbaum K, Pasley JD, Boll L, Hustad L, Reynolds J, Truitt M, Vesselinov R, Ghneim M. Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study. J Trauma Acute Care Surg 2023; 95:510-515. [PMID: 37349868 DOI: 10.1097/ta.0000000000004042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Lindsay O'Meara
- From the University of Maryland Medical Center (L.O.), Baltimore, Maryland; Mount Sinai South Nassau (J.N.B.), Oceanside, New York; Penn State Milton S. Hershey Medical Center (A.C.), Hershey, Pennsylvania; UCHealth Memorial Hospital (C.D.), Colorado Springs, Colorado; RWJMS, Rutgers at Newark (J.C.), Newark, New Jersey; Allina Health/Abbott Northwestern Hospital (D.S.C.), Minneapolis, Minnesota; Northwestern University (J.P.), Evanston, Illinois; George Washington University (J.E.), Washington, district of Columbia; Columbia University Irving Medical Center (B.H.), New York, New York; Cooper University (A.G.), Camden, New Jersey; Marshfield Clinic (D.C.C.), Marshfield, Wisconsin; Loma Linda University School of Medicine (R.D.C.), Loma Linda, California; Tufts Medical Center, Tuft University School of Medicine (N.B.), Boston, Massachusetts; Anne Arundel Medical Center (C.F.), Parole, Maryland; Memorial Health University Medical Center (K.M.), Savannah, Georgia; Brooke Army Medical Center (V.S.), Fort Sam Houston, Texas; Sidney Kimmel Medical College: Thomas Jefferson University (P.S.L.), Philadelphia, Pennsylvania; University of California Irvine Medical Center (J.N.), Irvine, California; McLaren Oakland Hospital (J.D.P.), Pontiac, Michigan; Sanford Health (L.H.), Sioux Falls, South Dakota; University of Kentucky Medical Center (J.R.), Lexington, Kentucky; and Methodist Medical Center (M.T.), Dallas, Texas
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11
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Ricard CA, Aalberg JJ, Bawazeer MA, Johnson BP, Hojman HM, Kim WC, Mahoney EJ, Bugaev N. Readmissions after emergent incisional ventral hernia repair: a retrospective review of the nationwide readmissions database. Updates Surg 2023; 75:1979-1989. [PMID: 36917365 DOI: 10.1007/s13304-023-01469-9] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023]
Abstract
Emergent ventral hernia repair (eVHR) is associated with significant morbidity, yet there is no consensus regarding optimal surgical approach. We hypothesized that eVHR with synthetic mesh would have a higher readmission rate compared to primary eVHR or biologic mesh repair. Retrospective analysis of the Nationwide Readmissions Database (NRD) was conducted for patient entries between 2016 and 2018. Adult patients who underwent eVHR were included. Patient demographics, comorbidities, and surgical techniques were compared between readmitted and non-readmitted patients. Predictors of readmission were assessed using multivariate analysis with propensity weighting for various eVHR techniques. Secondary outcomes included hospital length of stay and readmission diagnoses. 43,819 patients underwent eVHR; of the 22,732 with 6 months of follow-up, 6382 (28.1%) were readmitted. The majority of readmissions occurred within the first 30 days (51.8%). Over half of the readmissions were related to surgical complications (50.6%), the most common being superficial surgical site infection (30.1%) and bowel obstruction/ileus (12.2%). In the multivariate analysis, predictors of 30-day readmission included use of synthetic mesh (OR 1.07, 95% CI 1.00-1.14), biologic mesh (OR 1.26, 95% CI 1.06-1.49), and need for concomitant large bowel resection (OR 1.46, 95% CI 1.30-1.65). eVHR is associated with high rates of readmission. Primary repair had favorable odds for readmission and lower risk of surgical complications compared to synthetic and biologic mesh repairs. Synthetic repair had lower odds of readmission than biologic repair. Given the inherent limitations of the NRD, further institutional prospective studies are required to confirm these findings.
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Affiliation(s)
| | | | - Mohammed A Bawazeer
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Benjamin P Johnson
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Horacio M Hojman
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Woon Cho Kim
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Eric J Mahoney
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Nikolay Bugaev
- Emergency Surgical Services, Department of Surgery, Tufts Medical Center, Boston, MA, USA
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12
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Ra JH, Rattan R, Patel NJ, Bhattacharya B, Butts CA, Gupta S, Asfaw SH, Como JJ, Sahr SM, Bugaev N. Duration of antimicrobial treatment for complicated intra-abdominal infections after definitive source control: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2023; 95:603-612. [PMID: 37316989 DOI: 10.1097/ta.0000000000003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Recent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. METHODS A working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs. long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Noninferiority of short compared with long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and to formulate recommendations. RESULTS Sixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1 day to 28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.56-1.44), rate of surgical site infection (OR, 0.88; 95% CI, 0.56-1.38); persistent/recurrent abscess (OR, 0.76; 95% CI, 0.45-1.29); unplanned interventions (OR, 0.53; 95% CI, 0.12-2.26); hospital length of stay (mean difference, -2.62 days; CI, -7.08 to 1.83 days); or readmissions (OR, 0.92; 95% CI, 0.50-1.69). The level of evidence was assessed as very low. CONCLUSION The group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
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Affiliation(s)
- Jin H Ra
- Department of Surgery, UNC-Chapel Hill (J.H.R.), Chapel Hill, North Carolina; DeWitt Daughtry Family Department of Surgery (R.R.), University of Miami Miller School of Medicine, Miami, Florida; Department of Surgery MetroHealth Medical Center (N.J.P.), Case Western Reserve University, Cleveland, Ohio; Department of Surgery, Yale School of Medicine (B.B.), New Haven, Connecticut; Department of Surgery Rutgers Robert Wood Johnson Medical School (C.A.B.), New Brunswick, New Jersey; Department of Surgery (S.G.), School of Medicine, University of Maryland, College Park, Maryland; Department of Surgery, Cleveland Clinic, Digestive Disease and Surgical Institute (S.H.A.); Department of Surgery, MetroHealth Medical Center (J.J.C.), Cleveland, Ohio; Sanford Medical Center (S.M.S.), Fargo, North Dakota; and Department of Surgery, Tufts Medical Center, Tufts School of Medicine (N.B.), Boston, Massachusetts
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13
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Ghneim M, Kufera J, Zhang A, Penaloza-Villalobos L, Swentek L, Watras J, Smith A, Hahn A, Rodriguez Mederos D, Dickhudt TJ, Laverick P, Cunningham K, Norwood S, Fernandez L, Jacobson LE, Williams JM, Lottenberg L, Azar F, Shillinglaw W, Slivinski A, Nahmias J, Donnelly M, Bala M, Egodage T, Zhu C, Udekwu PO, Norton H, Dunn JA, Baer R, McBride K, Santos AP, Shrestha K, Metzner CJ, Murphy JM, Schroeppel TJ, Stillman Z, O'Connor R, Johnson D, Berry C, Ratner M, Reynolds JK, Humphrey M, Scott M, Hickman ZL, Twelker K, Legister C, Glass NE, Siebenburgen C, Palmer B, Semon GR, Lieser M, McDonald H, Bugaev N, LeClair MJ, Stein D. Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial. J Trauma Acute Care Surg 2023; 95:516-523. [PMID: 37335182 DOI: 10.1097/ta.0000000000004095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Mira Ghneim
- From the R Adams Cowley Shock Trauma Center (M.G., D.S.), Program in Trauma, Department of Surgery, University of Maryland School of Medicine; National Study Center for Trauma and Emergency Medical Systems, Program in Trauma, Center for Shock, Trauma and Anesthesiology Research (J.K.), University of Maryland School of Medicine; University of Maryland School of Medicine (A.Z.); Department of Surgery (L.P.-V., L.S.), Loma Linda University Medical Center; Inova Fairfax Hospital (J.W.); LSUHCS (A.S.); Ochsner Medical Center (A.H.); Broward Health Medical Center (D.R.M., T.J.D.); Atrium Health Carolinas Medical Center (P.L., K.C.); University of Texas Health Science Center (S.N., L.F.); Ascension St. Vincent Hospital (L.E.J., J.M.W.); St. Mary's Medical Center (L.L., F.A.), Florida Atlantic University, Schmidt College of Medicine; Mission Hospital (W.S., A.S.); University of California, Irvine (J.N., M.D.); Hadassah Medical Center and Faculty of Medicine (M.B.), Hebrew University of Jerusalem; Cooper University Health Care (T.E.); Cooper University Health Care (C.Z.); WakeMed Health and Hospitals (P.O.U., H.N.); Medical Center of the Rockies (J.A.D.), University of Colorado Health North; Orthopedic Center of the Rockies (R.B.); Memorial University Medical Center (K.M.); Texas Tech University Health Sciences Center (A.P.S., K.S.); Spartanburg Regional Medical Center (C.J.M., J.M.M.); Memorial Hospital Central (T.J.S., Z.S.); Yale School of Medicine (R.O., D.J.); NYU Grossman School of Medicine (C.B., M.R.,); University of Kentucky (J.K.R., M.H.); St. Mary's Medical Center (M.S.), Essentia Health; NYC Health + Hospitals/Elmhurst (Z.L.H., K.T.), Icahn School of Medicine at Mount Sinai; Rutgers New Jersey Medical School (C.L., N.E.G.); Kettering Health Main Campus (C.S., B.P.); Wright State University Boonshoft School of Medicine (G.R.S.); Research Medical Center (M.L., H.M.); Tufts Medical Center (N.B.), Tuft University School of Medicine; and Tufts Medical Center (M.J.L.)
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14
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Yang S, Esposito E, Spalding C, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Lieser MJ, Scalea TM, Stein DM, Lauerman M. Grade 1 Internal Carotid Artery Blunt Cerebrovascular Injury Persistence Risks Stroke With Current Management: An EAST Multicenter Study. Am Surg 2023; 89:2618-2627. [PMID: 35652129 DOI: 10.1177/00031348221082277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics. METHODS A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only. RESULTS From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury. DISCUSSION While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.
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Affiliation(s)
- Sarah Yang
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | - Linda Zier
- University of Colorado, Loveland, CO, USA
| | | | - Paul Kim
- Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Andrew J Young
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margaret Lauerman
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Tian T, Bugaev N, Johnson BP, Mahoney E, Nilson J, Sekhar P, Hojman H. Novel Tracheostomy and Percutaneous Endoscopic Gastrostomy Technique for COVID-19 Patients in a Nonnegative Pressure Environment. Am Surg 2023; 89:493-495. [PMID: 33284040 PMCID: PMC8687880 DOI: 10.1177/0003134820960072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tina Tian
- Department of Surgery, Division of
Trauma, Acute Care Surgery, and Surgical Critical Care, Tufts Medical Center, MA, USA,Tina Tian, Department of Surgery, Division
of Trauma, Acute Care Surgery, and Surgical Critical Care, Tufts Medical Center,
800 Washington Street, Boston 02111, MA, USA.
| | - Nikolay Bugaev
- Department of Surgery, Division of
Trauma, Acute Care Surgery, and Surgical Critical Care, Tufts Medical Center, MA, USA
| | - Benjamin P. Johnson
- Department of Surgery, Division of
Trauma, Acute Care Surgery, and Surgical Critical Care, Tufts Medical Center, MA, USA
| | - Eric Mahoney
- Department of Surgery, Division of
Trauma, Acute Care Surgery, and Surgical Critical Care, Tufts Medical Center, MA, USA
| | - James Nilson
- Department of Anesthesiology and
Perioperative Medicine, Tufts Medical Center, MA, USA
| | - Pavan Sekhar
- Department of Anesthesiology and
Perioperative Medicine, Tufts Medical Center, MA, USA
| | - Horacio Hojman
- Department of Surgery, Division of
Trauma, Acute Care Surgery, and Surgical Critical Care, Tufts Medical Center, MA, USA
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16
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Aziz HA, Bugaev N, Baltazar G, Brown Z, Haines K, Gupta S, Yeung L, Posluszny J, Como J, Freeman J, Kasotakis G. Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma. BMC Surg 2023; 23:22. [PMID: 36707832 PMCID: PMC9881253 DOI: 10.1186/s12893-023-01914-x] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma. METHODS The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation. RESULTS A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends. CONCLUSION In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury. LEVEL OF EVIDENCE Guideline; systematic review, level III.
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Affiliation(s)
- Hiba Abdel Aziz
- grid.260024.20000 0004 0627 4571Midwestern University, Drowners Grove, USA
| | - Nikolay Bugaev
- grid.67033.310000 0000 8934 4045Tufts Medical Center, Boston, USA
| | - Gerard Baltazar
- grid.240324.30000 0001 2109 4251New York University Langone Medical Center, New York, USA
| | - Zachary Brown
- grid.427904.c0000 0001 2315 4051United States Department of Army, Arlington County, USA
| | - Krista Haines
- grid.414179.e0000 0001 2232 0951Duke Medical Center, Durham, USA
| | - Sameer Gupta
- grid.412034.00000 0001 0300 7302Nassau University Medical Center, East Meadow, USA
| | - Lawrence Yeung
- grid.15276.370000 0004 1936 8091University of Florida, Gainesville, USA
| | - Joseph Posluszny
- grid.16753.360000 0001 2299 3507Northwestern University, Evanston, USA
| | - John Como
- grid.411931.f0000 0001 0035 4528Metrohealth Medical Center, Cleveland, USA
| | - Jennifer Freeman
- grid.264766.70000 0001 2289 1930Texas Christian University, Fort Worth, USA
| | - George Kasotakis
- grid.412100.60000 0001 0667 3730Duke University Health System, Durham, USA
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17
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Appelbaum RD, Esposito E, Spaulding MC, Simpson JP, Dunn J, Zier LB, Burruss S, Kim PP, Jacobson LE, Williams JM, Nahmias J, Grigorian A, Harmon L, Gergen AK, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Bugaev N, Tatar A, Zreik K, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study. Injury 2022; 53:3702-3708. [PMID: 36085175 DOI: 10.1016/j.injury.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. METHODS This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. RESULTS 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p < 0.001) as was the median AIS head score (2.0 vs 1.0, p < 0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. CONCLUSIONS Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.
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Affiliation(s)
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Margaret H Lauerman
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
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Mahoney EJ, Bugaev N, Appelbaum R, Goldenberg-Sandau A, Baltazar GA, Posluszny J, Dultz L, Kartiko S, Kasotakis G, Como J, Klein E. Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2022; 93:e110-e118. [PMID: 35546420 DOI: 10.1097/ta.0000000000003683] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 11/25/2022]
Abstract
BACKGROUND Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization. METHODS A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated. RESULTS Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity. CONCLUSION We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level IV.
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Affiliation(s)
- Eric J Mahoney
- From the Tufts Medical Center (E.J.M, N.B.), Division of Trauma and Acute Care Surgery, Department of Surgery, Boston, Massachusetts; Atrium Health Wake Forest Baptist (R.A.) Division of Acute Care Surgery, Department of Surgery, Winston-Salem, North Carolina; Cooper University Hospital (A.G.-S.), Division of Trauma and Acute Care Surgery, Department of Surgery, Camden, New Jersey; NYU Langone Hospital-Long Island (G.A.B.), Division of Trauma and Acute Care Surgery, Department of Surgery, Mineola, New York; Northwestern Memorial Hospital (J.P.), Division of Trauma and Critical Care, Department of Surgery, Chicago, Illinois; University of Texas Southwestern (L.D.), Division of Burn, Trauma, Acute and Critical Care Surgery, Department of Surgery, Dallas, Texas; The George Washington School of Medicine and Health Sciences (S.K.), Center of Trauma and Critical Care, Department of Surgery, Washington, District of Columbia; Duke University Medical Center (G.K.), Division of Trauma and Critical Care Surgery, Department of Surgery, Durham, North Carolina; MetroHealth Medical Center (J.C.), Cleveland, Ohio; and Northwell Health-North Shore University Hospital (E.K.) Division of Acute Care Surgery, Department of Surgery, Great Neck, New York
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19
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Urréchaga EM, Kodadek LM, Bugaev N, Bauman ZM, Shah KH, Abdel Aziz H, Beckman MA, Reynolds JM, Soe-Lin H, Crandall ML, Rattan R. Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2022; 224:1238-1246. [PMID: 35821175 DOI: 10.1016/j.amjsurg.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/11/2022] [Accepted: 06/23/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.
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Affiliation(s)
| | | | | | | | - Kaushal H Shah
- Department of Emergency Medicine, Weill Cornell Medicine, USA.
| | | | | | | | - Hahn Soe-Lin
- Department of Surgery, St. Joseph's Medical Center, USA.
| | - Marie L Crandall
- Department of Surgery, University of Florida, Jacksonville, USA.
| | - Rishi Rattan
- Department of Surgery, University of Miami, USA.
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20
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Lauerman M, Esposito E, Spalding C, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Lieser MJ, Scalea TM, Stein DM. Endovascular Intervention in Internal Carotid Artery Blunt Cerebrovascular Injury: An EAST Multicenter Study. Am Surg 2022; 88:1962-1969. [PMID: 35437020 DOI: 10.1177/00031348221078958] [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 Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown. METHODS A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use. RESULTS From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI. DISCUSSION Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.
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Affiliation(s)
- Margaret Lauerman
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Joshua Simpson
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Linda Zier
- University of Colorado, Loveland, CO, USA
| | | | - Paul Kim
- 4608Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Andrew J Young
- 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Rovinder S Sandhu
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachel Appelbaum
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nikolay Bugaev
- 1867Tufts University School of Medicine, Boston, MA, USA
| | - Antony Tatar
- 1867Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
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21
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Aicher BO, Betancourt-Ramirez A, Grossman MD, Heise H, Schroeppel TJ, Hernandez MC, Zielinski MD, Kongkaewpaisan N, Kaafarani HMA, Wagner A, Grabo D, Scott M, Peck G, Chang G, Matsushima K, Cullinane DC, Cullinane LM, Stocker B, Posluszny J, Simonoski UJ, Catalano RD, Vasileiou G, Yeh DD, Agrawal V, Truitt MS, Pickett M, Dultz L, Muller A, Ong AW, San Roman JL, Barth N, Fackelmayer O, Velopulos CG, Hendrix C, Estroff JM, Gambhir S, Nahmias J, Jeyamurugan K, Bugaev N, O'Meara L, Kufera J, Diaz JJ, Bruns BR. Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study. Am Surg 2022; 88:953-958. [PMID: 35275764 DOI: 10.1177/0003134820960022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.
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Affiliation(s)
- Brittany O Aicher
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Michael D Grossman
- Department of Surgery, Southside Hospital, Northwell Health, Bay Shore, Bay Shore, NY
| | - Holly Heise
- Department of Surgery, UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, Colorado
| | - Thomas J Schroeppel
- Department of Surgery, UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, Colorado
| | | | | | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Afton Wagner
- Department of Surgery, West Virginia University Medicine, Morgantown, West Virginia
| | - Daniel Grabo
- Department of Surgery, West Virginia University Medicine, Morgantown, West Virginia
| | - Michael Scott
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gregory Peck
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gloria Chang
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California
| | | | | | - Benjamin Stocker
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Joseph Posluszny
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ursula J Simonoski
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Richard D Catalano
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Georgia Vasileiou
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Daniel Dante Yeh
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Vaidehi Agrawal
- Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - Michael S Truitt
- Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - MaryAnne Pickett
- Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Linda Dultz
- Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Alison Muller
- Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Adrian W Ong
- Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | | | | | | | | | | | | | - Sahil Gambhir
- Department of Surgery, University of California, Irvine, Irvine, California
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Irvine, California
| | | | - Nikolay Bugaev
- Department of Surgery, Tufts University, Boston, Massachusetts
| | - Lindsay O'Meara
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Joseph Kufera
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Brandon R Bruns
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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22
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Esposito EC, Kufera JA, Wolff TW, Spalding MC, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Hustad L, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:347-354. [PMID: 34739003 DOI: 10.1097/ta.0000000000003455] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level IV.
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Affiliation(s)
- Emily C Esposito
- From the University of Maryland School of Medicine (E.E., J.A.K., T.M.S., M.H.L.), Baltimore, Maryland; Ohio State University Wexner Medical Center (T.W.W., M.C.S., A.J.Y.), Columbus, Ohio; Greenville Health System (J.S.), Greenville, South Carolina; University of Colorado (J.A.D., L.Z., La.H., An.G.), Boulder, Colorado; Loma Linda University (S.B., P.K.)., Loma Linda, California; Ascension Health (L.E.J., J.W.), St. Louis, Missouri; University of California (J.N., Ar.G.), Oakland, California; University of Miami (M.C., R.R.), Miami, Florida; Perelman School of Medicine at the University of Pennsylvania (J.L.P.), Philadelphia, Pennsylvania; UT Health Tyler (J.M.), Tyler, Texas; Towerhealth (A.W.O., A.M.), West Reading, Pennsylvania; Lehigh Valley Health Network (R.S.S., R.A.), Allentown, Pennsylvania; Tufts University School of Medicine (N.B., A.T.), Boston, Massachusetts; Sanford Health (K.Z., Le.H.), Sioux Falls, South Dakota; Research Medical Center (M.J.L.), Kansas City, Missouri; University of California San Francisco (D.M.S.), San Francisco, California
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23
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Yorkgitis BK, Tatum DM, Taghavi S, Schroeppel TJ, Noorbakhsh MR, Philps FH, Bugaev N, Mukherjee K, Bellora M, Ong AW, Ratnasekera A, Nordham KD, Carrick MM, Haan JM, Lightwine KL, Lottenberg L, Borrego R, Cullinane DC, Berne JD, Rodriguez Mederos D, Hayward TZ, Kerwin AJ, Crandall M. Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients. J Trauma Acute Care Surg 2022; 92:88-92. [PMID: 34570064 DOI: 10.1097/ta.0000000000003421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients. METHODS An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. RESULTS Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77). CONCLUSION Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk. LEVEL OF EVIDENCE Prognostic, level II.
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Affiliation(s)
- Brian K Yorkgitis
- From the Department of Surgery (B.K.Y., M.C., A.J.K.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida; Trauma Division (D.M.T.), Our Lady of the Lake RMC, Baton Rouge, Louisiana; Department of Surgery (S.T.), Tulane School of Medicine, New Orleans, Louisiana; Department of Surgery (T.J.S.), UC Health Memorial Hospital, Colorado Springs, Colorado; Department of Surgery (M.R.N., F.H.P.), Allegheny Health Network, Pittsburgh, Pennsylvania; Division of Trauma/Acute Care Surgery (N.B.), Tufts Medical Center, Boston, Massachusetts; Department of Surgery (K.M., M.B.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (A.W.O.), Reading Hospital Tower Health, Reading, Pennsylvania; Department of Surgery (A.R.), Crozer Keystone Health System, Upland, Pennsylvania; Tulane University Medical School (K.D.N.), New Orleans, Louisiana; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (J.M.H., K.L.L.), Via Christi Hospitals Wichita, Wichita, Kansas; Department of Surgery (L.L., R.B.), St. Mary's Medical Center, West Palm Beach, Florida; Department of Surgery (D.C.C.), Maine Medical Center, Portland, Maine; Department of Surgery (J.D.B., D.R.M.), Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery (T.Z.H.), Indiana University School of Medicine, Eskenazi Health, Indianapolis, Indiana
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24
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Johnson BP, Hojman HM, Mahoney EJ, Detelich D, Karamchandani M, Ricard C, Breeze JL, Bugaev N. Nationwide utilization of cardiopulmonary bypass in cardiothoracic trauma: A retrospective analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2021; 91:501-506. [PMID: 34137746 PMCID: PMC8387344 DOI: 10.1097/ta.0000000000003315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The American College of Surgeons Committee on Trauma requires that all level I trauma centers have cardiopulmonary bypass (CPB) capabilities immediately available. Despite this mandate, there are limited data on the utilization and clinical outcomes among trauma patients requiring CPB in the management of injuries. The aim of this study was to evaluate the current use of CPB in the care of trauma patients. METHODS This is a retrospective analysis of the National Trauma Data Bank from 2010 to 2015. Adult patients sustaining cardiothoracic injuries who underwent surgical repair within the first 24 hours of admission were included. Propensity score matching was used to compare outcomes (in-hospital mortality, hospital length of stay (LOS), intensive care unit LOS, and complications) between patients who underwent CPB within the first 24 hours of admission and those with similar injuries who did not receive CPB. RESULTS A total of 28,481 patients who met the inclusion criteria were identified, of whom 319 underwent CPB. Three-hundred three CPB patients were matched to 895 comparison patients who did not undergo CPB. Overall in-hospital mortality was 35%. Patients who were not treated with CPB had a significantly higher in-hospital mortality compared with those treated with CBP (odds ratio, 1.57; 95% confidence interval, 1.16-2.12; p = 0.003); however, complications were significantly lower in those who did not receive CPB (odds ratio, 0.63; 95% confidence interval, 0.47-0.86; p = 0.003). Hospital LOS (non-CPB: mean, 13.4 ± 16.3 days; CPB: mean, 14.7 ± 15.1 days; p = 0.23) and intensive care unit LOS (non-CPB: mean, 9.9 ± 10.7 days; CPB: mean, 10.1 ± 9.7 days; p = 0.08) did not differ significantly between groups. CONCLUSION The use of CPB in the initial management of select cardiothoracic injuries is associated with a survival benefit. Further investigation is required to delineate which specific injuries would benefit the most from the use of CPB. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Benjamin P Johnson
- From the Division of Trauma and Acute Care Surgery (B.P.J., H.M.H., E.J.M., N.B.), and Department of Surgery (D.D., M.K., C.R.), Tufts Medical Center; Tufts Clinical and Translational Science Institute (J.L.B.), Tufts University; and Institute for Clinical Research and Health Policy Studies (J.L.B.), Tufts Medical Center, Boston, Massachusetts
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Aalberg JJ, Johnson BP, Hojman HM, Rattan R, Arabian S, Mahoney EJ, Bugaev N. Readmission following surgical stabilization of rib fractures: Analysis of incidence, cost, and risk factors using the Nationwide Readmissions Database. J Trauma Acute Care Surg 2021; 91:361-368. [PMID: 33852561 PMCID: PMC8373660 DOI: 10.1097/ta.0000000000003227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate and cost of readmissions and to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications. METHODS This is a retrospective analysis of the 2015 to 2017 Nationwide Readmission Database. Adult patients with rib fractures treated by SSRF were included. Univariate and multivariate analyses were used to compare patients readmitted within 30 days with those who were not, based on demographics, comorbidities, and hospital characteristics. Financial information examined included average visit costs and national extrapolations. RESULTS A total of 2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients, the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted because of mostly nontrauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of US $176 million for initial admissions and US $5.9 million for readmissions. CONCLUSION Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients' preexisting medical conditions before discharge should be further investigated as a potential way to decrease rates of readmission after SSRF. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Jeffrey J Aalberg
- From the Tufts University School of Medicine (J.J.A.); Division of Trauma and Acute Care Surgery, Department of Surgery (B.P.J., H.M.H., S.A., E.J.M., N.B.), Tufts Medical Center, Boston, Massachusetts; and Division of Trauma Surgery and Critical Care (R.R.), DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
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Tutunjian AM, Arabian SS, Paolino J, Wolfe ES, Mahoney EJ, Hojman HM, Johnson BP, Bugaev N. ABO blood groups do not predict progression of traumatic intracranial hemorrhage. J Clin Neurosci 2021; 90:345-350. [PMID: 34275573 PMCID: PMC8290093 DOI: 10.1016/j.jocn.2021.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 12/25/2020] [Accepted: 06/14/2021] [Indexed: 11/21/2022]
Abstract
ABO blood groups are associated with genetically predisposed variations in von Willebrand factor (VWF) resulting in higher risks of thrombotic events in non-O blood types and bleeding complications in blood type O. The role of ABO blood groups in progression of traumatic intracranial hemorrhage (TICH) is unknown. Given statistically lower VWF levels in blood type O in the general population, we hypothesized that blood type O patients have a higher risk of such progression. A retrospective review of adult trauma patients with isolated TICH admitted to a Level 1 trauma center over eight years was conducted. Patients were categorized with blood type O and non-O (types A, B, AB) delineation. The primary outcome was radiological progression of TICH during the first 24 h. Secondary outcomes included surgical intervention after follow-up computed tomography (CT), complications, days on mechanical ventilation (DMV), intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Of 949 patients, 432 (45.5%) had blood type O. When comparing O and non-O groups, no significant differences were found in gender, age, race, admission vital signs, Glasgow Coma Scale, coagulation profile, TICH type, or Injury Severity Score. No difference in TICH progression was found between O and non-O groups: 73 (17%) vs 80 (15%), respectively, p = 0.55. Blood type O mortality was 12 (3% vs. 23 (4%), p = 0.174). Rate of TICH surgical intervention after follow-up CT, DMV, complications, and ICU and hospital LOS did not differ. No association between ABO blood types and radiological progression of TICH was identified.
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Affiliation(s)
- Alyssa M Tutunjian
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, United States.
| | - Sandra S Arabian
- Division of Trauma & Acute Care Surgery, Department of Surgery, Tufts Medical Center, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Jacqueline Paolino
- Department of Surgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111, United States
| | - Elizabeth S Wolfe
- Division of Trauma & Acute Care Surgery, Department of Surgery, Tufts Medical Center, 800 Washington St, #4488, Boston, MA 02111, United States
| | - Eric J Mahoney
- Division of Trauma & Acute Care Surgery, Department of Surgery, Tufts Medical Center, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Horacio M Hojman
- Division of Trauma & Acute Care Surgery, Department of Surgery, Tufts Medical Center, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Benjamin P Johnson
- Division of Trauma & Acute Care Surgery, Department of Surgery, Tufts Medical Center, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Department of Surgery, Tufts Medical Center, 800 Washington St, #4488, Boston, MA 02111, United States.
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Bottom-Tanzer SF, Poyant JO, Louzada MT, Ahmed SE, Boudouvas A, Poon E, Hojman HM, Bugaev N, Johnson BP, Van Kirk AL, Daniel E, Emoff C, Mahoney EJ. High occurrence of postintensive care syndrome identified in surgical ICU survivors after implementation of a multidisciplinary clinic. J Trauma Acute Care Surg 2021; 91:406-412. [PMID: 34108416 DOI: 10.1097/ta.0000000000003231] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postintensive care syndrome (PICS) has been identified in a large proportion of medical intensive care unit survivors; however, the occurrence surgical intensive care unit (SICU) survivors is unknown. We implemented a multidisciplinary critical care outpatient clinic (CCOC) to identify the occurrence of PICS in SICU survivors. METHODS Seventy acute care surgery and trauma patients, 18 years or older, who remained in the SICU for 72 hours or longer at a Level I trauma center were seen in CCOC at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. The CCOC staffing included a nurse coordinator, social worker, critical care pharmacist, physical therapist, and acute care surgeon who identified PICS sequelae in their respective specialties by clinical criteria and screening questionnaires. RESULTS Of 82 eligible patients, 70 (85.4%) were seen at least once for 116 total visits. Forty-three (61.4%) patients suffered traumatic injuries and 27 (38.6%) underwent emergent general surgery. Sixty-seven (95.7%) demonstrated at least one PICS criterion. Over all visits, 26 (37.1%) patients presented with one PICS criterion, 24 (34.3%) patients with two, and 17 (24.3%) with three. Cognitive impairment was observed in 29 (41.4%) patients, psychiatric in 30 (42.9%), and physical symptoms in 65 (92.9%). Activity Measure for Post-Acute Care scores improved from severe impairment at admission to full function by 12 weeks postdischarge, yet 6 Minute Walk Test scores remained below age-matched references through all visits. Patients expressed mild to moderate depression based on Patient Health Questionnaire-9 scores. A medication reconciliation was completed at 96.5% (112/116) of the visits with 116 total medication recommendations. By 24 weeks following discharge, only 26.4% (14/53) of previously employed patients had resumed work. CONCLUSION Through the successful implementation of a multidisciplinary CCOC, this study identifies an exorbitant rate of PICS among SICU survivors. LEVEL OF EVIDENCE Therapeutic/epidemiological, level III.
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Affiliation(s)
- Samantha F Bottom-Tanzer
- From the Tufts University School of Medicine & Tufts Graduate School of Biomedical Sciences (S.F.B.-T.); Department of Pharmacy (J.O.P.), Tufts Medical Center; Department of General Surgery (M.T.L.), Tufts Medical Center, Tufts University School of Medicine; Department of Social Work Services (S.E.A., A.L.V.K., C.E.); Department of Physical and Occupational Therapy (A.B., E.P., E.D.), Tufts Medical Center; and Division of Trauma & Acute Care Surgery (H.M.H., N.B., B.P.J., E.J.M.), Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Taghavi S, Maher Z, Goldberg AJ, Chang G, Mendiola M, Anderson C, Ninokawa S, Tatebe LC, Maluso P, Raza S, Keating JJ, Burruss S, Reeves M, Coleman LE, Shatz DV, Goldenberg-Sandau A, Bhupathi A, Spalding MC, LaRiccia A, Bird E, Noorbakhsh MR, Babowice J, Nelson MC, Jacobson LE, Williams J, Vella M, Dellonte K, Hayward TZ, Holler E, Lieser MJ, Berne JD, Mederos DR, Askari R, Okafor BU, Haut ER, Etchill EW, Fang R, Roche SL, Whittenburg L, Bernard AC, Haan JM, Lightwine KL, Norwood SH, Murry J, Gamber MA, Carrick MM, Bugaev N, Tatar A, Duchesne J, Tatum D. An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg 2021; 91:130-140. [PMID: 33675330 PMCID: PMC8216597 DOI: 10.1097/ta.0000000000003151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/01/2021] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined. RESULTS Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables. CONCLUSION Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes. LEVEL OF EVIDENCE Prognostic, level III.
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Patel NJ, Dultz L, Ladhani HA, Cullinane DC, Klein E, McNickle AG, Bugaev N, Fraser DR, Kartiko S, Dodgion C, Pappas PA, Kim D, Cantrell S, Como JJ, Kasotakis G. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2021; 221:873-884. [DOI: 10.1016/j.amjsurg.2020.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
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Bugaev N, Breeze JL, Tutunjian AM, Hojman HM, Mahoney EJ, Johnson BP, Arabian SS. The Challenges of Using ICD codes to Perform a Comparative Analysis between Patients with Penetrating Cardiac Injuries who Underwent Non-Resuscitative Thoracotomy versus Sternotomy. Perspect Health Inf Manag 2020; 18:1c. [PMID: 33633513 PMCID: PMC7883360] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Comparative morbidity after either sternotomy or non-resuscitative thoracotomy in penetrating cardiac injuries (PCI) is unknown. METHODS Retrospective review of adults with PCI who underwent either sternotomy or non-resuscitative thoracotomy using the National Trauma Data Bank 2007-2015. Since there is no unique International Classification of Diseases Procedure Coding System (ICD-PCS) codes assigned for resuscitative vs. non-resuscitative thoracotomy, and both procedures were coded as "thoracotomy", propensity score (PS) methods were applied to avoid inclusion of resuscitative thoracotomy. RESULTS Despite well PS matching on injury severity score the non-thoracotomy group compared to the sternotomy group had a significantly increased risk of mortality (30 percent vs 8 percent, p<0.0001). The morbidity differed as well-25 percent vs. 12 percent, p=0.0007. CONCLUSIONS The differences in mortality in PCI patients who underwent non-resuscitative thoracotomy vs. sternotomy may be biased by unintentional inclusion of resuscitative thoracotomy. To accurately capture thoracotomy type, separate unique resuscitative and non-resuscitative thoracotomy procedure codes should be created in future revisions of the ICD PCS.
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Affiliation(s)
- Nikolay Bugaev
- , is associate director of trauma, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Assistant Professor of Surgery
| | - Janis L Breeze
- is associate director and an epidemiologist, Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center
| | | | - Horacio M Hojman
- is trauma medical director, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Assistant Professor of Surgery
| | - Eric J Mahoney
- is attending surgeon, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Assistant Professor of Surgery
| | - Benjamin P Johnson
- is attending surgeon, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Assistant Professor of Surgery
| | - Sandra S Arabian
- is trauma program manager, Division of Trauma & Acute Care Surgery, Tufts Medical Center
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Bugaev N, Hojman HM, Breeze JL, Nasraway SA, Arabian SS, Holewinski S, Johnson BP. Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic. Am Surg 2020; 86:1629-1635. [PMID: 33231486 PMCID: PMC7688435 DOI: 10.1177/0003134820972084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established. METHODS A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared. RESULTS Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% (P = .99) for all critically ill patients; and 13.9% vs. 27.4% (P = .12) for COVID-19 critically ill patients. CONCLUSION Acute care surgery is an "essential" service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services. LEVEL OF EVIDENCE III. STUDY TYPE Therapeutic.
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Affiliation(s)
- Nikolay Bugaev
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Horacio M. Hojman
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Janis L. Breeze
- Tufts Clinical and Translational Science
Institute, Tufts University, and Institute for Clinical Research and
Health Policy Studies, Tufts Medical
Center, Boston, MA, USA
| | - Stanley A. Nasraway
- Department of Surgery,
Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Sandra S. Arabian
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Sharon Holewinski
- Department of Surgery,
Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
| | - Benjamin P. Johnson
- Division of Trauma & Acute Care
Surgery, Tufts
University School of Medicine, Tufts Medical
Center, Boston, MA, USA
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Nilson J, Bugaev N, Sekhar P, Hojman H, Gonzalez-Ciccarelli L, Quraishi SA. Portable negative pressure environment to protect staff during aerosol-generating procedures in patients with COVID-19. BMJ Open Respir Res 2020; 7:7/1/e000653. [PMID: 33023899 PMCID: PMC7539582 DOI: 10.1136/bmjresp-2020-000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 01/25/2023] Open
Abstract
Patients with COVID-19 often need therapeutic interventions that are considered high aerosol-generating procedures. These are either being performed by healthcare providers with potentially inadequate personal protective equipment or the procedures are being delayed until patients clear their viral load. Both scenarios are suboptimal. We present a simple, cost-effective method of creating a portable negative pressure environment using equipment that is found in most hospitals to better protect healthcare providers and to facilitate more timely care for patients with COVID-19.
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Affiliation(s)
- James Nilson
- Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA.,Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nikolay Bugaev
- Tufts University School of Medicine, Boston, Massachusetts, USA.,Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Pavan Sekhar
- Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA.,Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Haracio Hojman
- Tufts University School of Medicine, Boston, Massachusetts, USA.,Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Sadeq A Quraishi
- Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA .,Tufts University School of Medicine, Boston, Massachusetts, USA
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Aalberg JJ, Hojman H, Johnson BP, Arabian SS, John Mahoney E, Bugaev N. Readmission after Surgical Stabilization of Rib Fracture: Incidence, Cost, and Risk Factors. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Bugaev N, Rattan R, Goodman M, Mukherjee K, Robinson BRH, McDonald AA, Bogert JN, Croft CA, Edavettal M, Engels PT, Jayaraman V, Khwaja K, Kasotakis G, Lawless RA, Maine RG, Hasenboehler EA, Schroeder ME, Schroll RW, Kim D, Mentzer C, Litt J, Como JJ. Preperitoneal packing for pelvic fracture-associated hemorrhage: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2020; 220:873-888. [PMID: 32600847 DOI: 10.1016/j.amjsurg.2020.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/29/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University, School of Medicine, 800 Washington st, #4488, Boston, MA, USA.
| | - Rishi Rattan
- Division of Trauma Surgery & Critical Care, DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, 1800 NW 10th Ave, Miami, FL, 33136, USA.
| | - Michael Goodman
- Division of Trauma, Critical Care, and Acute Care Surgery, University of Cincinnati, Department of Surgery, 231 Albert Sabin Way, ML 0558, Cincinnati, OH, 45267, USA.
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street, CP 21111, Loma Linda, CA, 92350, USA.
| | - Bryce R H Robinson
- Harborview Medical Center, University of Washington, Norm Maleng Building, 410 9th Ave., Seattle, WA, 98104, USA.
| | - Amy A McDonald
- Department of Surgery, Louis Stokes Cleveland VA Medical Center, 10701 East Blvd, Cleveland, OH, 44106, USA.
| | - James N Bogert
- Division of Trauma, St. Joseph Hospital and Medical Center, Creighton University, College of Medicine, Phoenix Campus, 500 W Thomas Rd Ste 400, Phoenix, AZ, 85013, USA.
| | - Chasen A Croft
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Florida Health Science Center, 1600 SW Archer Road, Box 100108, Gainesville, FL, 32610, USA.
| | - Mathew Edavettal
- Department of Surgery, Lake Havasu Regional Medical Center, 101 Civic Center Ln, Lake Havasu City, AZ, 86403, USA.
| | - Paul T Engels
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton, Ontario, L8L 2X2, Canada.
| | - Vijay Jayaraman
- Saint Francis Hospital and Medical Center, Trinity Health of New England, 114 Woodland St, Hartford, CT, 06105, USA.
| | - Kosar Khwaja
- Departments of Surgery and Critical Care Medicine, McGill University Health Centre, 1650 Cedar Avenue, L9.411, Montreal, Quebec, H3G 1A4, Canada.
| | - George Kasotakis
- Division of Trauma and Critical Care Surgery, Department of Surgery, Duke University School of Medicine, 40 Duke Medicine Circle Clinic 2B/2C, Durham, NC, 27710, USA.
| | - Ryan A Lawless
- Department of Surgery, Denver Health and Hospital Authority, 777 Bannock St. MC 0206, Denver, CO, 80204, USA.
| | - Rebecca G Maine
- Division of Burn, Trauma and Critical Care, Harborview Medical Center, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA.
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Adult and Trauma Surgery, 4940 Eastern Ave. Bldg A 667, Baltimore, 21224, MD, USA.
| | - Mary E Schroeder
- Division of Acute Care Surgery, Department of Surgery, Rutgers-Robert Wood Johnson University Hospital, 125 Paterson Street, New Brunswick, NJ, 08901, USA.
| | - Rebecca W Schroll
- Division of Trauma, Critical Care and Acute Care Surgery, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA, 70112, USA.
| | - Dennis Kim
- Division of Trauma, Acute Care Surgery, Surgical Critical Care, LA County Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, 90502, USA.
| | - Caleb Mentzer
- Division of Trauma, Critical Care, & Acute Care Surgery, 853 N. Church St. Suite 500, Spartanburg Regional Medical Center, Spartanburg, SC, 29303, USA.
| | - Jeff Litt
- Division of Acute Care Surgery, Department of General Surgery, University of Missouri, 1 Hospital Dr, Columbia, MO, 65212, USA.
| | - John J Como
- Department of Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, USA.
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Xu AA, Breeze JL, Jackson CCA, Paulus JK, Bugaev N. Comparative analysis of traumatic esophageal injury in pediatric and adult populations. Pediatr Surg Int 2019; 35:793-801. [PMID: 31076868 DOI: 10.1007/s00383-019-04481-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Distribution and outcomes of traumatic injury of the esophagus (TIE) in pediatric versus adult populations are unknown. Our study sought to perform a descriptive analysis of TIE in children and adults. METHODS We reviewed the National Trauma Data Bank (NTDB) for the years 2010-2015. Demographics, characteristics, and outcomes of pediatric (age < 16 years) and adult TIE patients were described and compared. RESULTS Among 526,850 pediatric and 3,838,895 adult trauma patients, 90 pediatric (0.02%) and 1,411 (0.04%) adult TIE patients were identified. Demographics and esophageal injury severity did not differ. Children were more likely to sustain blunt trauma (63% versus 37%), with the most common mechanism being transportation-related accidents, were less-severely injured (median ISS 14 versus 22), and had fewer associated injuries (79% versus 95%) and complications (30% versus 51%) (all p < 0.001). Children had shorter hospitalizations (median 5 versus 10 days) and were more likely to be discharged home (84% versus 64%) (both p = 0.01). In-hospital mortality did not differ significantly between children and adults (10% versus 19%, p = 0.09). CONCLUSION TIE in the pediatric population has unique characteristics compared to adults: it is more likely to be a result of blunt trauma, has lower injury burden, and has more favorable clinical outcomes.
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Affiliation(s)
| | - Janis L Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Carl-Christian A Jackson
- Floating Hospital for Children at Tufts Medical Center, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica K Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, MA, USA
| | - Nikolay Bugaev
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA, 02111, USA.
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Abstract
Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010–2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.
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Affiliation(s)
| | - Janis L. Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Jessica K. Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts; and
| | - Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Xu AA, Breeze JL, Paulus JK, Bugaev N. Epidemiology of Traumatic Esophageal Injury: An Analysis of the National Trauma Data Bank. Am Surg 2019; 85:342-349. [PMID: 31043192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010-2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.
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Shpiner AC, Bugaev N, Riesenburger R, Ng I, Breeze JL, Arabian SS, Rabinovici R. The profile of blunt traumatic supratentorial cranial bleed types. J Clin Neurosci 2018; 59:79-83. [PMID: 30420206 DOI: 10.1016/j.jocn.2018.10.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 10/29/2018] [Indexed: 01/05/2023]
Abstract
The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.
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Affiliation(s)
- Aaron C Shpiner
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, United States.
| | - Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #8484, Boston, MA 02111, United States.
| | - Isaac Ng
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, United States.
| | - Janis L Breeze
- Tufts Clinical and Translational Science Institute, Tufts University and Institute for Clinical Research and Health Policy Studies, Kneeland St, Boston, MA 02111, United States.
| | - Sandra S Arabian
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA 02111, United States.
| | - Reuven Rabinovici
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, #4488, Boston, MA 02111, United States.
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Enniss TM, Basiouny K, Brewer B, Bugaev N, Cheng J, Danner OK, Duncan T, Foster S, Hawryluk G, Jung HS, Lui F, Rattan R, Violano P, Crandall M. Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2018; 3:e000153. [PMID: 30023433 PMCID: PMC6018851 DOI: 10.1136/tsaco-2017-000153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 12/14/2017] [Accepted: 05/11/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. RESULTS Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. CONCLUSION Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. LEVEL OF EVIDENCE IV. PROSPERO REGISTRATION NUMBER #42016043019.
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Affiliation(s)
- Toby M Enniss
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Khaled Basiouny
- Department of Trauma Surgery, George Washington University School of Medicine and Health Sciences, Washington, Columbia, USA
| | - Brian Brewer
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nikolay Bugaev
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Julius Cheng
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Omar K Danner
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Thomas Duncan
- Department of Trauma Services, Ventura County Medical Center, Ventura, California, USA
| | - Shannon Foster
- Department of Trauma and Surgical Critical Care, University of Pennsylvania Reading Hospital, West Reading, Pennsylvania, USA
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Hee Soo Jung
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Felix Lui
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rishi Rattan
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pina Violano
- Injury Prevention, Community Outreach and Research, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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Bugaev N, McKay K, Breeze JL, Arabian SS, Rabinovici R. Self-Inflicted Abdominal Stab Wounds Have a Higher Rate of Non-therapeutic Laparotomy/Laparoscopy and a Lower Risk of Injury. World J Surg 2018. [PMID: 28634840 DOI: 10.1007/s00268-017-4083-7] [Citation(s) in RCA: 8] [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] [Indexed: 11/24/2022]
Abstract
BACKGROUND The profile and management of self-inflicted abdominal stab wounds (SI-ASW) patients is still obscure. METHODS The National Trauma Data Bank (2012) was queried for adults with abdominal stab wounds (n = 9544). Patients with SI-ASW (n = 1724) and non-SI-ASW (n = 7820) were compared. Predictors for non-therapeutic laparotomy/laparoscopy (non-TL) in SI-ASW patients were identified. RESULTS SI-ASW patients were older, had more females and behavioral disorders, similar physiology, but a lower Injury Severity Score. They had more laparotomies overall (54 versus 48%, p < 0.0001) and more non-TL (42 versus 32%, p < 0.0001), but less injuries (43 versus 53%, p < 0.0001), although peritoneal violation rate was similar. Complications and mortality were similar. In the SI-ASW cohort, non-TL patients were more likely to be female and younger, and to have Glasgow Coma Scale (GCS) ≥13 and a higher systolic blood pressure. History of psychiatric, drug and alcohol disorders was associated with SI-ASW, but did not independently predict the need for treatment in adjusted models. CONCLUSION Patients with SI-ASW underwent more non-TL than patients with non-SI-ASW. Female gender, younger age, and a higher GCS and systolic blood pressure predicted non-TL in this group.
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Affiliation(s)
- Nikolay Bugaev
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington st, #4488, Boston, MA, 02111, USA.
| | - Kevin McKay
- Tufts University School of Medicine, 800 Washington st, #4488, Boston, MA, 02111, USA
| | - Janis L Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, 800 Washington st, #63, Boston, MA, 02111, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington st, #63, Boston, MA, 02111, USA
| | - Sandra S Arabian
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington st, #4488, Boston, MA, 02111, USA
| | - Reuven Rabinovici
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington st, #4488, Boston, MA, 02111, USA
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Peponis T, Kasotakis G, Yu J, Alouidor R, Burkott B, Maung AA, Johnson DC, Saillant N, Walden H, Salim A, Bryant E, Dorfman JD, Klein EN, Elefant R, Tabrizi MB, Bugaev N, Arabian SS, Velmahos GC. Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT). J Am Coll Surg 2017; 224:1036-1045. [DOI: 10.1016/j.jamcollsurg.2016.12.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/30/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
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Bugaev N, Breeze JL, Alhazmi M, Anbari HS, Arabian SS, Rabinovici R. Displacement Patterns of Blunt Rib Fractures and Their Relationship to Thoracic Coinjuries: Minimal Displacements Count. Am Surg 2016; 82:199-206. [PMID: 27099054] [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: 06/05/2023]
Abstract
Displacement patterns of rib fractures (RF) and their association with thoracic coinjuries and outcomes are unknown. This is a retrospective review of adult patients with blunt closed RF who underwent chest CT at a Level I trauma center (2007-2012). Displacement patterns of RF were compared among the three-dimensional planes using CT images. An analysis of receiver operating characteristic (ROC) curves was performed to identify displacements in each plane most strongly associated with chest coinjuries. Univariate analysis was used to find association of displaced RF with hospital course and outcome. There were 1127 RF (245 patients, most in ribs 3-9, 45 per cent displaced). Axial displacement was the most common, with odds ratios 7.20 and 2.13 compared with cranio-caudal, and impaction-separation (along rib axis) movement, respectively. Axial displacement thresholds performed well with hemothorax (2.8 mm, ROC = 0.74), pneumothorax (2.6 mm, ROC = 0.70), hemopneumothorax (3.1 mm, ROC = 0.77), flail chest (3.4 mm, ROC = 0.80), and chest tube placement (2.8 mm, ROC = 0.75). RF displacement was associated with increased days on mechanical ventilation and hospital length of stay. In conclusion, even minimal RF displacement is associated with increased risk of chest coinjuries and chest tube placement, and displacements correlated with increased days on mechanical ventilation and hospital length of stay. Future studies are required to investigate these associations, especially in relationship to the indications for rib plating.
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Affiliation(s)
- Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Bugaev N, Breeze JL, Alhazmi M, Anbari HS, Arabian SS, Rabinovici R. Displacement Patterns of Blunt Rib Fractures and Their Relationship to Thoracic Coinjuries: Minimal Displacements Count. Am Surg 2016. [DOI: 10.1177/000313481608200311] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Displacement patterns of rib fractures (RF) and their association with thoracic coinjuries and outcomes are unknown. This is a retrospective review of adult patients with blunt closed RF who underwent chest CT at a Level I trauma center (2007–2012). Displacement patterns of RF were compared among the three-dimensional planes using CT images. An analysis of receiver operating characteristic (ROC) curves was performed to identify displacements in each plane most strongly associated with chest coinjuries. Univariate analysis was used to find association of displaced RF with hospital course and outcome. There were 1127 RF (245 patients, most in ribs 3–9, 45 per cent displaced). Axial displacement was the most common, with odds ratios 7.20 and 2.13 compared with cranio-caudal, and impaction-separation (along rib axis) movement, respectively. Axial displacement thresholds performed well with hemothorax (2.8 mm, ROC = 0.74), pneumothorax (2.6 mm, ROC = 0.70), hemopneumothorax (3.1 mm, ROC = 0.77), flail chest (3.4 mm, ROC = 0.80), and chest tube placement (2.8 mm, ROC = 0.75). RF displacement was associated with increased days on mechanical ventilation and hospital length of stay. In conclusion, even minimal RF displacement is associated with increased risk of chest coinjuries and chest tube placement, and displacements correlated with increased days on mechanical ventilation and hospital length of stay. Future studies are required to investigate these associations, especially in relationship to the indications for rib plating.
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Affiliation(s)
- Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts and
| | - Janis L. Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Majid Alhazmi
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts and
| | - Hassan S. Anbari
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts and
| | - Sandra S. Arabian
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts and
| | - Reuven Rabinovici
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts and
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Bugaev N, Al-Hazmi M, Allcorn M, Arabian SS, Riesenburger R, Safain M, Burke S, Colangelo A, Rabinovici R. Blood pressure regulation to prevent progression of blunt traumatic intracranial hemorrhage in stable patients. Neurocrit Care 2015; 21:58-66. [PMID: 24493080 DOI: 10.1007/s12028-014-9957-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients. METHODS A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval. RESULTS Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD. CONCLUSIONS A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated. LEVEL OF EVIDENCE III Prognostic, Level II study.
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Affiliation(s)
- Nikolay Bugaev
- Department of Surgery, Tufts Medical Center, 800 Washington St., #4488, Boston, MA, 02111, USA
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Abstract
BACKGROUND Resuscitative thoracotomy is a heroic procedure that may offer the only survival hope for trauma patients in extremis. However, this operation has been the subject of much debate and its use, feasibility, outcomes, and cost are being continuously re-evaluated. METHODS This is a review of the most current (after 2000) literature on resuscitative thoracotomy, based on computer database searches for studies on resuscitative thoracotomy, emergency department thoracotomy, and emergency thoracotomy. Studies were selected for inclusion in this review based on their relevance and contribution to our understanding of resuscitative thoracotomy. RESULTS A total of 37 studies were included, and the following resuscitative thoracotomy-related topics were critically discussed: indications, biochemical profile, long-term outcome, organ donation, pre-hospital use, military use, international aspects, intra-aortic balloon occlusion, suspended animation, and cost and occupational exposure. CONCLUSIONS This review demonstrates that the indications for resuscitative thoracotomy become clearer and that new information is available regarding its use in the pre-hospital urban environment and military settings. Furthermore, it points to new strategies to supplement resuscitative thoracotomy including intra-aortic balloon occlusion and suspended animation. Finally, it sheds light on the long-term outcomes, organ donation, and cost and occupational exposure following resuscitative thoracotomy.
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Affiliation(s)
- R Rabinovici
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Boston, MA, USA
| | - N Bugaev
- Division of Trauma and Acute Care Surgery, Tufts Medical Center, Boston, MA, USA
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Neufeld D, Shpitz B, Bugaev N, Grankin M, Bernheim J, Klein E, Ziv Y. Young-age onset of colorectal cancer in Israel. Tech Coloproctol 2009; 13:201-4. [PMID: 19609485 DOI: 10.1007/s10151-009-0501-7] [Citation(s) in RCA: 14] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 05/17/2009] [Indexed: 12/15/2022]
Abstract
AIM The study was conducted to investigate the differences in clinical-pathological, ethnic, and demographic presentations and the expression of mismatch repair proteins in a cohort of young-onset (</=50 years) versus late-onset Israeli patients (>50 years) with colorectal cancer. MATERIALS AND METHODS Clinical, demographic, and histopathological data of patients with colorectal cancer were collected retrospectively from medical records and pathology reports. RESULTS Ninety patients, 50 years of age or younger with a mean age of 42 years were compared with a group of 190 patients above 50 years of 50 (see Table 1). Sixty percent of the young-onset patients were females, compared to 40% in the older age group (P = 0.02). Twenty-one percent of the young-onset patients were Arabs as compared to 2% of older-onset patients (P = 0.001). Younger patients displayed a higher percentage of mucinous cancers and a higher percentage of diagnosis at an advanced stage of disease; 40% of young-onset versus 31% of older-onset patients presented Duke's stages C and D (P = 0.02). CONCLUSIONS Younger age of onset colorectal cancer in our cohort of Israeli patients is associated with higher percentage of Arab patients, mucinous cancers, female gender, and advanced stage at diagnosis.
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Affiliation(s)
- D Neufeld
- Department of Surgery, Meir Medical Center, Kfar Sava, Israel.
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