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Filiberto AC, Loftus TJ, Crippen CJ, Hu D, Balch JA, Efron PA, Sarosi GA, Upchurch GR. Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention. J Am Coll Surg 2024; 238:404-413. [PMID: 38224109 DOI: 10.1097/xcs.0000000000000972] [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: 01/16/2024]
Abstract
BACKGROUND Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs. STUDY DESIGN An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes. For inpatient procedures, predicted mortality and length of stay were used to calculate observed-to-expected ratios and value of care using validated equations. For commonly performed (1 or more per week) procedures, the pipeline generated figures illustrating individual surgeon performance vs peers, costs for each surgeon performing each case type, and control charts identifying out-of-control cases and surgeons with more than 90th percentile costs, which were shared with surgeons and division chiefs alongside guidance for modifying case-specific supply instructions to operating room nurses and technicians. RESULTS Preintervention control (1,064 cases for 7 months) and postintervention (307 cases for 2 months) cohorts had similar baseline characteristics across all 16 commonly performed procedures. Median costs per case were lower in the intervention cohort ($811 [$525 to $1,367] vs controls: $1,080 [$603 to $1,574], p < 0.001), as was the incidence of out-of-control cases (19 (6.2%) vs 110 (10.3%), p = 0.03). Duration of surgery, length of stay, discharge disposition, and 30-day mortality and readmission rates were similar between cohorts. Value of care was higher in the intervention cohort (1.1 [0.1 to 1.5] vs 1.0 [0.2 to 1.4], p = 0.04). Pipeline runtime was 16:07. CONCLUSIONS An automated, sustainable quality improvement intervention was associated with decreased operating room supply costs and increased value of care.
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Affiliation(s)
- Amanda C Filiberto
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Tyler J Loftus
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL (Loftus, Hu)
| | - Cristina J Crippen
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Die Hu
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL (Loftus, Hu)
| | - Jeremy A Balch
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Philip A Efron
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - George A Sarosi
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
| | - Gilbert R Upchurch
- From the Department of Surgery, University of Florida Health, Gainesville, FL (Filiberto, Loftus, Crippen, Balch, Efron, Sarosi, Upchurch)
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Munley JA, Willis ML, Gillies GS, Kannan KB, Polcz VE, Balch JA, Barrios EL, Wallet SM, Bible LE, Efron PA, Maile R, Mohr AM. Exosomal microRNA following severe trauma: Role in bone marrow dysfunction. J Trauma Acute Care Surg 2024; 96:548-556. [PMID: 38151766 PMCID: PMC10978306 DOI: 10.1097/ta.0000000000004225] [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: 12/29/2023]
Abstract
INTRODUCTION Severe trauma disrupts bone marrow function and is associated with persistent anemia and altered hematopoiesis. Previously, plasma-derived exosomes isolated after trauma have been shown to suppress in vitro bone marrow function. However, the cargo contained in these vesicles has not been examined. We hypothesized that trauma plasma-derived exosomes exhibit microRNA (miRNA) changes that impact bone marrow function after severe injury. METHODS Plasma was collected from a prospective cohort study of trauma patients (n = 15; 7 males, 8 females) with hip and/or femur fractures and an Injury Severity Score of ≥15; elective total hip arthroplasty (THA) patients (n = 8; 4 males, 4 females) served as operative controls. Exosomes were isolated from plasma with the Invitrogen Total Exosome Isolation Kit (Thermo Fisher Scientific, Waltham, MA), and RNA was isolated using a miRNeasy Mini Kit (Qiagen, Hilden, Germany). Direct quantification of miRNA was performed by NanoString Technologies on a human miRNA gene panel and analyzed with nSolver with significance defined as p < 0.05. RESULTS There were no differences in age or sex distribution between trauma and THA groups; the average Injury Severity Score was 23. Trauma plasma-derived exosomes had 60 miRNA identities that were significantly downregulated and 3 miRNAs that were upregulated when compared with THA ( p < 0.05). Twelve of the downregulated miRNAs have a direct role in hematopoiesis regulation. Furthermore, male trauma plasma-derived exosomes demonstrated downregulation of 150 miRNAs compared with male THA ( p < 0.05). Female trauma plasma-derived exosomes demonstrated downregulation of only four miRNAs and upregulation of two miRNAs compared with female THA ( p < 0.05). CONCLUSION We observed downregulation of 12 miRNAs linked to hematopoiesis along with sexual dimorphism in miRNA expression from plasma-derived exosomes following severe trauma. Understanding sexually dimorphic miRNA expression provides new insight into sex-based changes in postinjury systemic inflammation, immune system dysregulation, and bone marrow dysfunction and will aid us in more precise future potential therapeutic strategies. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Micah L. Willis
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Valerie E. Polcz
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Jeremy A. Balch
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Evan L. Barrios
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Shannon M. Wallet
- Department of Oral Biology, University of Florida College of Medicine, Gainesville, Florida
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Robert Maile
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Leroy V, Manual Kollareth DJ, Tu Z, Valisno JAC, Woolet-Stockton M, Saha B, Emtiazjoo AM, Rackauskas M, Moldawer LL, Efron PA, Cai G, Atkinson C, Upchurch GR, Sharma AK. MerTK-dependent efferocytosis by monocytic-MDSCs mediates resolution of post-lung transplant injury. bioRxiv 2024:2024.01.18.576261. [PMID: 38328174 PMCID: PMC10849528 DOI: 10.1101/2024.01.18.576261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Rationale Patients with end stage lung diseases require lung transplantation (LTx) that can be impeded by ischemia-reperfusion injury (IRI) leading to subsequent chronic lung allograft dysfunction (CLAD) and inadequate outcomes. Objectives We examined the undefined role of MerTK (receptor Mer tyrosine kinase) on monocytic myeloid-derived suppressor cells (M-MDSCs) in efferocytosis (phagocytosis of apoptotic cells) to facilitate resolution of lung IRI. Methods Single-cell RNA sequencing of lung tissue and BAL from post-LTx patients was analyzed. Murine lung hilar ligation and allogeneic orthotopic LTx models of IRI were used with Balb/c (WT), cebpb -/- (MDSC-deficient), Mertk -/- or MerTK-CR (cleavage resistant) mice. Lung function, IRI (inflammatory cytokine and myeloperoxidase expression, immunohistology for neutrophil infiltration), and flow cytometry of lung tissue for efferocytosis of apoptotic neutrophils were assessed in mice. Measurements and Main Results A significant downregulation in MerTK-related efferocytosis genes in M-MDSC populations of CLAD patients compared to healthy subjects was observed. In the murine IRI model, significant increase in M-MDSCs, MerTK expression and efferocytosis was observed in WT mice during resolution phase that was absent in cebpb -/- Land Mertk -/- mice. Adoptive transfer of M-MDSCs in cebpb -/- mice significantly attenuated lung dysfunction, and inflammation leading to resolution of IRI. Additionally, in a preclinical murine orthotopic LTx model, increases in M-MDSCs were associated with resolution of lung IRI in the transplant recipients. In vitro studies demonstrated the ability of M-MDSCs to efferocytose apoptotic neutrophils in a MerTK-dependent manner. Conclusions Our results suggest that MerTK-dependent efferocytosis by M-MDSCs can significantly contribute to the resolution of post-LTx IRI.
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Barrios EL, Mazer MB, McGonagill PW, Bergmann CB, Goodman MD, Gould RW, Rao M, Polcz VE, Davis RJ, Del Toro DE, Dirain ML, Dram A, Hale LO, Heidarian M, Kim CY, Kucaba TA, Lanz JP, McCray AE, Meszaros S, Miles S, Nelson CR, Rocha IL, Silva EE, Ungaro RF, Walton AH, Xu J, Zeumer-Spataro L, Drewry AM, Liang M, Bible LE, Loftus TJ, Turnbull IR, Efron PA, Remy KE, Brakenridge SC, Badovinac VP, Griffith TS, Moldawer LL, Hotchkiss RS, Caldwell CC. Adverse outcomes and an immunosuppressed endotype in septic patients with reduced IFN-γ ELISpot. JCI Insight 2024; 9:e175785. [PMID: 38100268 PMCID: PMC10906237 DOI: 10.1172/jci.insight.175785] [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: 09/26/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUNDSepsis remains a major clinical challenge for which successful treatment requires greater precision in identifying patients at increased risk of adverse outcomes requiring different therapeutic approaches. Predicting clinical outcomes and immunological endotyping of septic patients generally relies on using blood protein or mRNA biomarkers, or static cell phenotyping. Here, we sought to determine whether functional immune responsiveness would yield improved precision.METHODSAn ex vivo whole-blood enzyme-linked immunosorbent spot (ELISpot) assay for cellular production of interferon γ (IFN-γ) was evaluated in 107 septic and 68 nonseptic patients from 5 academic health centers using blood samples collected on days 1, 4, and 7 following ICU admission.RESULTSCompared with 46 healthy participants, unstimulated and stimulated whole-blood IFN-γ expression was either increased or unchanged, respectively, in septic and nonseptic ICU patients. However, in septic patients who did not survive 180 days, stimulated whole-blood IFN-γ expression was significantly reduced on ICU days 1, 4, and 7 (all P < 0.05), due to both significant reductions in total number of IFN-γ-producing cells and amount of IFN-γ produced per cell (all P < 0.05). Importantly, IFN-γ total expression on days 1 and 4 after admission could discriminate 180-day mortality better than absolute lymphocyte count (ALC), IL-6, and procalcitonin. Septic patients with low IFN-γ expression were older and had lower ALCs and higher soluble PD-L1 and IL-10 concentrations, consistent with an immunosuppressed endotype.CONCLUSIONSA whole-blood IFN-γ ELISpot assay can both identify septic patients at increased risk of late mortality and identify immunosuppressed septic patients.TRIAL REGISTRYN/A.FUNDINGThis prospective, observational, multicenter clinical study was directly supported by National Institute of General Medical Sciences grant R01 GM-139046, including a supplement (R01 GM-139046-03S1) from 2022 to 2024.
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Affiliation(s)
- Evan L. Barrios
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Monty B. Mazer
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Patrick W. McGonagill
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Christian B. Bergmann
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- University Hospital Ulm, Clinic for Trauma Surgery, Hand, Plastic, and Reconstructive Surgery Albert-Einstein-Allee 23, Ulm, Germany
| | - Michael D. Goodman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Robert W. Gould
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mahil Rao
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Valerie E. Polcz
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ruth J. Davis
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Drew E. Del Toro
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marvin L.S. Dirain
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alexandra Dram
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lucas O. Hale
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mohammad Heidarian
- Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Caleb Y. Kim
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Tamara A. Kucaba
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer P. Lanz
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ashley E. McCray
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sandra Meszaros
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sydney Miles
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Candace R. Nelson
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ivanna L. Rocha
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Elvia E. Silva
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ricardo F. Ungaro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew H. Walton
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julie Xu
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Leilani Zeumer-Spataro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Muxuan Liang
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Biostatistics, University of Florida College of Public Health and Health Professions and the University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tyler J. Loftus
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Isaiah R. Turnbull
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Philip A. Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kenneth E. Remy
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Scott C. Brakenridge
- Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vladimir P. Badovinac
- Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Experimental Pathology PhD Program, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Thomas S. Griffith
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Center for Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
| | - Lyle L. Moldawer
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Richard S. Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles C. Caldwell
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Park G, Munley JA, Kelly LS, Kannan KB, Mankowski RT, Sharma A, Upchurch G, Casadesus G, Chakrabarty P, Wallet SM, Maile R, Bible LE, Wang B, Moldawer LL, Mohr AM, Efron PA, Nagpal R. Gut mycobiome dysbiosis after sepsis and trauma. Crit Care 2024; 28:18. [PMID: 38212826 PMCID: PMC10785534 DOI: 10.1186/s13054-023-04780-4] [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: 11/15/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Sepsis and trauma are known to disrupt gut bacterial microbiome communities, but the impacts and perturbations in the fungal (mycobiome) community after severe infection or injury, particularly in patients experiencing chronic critical illness (CCI), remain unstudied. METHODS We assess persistence of the gut mycobiome perturbation (dysbiosis) in patients experiencing CCI following sepsis or trauma for up to two-to-three weeks after intensive care unit hospitalization. RESULTS We show that the dysbiotic mycobiome arrays shift toward a pathobiome state, which is more susceptible to infection, in CCI patients compared to age-matched healthy subjects. The fungal community in CCI patients is largely dominated by Candida spp; while, the commensal fungal species are depleted. Additionally, these myco-pathobiome arrays correlate with alterations in micro-ecological niche involving specific gut bacteria and gut-blood metabolites. CONCLUSIONS The findings reveal the persistence of mycobiome dysbiosis in both sepsis and trauma settings, even up to two weeks post-sepsis and trauma, highlighting the need to assess and address the increased risk of fungal infections in CCI patients.
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Affiliation(s)
- Gwoncheol Park
- Department of Health, Nutrition, and Food Sciences, Florida State University, Tallahassee, FL, 32306, USA
| | - Jennifer A Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Lauren S Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Robert T Mankowski
- Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Ashish Sharma
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Gilbert Upchurch
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Gemma Casadesus
- Department of Pharmacology and Therapeutics, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Paramita Chakrabarty
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Shannon M Wallet
- Department of Oral Biology, University of Florida College of Dentistry, Gainesville, FL, 32611, USA
| | - Robert Maile
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Letitia E Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Bo Wang
- Department of Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL, 32901, USA
| | - Lyle L Moldawer
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, 32611, USA
| | - Ravinder Nagpal
- Department of Health, Nutrition, and Food Sciences, Florida State University, Tallahassee, FL, 32306, USA.
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Gillies GS, Munley JA, Kelly LS, Kirkpatrick SL, Pons EE, Kannan KB, Bible LE, Efron PA, Mohr AM. Posttraumatic pneumonia exacerbates bone marrow erythropoietic dysfunction. J Trauma Acute Care Surg 2024; 96:17-25. [PMID: 37853556 PMCID: PMC10842431 DOI: 10.1097/ta.0000000000004157] [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: 10/20/2023]
Abstract
INTRODUCTION Pneumonia is a common complication after severe trauma that is associated with worse outcomes with increased mortality. Critically ill trauma patients also have persistent inflammation and bone marrow dysfunction that manifests as persistent anemia. Terminal erythropoiesis, which occurs in bone marrow structures called erythroblastic islands (EBIs), has been shown to be impacted by trauma. Using a preclinical model of polytrauma (PT) and pneumonia, we sought to determine the effect of infection on bone marrow dysfunction and terminal erythropoiesis. METHODS Male and female Sprague-Dawley rats aged 9 to 11 weeks were subjected to either PT (lung contusion, hemorrhagic shock, cecectomy, and bifemoral pseudofracture) or PT with postinjury day 1 Pseudomonas pneumonia (PT-PNA) and compared with a naive cohort. Erythroblastic islands were isolated from bone marrow samples and imaged via confocal microscopy. Hemoglobin, early bone marrow erythroid progenitors, erythroid cells/EBI, and % reticulocytes/EBI were measured on day 7. Significance was defined as p < 0.05. RESULTS Day 7 hemoglobin was significantly lower in both PT and PT-PNA groups compared with naive (10.8 ± 0.6 and 10.9 ± 0.7 vs. 12.1 ± 0.7 g/dL [ p < 0.05]). Growth of bone marrow early erythroid progenitors (colony-forming units-granulocyte, erythrocyte, monocyte, megakaryocyte; erythroid burst-forming unit; and erythroid colony-forming unit) on day 7 was significantly reduced in PT-PNA compared with both PT and naive. Despite a peripheral reticulocytosis following PT and PT-PNA, the percentage of reticulocytes/EBI was not different between naive, PT, and PT-PNA. However, the number of erythroblasts/EBI was significantly lower in PT-PNA compared with naive (2.9 ± 1.5 [ p < 0.05] vs. 8.9 ± 1.1 cells/EBI macrophage). In addition to changes in EBI composition, EBIs were also found to have significant structural changes following PT and PT-PNA. CONCLUSION Multicompartmental PT altered late-stage erythropoiesis, and these changes were augmented with the addition of pneumonia. To improve outcomes following trauma and pneumonia, we need to better understand how alterations in EBI structure and function impact persistent bone marrow dysfunction and anemia.
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Affiliation(s)
- Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Stacey L. Kirkpatrick
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Munley JA, Kelly LS, Gillies GS, Pons EE, Kannan KB, Whitley EM, Bible LE, Efron PA, Mohr AM. Multicompartmental Trauma Induces Persistent Inflammation and Organ Injury. J Surg Res 2024; 293:266-273. [PMID: 37804796 DOI: 10.1016/j.jss.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/22/2023] [Accepted: 08/26/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Previous preclinical models of multicompartmental injury have investigated its effects for durations of less than 72 h and the long-term effects have not been defined. We hypothesized that a model of multicompartmental injury would result in systemic inflammation and multiorgan dysfunction that persists at 1 wk. METHODS Male and proestrus female Sprague-Dawley rats (n = 16/group) underwent polytrauma (PT) (unilateral right lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofractures) and were compared to naive controls. Weight, hemoglobin, plasma neutrophil gelatinase-associated lipocalin, and plasma toll-like receptor 4 were evaluated on days two and seven. Bilateral lungs were sectioned, stained and assessed for injury at day seven. Comparisons were performed in Graphpad with significance defined as ∗P <0.05. RESULTS Rats who underwent PT had significant weight loss and anemia at day 2 (P = 0.001) compared to naïve rats which persisted at day 7 (P = 0.001). PT rats had elevated plasma neutrophil gelatinase-associated lipocalin at day 2 compared to naïve (P <0.0001) which remained elevated at day 7 (P <0.0001). Plasma toll-like receptor 4 was elevated in PT compared to naïve at day 2 (P = 0.03) and day 7 (P = 0.01). Bilateral lungs showed significant injury in PT cohorts at day 7 compared to naïve (P <0.0004). PT males had worse renal function at day seven compared to females (P = 0.02). CONCLUSIONS Multicompartmental trauma induces systemic inflammation and multiorgan dysfunction without recovery by day seven. However, females demonstrate improved renal recovery compared to males. Long-term assessment of preclinical PT models are crucial to better understand and evaluate future therapeutic immunomodulatory and anti-inflammatory treatments.
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Affiliation(s)
- Jennifer A Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | - Lauren S Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | - Gwendolyn S Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | - Erick E Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | | | - Letitia E Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida, College of Medicine, Gainesville, Florida.
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8
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Unsinger J, Osborne D, Walton AH, Han E, Sheets L, Mazer MB, Remy KE, Griffith TS, Rao M, Badovinac VP, Brackenridge SC, Turnbull I, Efron PA, Moldawer LL, Caldwell CC, Hotchkiss RS. Temporal Changes in Innate and Adaptive Immunity During Sepsis as Determined by ELISpot. bioRxiv 2023:2023.12.14.571668. [PMID: 38168302 PMCID: PMC10760123 DOI: 10.1101/2023.12.14.571668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background The inability to evaluate host immunity in a rapid quantitative manner in patients with sepsis has severely hampered development of novel immune therapies. The ELISpot assay is a functional bioassay that measures the number of cytokine-secreting cells and the relative amount of cytokine produced at the single-cell level. A key advantage of ELISpot is its excellent dynamic range enabling a more precise quantifiable assessment of host immunity. Herein, we tested the hypothesis on whether the ELISpot assay can detect dynamic changes in both innate and adaptive immunity as they often occur during sepsis. We also tested whether ELISpot could detect the effect of immune drug therapies to modulate innate and adaptive immunity. Methods Mice were made septic using sublethal cecal ligation and puncture (CLP). Blood and spleens were harvested serially and ex vivo IFN-γ and TNF-α production were compared by ELISpot and ELISA. The capability of ELISpot to detect changes in innate and adaptive immunity due to in vivo immune therapy with dexamethasone, IL-7, and arginine was also evaluated. Results ELISpot confirmed a decreased innate and adaptive immunity responsiveness during sepsis progression. More importantly, ELISpot was also able to detect changes in adaptive and innate immunity in response to immune-modulatory reagents, for example dexamethasone, arginine, and IL-7 in a readily quantifiable manner, as predicted by the reagents known mechanisms of action. ELISpot and ELISA results tended to parallel one another although some differences were noted. Conclusion ELISpot offers a unique capability to assess the functional status of both adaptive and innate immunity over time. The results presented herein demonstrate that ELISpot can also be used to detect and follow the in vivo effects of drugs to ameliorate sepsis-induced immune dysfunction. This capability would be a major advance in guiding new immune therapies in sepsis.
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9
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Munley JA, Kelly LS, Park G, Gillies GS, Pons EE, Kannan KB, Bible LE, Efron PA, Nagpal R, Mohr AM. Sex-specific intestinal dysbiosis persists after multicompartmental injury. Surgery 2023; 174:1453-1462. [PMID: 37833155 DOI: 10.1016/j.surg.2023.08.023] [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] [Received: 04/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Preclinical studies of the gut microbiome after severe traumatic injury have demonstrated severe dysbiosis in males, with sex-specific microbial differences up to 2 days after injury. However, the impact of host sex on injury-driven dysbiosis over time remains unknown. We hypothesized that sex-specific differences in intestinal microbiome diversity and composition after traumatic injury with and without stress would persist after 7 days. METHODS Male and proestrus female Sprague-Dawley rats (n = 8/group) were subjected to either polytrauma (lung contusion, hemorrhagic shock, cecectomy, bifemoral pseudofractures), polytrauma plus chronic restraint stress, or naïve controls. The fecal microbiome was measured on days 0, 3, and 7 using 16S rRNA sequencing and Quantitative Insights into Microbial Ecology bioinformatics analyses. Microbial alpha-diversity (Chao1 and Shannon indices) and beta-diversity were assessed. Analyses were performed in GraphPad and "R," with significance defined as P < .05. RESULTS Polytrauma and polytrauma plus chronic restraint stress reduced alpha-diversity (Chao1, Shannon) within 3 days postinjury, which persisted up to day 7 in both sexes; polytrauma and polytrauma plus chronic restraint stress females had significantly decreased Chao1 compared to male counterparts at day 7 (P = .02). At day 7, the microbiome composition in polytrauma females had higher proportion of Mucispirillum, whereas polytrauma plus chronic restraint stress males demonstrated elevated abundance of Ruminococcus and Akkermansia. CONCLUSION Multicompartmental trauma induces intestinal dysbiosis that is sex-specific with persistence of decreased diversity and unique "pathobiome" signatures in females after 1 week. These findings underline sex as an important biological variable that may influence variable host-specific responses and outcomes after severe trauma and critical illness. This underscores the need to consider precision medicine strategies to ameliorate these outcomes.
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Affiliation(s)
- Jennifer A Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/jen_munley
| | - Lauren S Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/LaurenKelly_MD
| | - Gwoncheol Park
- Department of Nutrition and Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, FL
| | - Gwendolyn S Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/gee_gills
| | - Erick E Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Letitia E Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL. https://twitter.com/LBibleMD
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL
| | - Ravinder Nagpal
- Department of Nutrition and Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, FL
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL.
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10
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Efron PA, Brakenridge SC, Mohr AM, Barrios EL, Polcz VE, Anton S, Ozrazgat-Baslanti T, Bihorac A, Guirgis F, Loftus TJ, Rosenthal M, Leeuwenburgh C, Mankowski R, Moldawer LL, Moore FA. The persistent inflammation, immunosuppression, and catabolism syndrome 10 years later. J Trauma Acute Care Surg 2023; 95:790-799. [PMID: 37561664 PMCID: PMC10615691 DOI: 10.1097/ta.0000000000004087] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 08/12/2023]
Abstract
With the implementation of new intensive care unit (ICU) therapies in the 1970s, multiple organ failure (MOF) emerged as a fulminant inflammatory phenotype leading to early ICU death. Over the ensuing decades, with fundamental advances in care, this syndrome has evolved into a lingering phenotype of chronic critical illness (CCI) leading to indolent late post-hospital discharge death. In 2012, the University of Florida (UF) Sepsis Critical Illness Research Center (SCIRC) coined the term Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) to provide a mechanistic framework to study CCI in surgical patients. This was followed by a decade of research into PICS-CCI in surgical ICU patients in order to define the epidemiology, dysregulated immunity, and long-term outcomes after sepsis. Other focused studies were performed in trauma ICU patients and emergency department sepsis patients. Early deaths were surprisingly low (4%); 63% experienced rapid recovery. Unfortunately, 33% progressed to CCI, of which 79% had a poor post-discharge disposition and 41% were dead within one year. These patients had biomarker evidence of PICS, and these biomarkers enhanced clinical prediction models for dismal one-year outcomes. Emergency myelopoiesis appears to play a central role in the observed persistent immune dysregulation that characterizes PICS-CCI. Older patients were especially vulnerable. Disturbingly, over half of the older CCI patients were dead within one year and older CCI survivors remained severely disabled. Although CCI is less frequent (20%) after major trauma, PICS appears to be a valid concept. This review will specifically detail the epidemiology of CCI, PICS biomarkers, effect of site of infection, acute kidney injury, effect on older patients, dysfunctional high-density lipoproteins, sarcopenia/cachexia, emergency myelopoiesis, dysregulated erythropoiesis, and potential therapeutic interventions. A review of UF SCIRC’s research efforts characterizing CCI, PICS biomarkers, effect of site of infection, acute kidney injury, effects on older patients, dysfunctional high-density lipoproteins, sarcopenia/cachexia, emergency myelopoiesis, and dysregulated erythropoiesis.
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Affiliation(s)
- Philip A Efron
- From the Department of Surgery and Anesthesiology (P.A.E., A.M.M., M.R.), University of Florida, Gainesville, Florida, Department of Surgery (S.C.B.), University of Washington, Seattle, Washington; Department of Surgery (E.L.B., V.E.P., T.J.L., L.L.M., F.A.M.), Department of Physiology and Aging (S.A., C.L., R.M.), Department of Medicine (T.O.-B., A.B.), University of Florida, Gainesville; and Department of Emergency Medicine (F.G.), University of Florida, Jacksonville, Florida
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11
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Gillies GS, Munley JA, Kelly LS, Pons EE, Kannan KB, Bible LE, Efron PA, Mohr AM. Anemia Recovery After Lung Contusion, Hemorrhagic Shock, and Chronic Stress Is Gender-Specific in a Rat Model. Surg Infect (Larchmt) 2023; 24:773-781. [PMID: 37903014 PMCID: PMC10659020 DOI: 10.1089/sur.2023.154] [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: 11/01/2023] Open
Abstract
Background: Severe trauma and hemorrhagic shock lead to persistent anemia. Although biologic gender is known to modulate inflammatory responses after critical illness, the impact of gender on anemia recovery after injury remains unknown. The aim of this study was to identify gender-specific differences in anemia recovery after critical illness. Materials and Methods: Male and proestrus female Sprague-Dawley rats (n = 8-9 per group) were subjected to lung contusion and hemorrhagic shock (LCHS) or LCHS with daily chronic stress (LCHS/CS) compared with naïve. Hematologic data, bone marrow progenitor growth, and bone marrow and liver gene transcription were analyzed on day seven. Significance was defined as p < 0.05. Results: Males lost substantial weight after LCHS and LCHS/CS compared with naïve males, while female LCHS rats did not compared with naive counterparts. Male LCHS rats had a drastic decrease in hemoglobin from naïve males. Male LCHS/CS rats had reduced colony-forming units-granulocyte, -erythrocyte, -monocyte, -megakaryocyte (CFU-GEMM) and burst-forming unit-erythroid (BFU-E) when compared with female counterparts. Naïve, LCHS, and LCHS/CS males had lower serum iron than their respective female counterparts. Liver transcription of BMP4 and BMP6 was elevated after LCHS and LCHS/CS in males compared with females. The LCHS/CS males had decreased expression of bone marrow pro-erythroid factors compared with LCHS/CS females. Conclusions: After trauma with or without chronic stress, male rats demonstrated increased weight loss, substantial decrease in hemoglobin level, dysregulated iron metabolism, substantial suppression of bone marrow erythroid progenitor growth, and no change in transcription of pro-erythroid factors. These findings confirm that gender is an important variable that impacts anemia recovery and bone marrow dysfunction after traumatic injury and shock in this rat model.
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Affiliation(s)
- Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
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12
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Barrios EA, Mazer MB, McGonagill P, Bergmann CB, Goodman MD, Gould R, Rao M, Polcz V, Davis R, Del Toro D, Dirain M, Dram A, Hale L, Heidarian M, Kucaba TA, Lanz JP, McCray A, Meszaros S, Miles S, Nelson C, Rocha I, Silva EE, Ungaro R, Walton A, Xu J, Zeumer-Spataro L, Drewry A, Liang M, Bible LE, Loftus T, Turnbull I, Efron PA, Remy KE, Brakenridge S, Badovinac VP, Griffith TS, Moldawer LL, Hotchkiss RS, Caldwell CC. Adverse Long-Term Outcomes and an Immune Suppressed Endotype in Sepsis Patients with Reduced Interferon-γELISpot: A Multicenter, Prospective Observational Study. medRxiv 2023:2023.09.13.23295360. [PMID: 37745385 PMCID: PMC10516075 DOI: 10.1101/2023.09.13.23295360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Sepsis remains a major clinical challenge for which successful treatment requires greater precision in identifying patients at increased risk of adverse outcomes requiring different therapeutic approaches. Predicting clinical outcomes and immunological endotyping of septic patients has generally relied on using blood protein or mRNA biomarkers, or static cell phenotyping. Here, we sought to determine whether functional immune responsiveness would yield improved precision. METHODS An ex vivo whole blood enzyme-linked immunosorbent (ELISpot) assay for cellular production of interferon-γ (IFN-γ) was evaluated in 107 septic and 68 non-septic patients from five academic health centers using blood samples collected on days 1, 4 and 7 following ICU admission. RESULTS Compared with 46 healthy subjects, unstimulated and stimulated whole blood IFNγ expression were either increased or unchanged, respectively, in septic and nonseptic ICU patients. However, in septic patients who did not survive 180 days, stimulated whole blood IFNγ expression was significantly reduced on ICU days 1, 4 and 7 (all p<0.05), due to both significant reductions in total number of IFNγ producing cells and amount of IFNγ produced per cell (all p<0.05). Importantly, IFNγ total expression on day 1 and 4 after admission could discriminate 180-day mortality better than absolute lymphocyte count (ALC), IL-6 and procalcitonin. Septic patients with low IFNγ expression were older and had lower ALC and higher sPD-L1 and IL-10 concentrations, consistent with an immune suppressed endotype. CONCLUSIONS A whole blood IFNγ ELISpot assay can both identify septic patients at increased risk of late mortality, and identify immune-suppressed, sepsis patients.
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13
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Munley JA, Kirkpatrick SL, Gillies GS, Bible LE, Efron PA, Nagpal R, Mohr AM. The Intestinal Microbiome after Traumatic Injury. Microorganisms 2023; 11:1990. [PMID: 37630549 PMCID: PMC10459834 DOI: 10.3390/microorganisms11081990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 07/29/2023] [Accepted: 07/30/2023] [Indexed: 08/27/2023] Open
Abstract
The intestinal microbiome plays a critical role in host immune function and homeostasis. Patients suffering from-as well as models representing-multiple traumatic injuries, isolated organ system trauma, and various severities of traumatic injury have been studied as an area of interest in the dysregulation of immune function and systemic inflammation which occur after trauma. These studies also demonstrate changes in gut microbiome diversity and even microbial composition, with a transition to a pathobiome state. In addition, sex has been identified as a biological variable influencing alterations in the microbiome after trauma. Therapeutics such as fecal transplantation have been utilized to ameliorate not only these microbiome changes but may also play a role in recovery postinjury. This review summarizes the alterations in the gut microbiome that occur postinjury, either in isolated injury or multiple injuries, along with proposed mechanisms for these changes and future directions for the field.
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Affiliation(s)
- Jennifer A. Munley
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Stacey L. Kirkpatrick
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Gwendolyn S. Gillies
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Letitia E. Bible
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Philip A. Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
| | - Ravinder Nagpal
- Department of Nutrition & Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, FL 32306, USA;
| | - Alicia M. Mohr
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (J.A.M.); (S.L.K.); (G.S.G.); (L.E.B.); (P.A.E.)
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14
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Munley JA, Kelly LS, Gillies GS, Pons EE, Coldwell PS, Kannan KB, Whitley EM, Bible LE, Efron PA, Mohr AM. NARROWING THE GAP: PRECLINICAL TRAUMA WITH POSTINJURY SEPSIS MODEL WITH INCREASED CLINICAL RELEVANCE. Shock 2023; 60:272-279. [PMID: 37310788 PMCID: PMC10526624 DOI: 10.1097/shk.0000000000002161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ABSTRACT Background : Overall outcomes for trauma patients have improved over time. However, mortality for postinjury sepsis is unchanged. The use of relevant preclinical studies remains necessary to understand mechanistic changes after injury and sepsis at the cellular and molecular level. We hypothesized that a preclinical rodent model of multicompartmental injury with postinjury pneumonia and chronic stress would replicate inflammation and organ injury similar to trauma patients in the intensive care unit. Methods : Male and proestrus female Sprague-Dawley rats ( n = 16/group) were subjected to either polytrauma (PT) (lung contusion, hemorrhagic shock, cecectomy, and bifemoral pseudofracture), PT with daily chronic restraint stress (PT/CS), PT with postinjury day one Pseudomonas pneumonia (PT + PNA), PT/CS with pneumonia (PT/CS + PNA) or naive controls. Weight, white blood cell count, plasma toll-like receptor 4 (TLR4), urine norepinephrine (NE), hemoglobin, serum creatinine, and bilateral lung histology were evaluated. Results : PT + PNA and PT/CS + PNA groups lost more weight compared with those without sepsis (PT, PT/CS) and naive rats ( P < 0.03). Similarly, both PT + PNA and PT/CS + PNA had increased leukocytosis and plasma TLR4 compared with uninfected counterparts. Urine NE was elevated in PT + PNA and PT/CS + PNA compared with naive ( P < 0.03), with PT/CS + PNA exhibiting the highest levels. PT/CS + PNA exhibited worse acute kidney injury with elevated serum creatinine compared with PT/CS ( P = 0.008). PT/CS + PNA right and left lung injury scores were worse than PT + PNA ( P < 0.01). Conclusions : Sepsis, with postinjury pneumonia, induced significant systemic inflammation, organ dysfunction following polytrauma and chronic stress. Advanced animal models that replicate the critically ill human condition will help overcome the classic limitations of previous experimental models and enhance their translational value.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | | | - Letita E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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15
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Filiberto AC, Nyren MQ, Underwood PW, Balch JA, Abbott KL, Efron PA, Sarosi GA, Bihorac A, Upchurch GR, Loftus TJ. Resource use for cholecystectomy with versus without cholangiography: A multicenter, propensity-matched analysis. Surgery 2023; 174:152-158. [PMID: 37188579 DOI: 10.1016/j.surg.2023.04.027] [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] [Received: 12/12/2022] [Revised: 02/23/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intraoperative cholangiography may allow for earlier identification of common bile duct injury and choledocholithiasis. The role of intraoperative cholangiography in decreasing resource use related to biliary pathology remains unclear. This study tests the null hypothesis that there is no difference in resource use for patients undergoing laparoscopic cholecystectomy with versus without intraoperative cholangiography. METHODS This retrospective, longitudinal cohort study included 3,151 patients who underwent laparoscopic cholecystectomy at 3 university hospitals. To minimize differences in baseline characteristics while maintaining adequate statistical power, propensity scores were used to match 830 patients who underwent intraoperative cholangiography at surgeon discretion and 795 patients who underwent cholecystectomy without intraoperative cholangiography. Primary outcomes were the incidence of postoperative endoscopic retrograde cholangiography, the interval between surgery and endoscopic retrograde cholangiography, and total direct costs. RESULTS In the propensity-matched analysis, the intraoperative cholangiography and no intraoperative cholangiography cohorts had similar age, comorbidities, American Society of Anesthesiologists Sequential Organ Failure Assessment scores, and total/direct bilirubin ratios. The intraoperative cholangiography cohort had a lower postoperative endoscopic retrograde cholangiography (2.4% vs 4.3%; P = .04), a shorter interval between cholecystectomy and endoscopic retrograde cholangiography (2.5 [1.0-17.8] vs 4.5 [2.0-9.5] days; P = .04), and shorter length of stay (0.3 [0.2-1.5] vs 1.4 [0.3-3.2] days; P < .001). Patients undergoing intraoperative cholangiography had lower total direct costs ($4.0K [3.6K-5.4K] vs $8.1K [4.9K-13.0K]; P < .001). There were no differences in 30-day or 1-year mortality among the cohorts. CONCLUSION Compared with laparoscopic cholecystectomy without intraoperative cholangiography, cholecystectomy with intraoperative cholangiography was associated with decreased resource use, which was primarily attributable to decreased incidence and the earlier timing of postoperative endoscopic retrograde cholangiography.
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Affiliation(s)
| | - Molly Q Nyren
- College of Medicine, University of Florida Health, Gainesville, FL. https://twitter.com/Molly_Nyren
| | - Patrick W Underwood
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/P_Underwood21
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/balchja
| | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL. https://twitter.com/AzraBihorac
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/gru6n
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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16
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Balch JA, Chen UI, Liesenfeld O, Starostik P, Loftus TJ, Efron PA, Brakenridge SC, Sweeney TE, Moldawer LL. Defining critical illness using immunological endotypes in patients with and without sepsis: a cohort study. Crit Care 2023; 27:292. [PMID: 37474944 PMCID: PMC10360294 DOI: 10.1186/s13054-023-04571-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Sepsis is a heterogenous syndrome with limited therapeutic options. Identifying immunological endotypes through gene expression patterns in septic patients may lead to targeted interventions. We investigated whether patients admitted to a surgical intensive care unit (ICU) with sepsis and with high risk of mortality express similar endotypes to non-septic, but still critically ill patients using two multiplex transcriptomic metrics obtained both on admission to a surgical ICU and at set intervals. METHODS We analyzed transcriptomic data from 522 patients in two single-site, prospective, observational cohorts admitted to surgical ICUs over a 5-year period ending in July 2020. Using an FDA-cleared analytical platform (nCounter FLEX®, NanoString, Inc.), we assessed a previously validated 29-messenger RNA transcriptomic classifier for likelihood of 30-day mortality (IMX-SEV-3) and a 33-messenger RNA transcriptomic endotype classifier. Clinical outcomes included all-cause mortality, development of chronic critical illness, and secondary infections. Univariate and multivariate analyses were performed to assess for true effect and confounding. RESULTS Sepsis was associated with a significantly higher predicted and actual hospital mortality. At enrollment, the predominant endotype for both septic and non-septic patients was adaptive, though with significantly different distributions. Inflammopathic and coagulopathic septic patients, as well as inflammopathic non-septic patients, showed significantly higher frequencies of secondary infections compared to those with adaptive endotypes (p < 0.01). Endotypes changed during ICU hospitalization in 57.5% of patients. Patients who remained adaptive had overall better prognosis, while those who remained inflammopathic or coagulopathic had worse overall outcomes. For severity metrics, patients admitted with sepsis and a high predicted likelihood of mortality showed an inflammopathic (49.6%) endotype and had higher rates of cumulative adverse outcomes (67.4%). Patients at low mortality risk, whether septic or non-septic, almost uniformly presented with an adaptive endotype (100% and 93.4%, respectively). CONCLUSION Critically ill surgical patients express different and evolving immunological endotypes depending upon both their sepsis status and severity of their clinical course. Future studies will elucidate whether endotyping critically ill, septic patients can identify individuals for targeted therapeutic interventions to improve patient management and outcomes.
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Affiliation(s)
- Jeremy A Balch
- Sepsis and Critical Illness Research Center, Department of Surgery, Shands Hospital, University of Florida College of Medicine, Room 6116, 1600 SW Archer Road, P. O. Box 100019, Gainesville, FL, 32610-0019, USA
| | - Uan-I Chen
- Inflammatix, Inc., Sunnyvale, CA, 94085, USA
| | | | - Petr Starostik
- UF Health Medical Laboratory at Rocky Point, Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Tyler J Loftus
- Sepsis and Critical Illness Research Center, Department of Surgery, Shands Hospital, University of Florida College of Medicine, Room 6116, 1600 SW Archer Road, P. O. Box 100019, Gainesville, FL, 32610-0019, USA
| | - Philip A Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, Shands Hospital, University of Florida College of Medicine, Room 6116, 1600 SW Archer Road, P. O. Box 100019, Gainesville, FL, 32610-0019, USA
| | - Scott C Brakenridge
- Sepsis and Critical Illness Research Center, Department of Surgery, Shands Hospital, University of Florida College of Medicine, Room 6116, 1600 SW Archer Road, P. O. Box 100019, Gainesville, FL, 32610-0019, USA
- Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, 63110, USA
| | | | - Lyle L Moldawer
- Sepsis and Critical Illness Research Center, Department of Surgery, Shands Hospital, University of Florida College of Medicine, Room 6116, 1600 SW Archer Road, P. O. Box 100019, Gainesville, FL, 32610-0019, USA.
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Polcz VE, Barrios EL, Chapin B, Price C, Nagpal R, Chakrabarty P, Casadesus G, Foster T, Moldawer L, Efron PA. Sex, sepsis and the brain: defining the role of sexual dimorphism on neurocognitive outcomes after infection. Clin Sci (Lond) 2023; 137:963-978. [PMID: 37337946 PMCID: PMC10285043 DOI: 10.1042/cs20220555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
Sexual dimorphisms exist in multiple domains, from learning and memory to neurocognitive disease, and even in the immune system. Male sex has been associated with increased susceptibility to infection, as well as increased risk of adverse outcomes. Sepsis remains a major source of morbidity and mortality globally, and over half of septic patients admitted to intensive care are believed to suffer some degree of sepsis-associated encephalopathy (SAE). In the short term, SAE is associated with an increased risk of in-hospital mortality, and in the long term, has the potential for significant impairment of cognition, memory, and acceleration of neurocognitive disease. Despite increasing information regarding sexual dimorphism in neurologic and immunologic systems, research into these dimorphisms in sepsis-associated encephalopathy remains critically understudied. In this narrative review, we discuss how sex has been associated with brain morphology, chemistry, and disease, sexual dimorphism in immunity, and existing research into the effects of sex on SAE.
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Affiliation(s)
- Valerie E. Polcz
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Evan L. Barrios
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Benjamin Chapin
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Catherine C. Price
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions, Gainesville, Florida, U.S.A
| | - Ravinder Nagpal
- Florida State University College of Health and Human Sciences, Tallahassee, Florida, U.S.A
| | - Paramita Chakrabarty
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Gemma Casadesus
- Department of Pharmacology and Therapeutics, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Thomas Foster
- Department of Neuroscience, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Lyle L. Moldawer
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, U.S.A
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18
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Balch JA, Loftus TJ, Ruppert MM, Rosenthal MD, Mohr AM, Efron PA, Upchurch GR, Smith RS. Retrospective value assessment of a dedicated, trauma hybrid operating room. J Trauma Acute Care Surg 2023; 94:814-822. [PMID: 36727772 PMCID: PMC10205659 DOI: 10.1097/ta.0000000000003873] [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: 02/03/2023]
Abstract
BACKGROUND In traumatic hemorrhage, hybrid operating rooms offer near simultaneous performance of endovascular and open techniques, with correlations to earlier hemorrhage control, fewer transfusions, and possible decreased mortality. However, hybrid operating rooms are resource intensive. This study quantifies and describes a single-center experience with the complications, cost-utility, and value of a dedicated trauma hybrid operating room. METHODS This retrospective cohort study evaluated 292 consecutive adult trauma patients who underwent immediate (<4 hours) operative intervention at a Level I trauma center. A total of 106 patients treated before the construction of a hybrid operating room served as historical controls to the 186 patients treated thereafter. Demographics, hemorrhage-control procedures, and financial data as well as postoperative complications and outcomes were collected via electronic medical records. Value and incremental cost-utility ratio were calculated. RESULTS Demographics and severity of illness were similar between cohorts. Resuscitative endovascular occlusion of the aorta was more frequently used in the hybrid operating room. Hemorrhage control occurred faster (60 vs. 49 minutes, p = 0.005) and, in the 4- to 24-hour postadmission period, required less red blood cell (mean, 1.0 vs. 0 U, p = 0.001) and plasma (mean, 1.0 vs. 0 U, p < 0.001) transfusions. Complications were similar except for a significant decrease in pneumonia (7% vs. 4%, p = 0.008). Severe complications (Clavien-Dindo classification, ≥3) were similar. Across the patient admission, costs were not significantly different ($50,023 vs. $54,740, p = 0.637). There was no change in overall value (1.00 vs. 1.07, p = 0.778). CONCLUSION The conversion of our standard trauma operating room to an endovascular hybrid operating room provided measurable improvements in hemorrhage control, red blood cell and plasma transfusions, and postoperative pneumonia without significant increase in cost. Value was unchanged. LEVEL OF EVIDENCE Economic/Value-Based Evaluations; Level III.
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Affiliation(s)
- Jeremy A. Balch
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | - Tyler J. Loftus
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | - Matthew M. Ruppert
- University of Florida Health, Department of Medicine, Gainesville, Florida
| | | | - Alicia M. Mohr
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | - Philip A. Efron
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | | | - R. Stephen Smith
- University of Florida Health, Department of Surgery, Gainesville, Florida
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Carmichael ED, Apple CG, Kannan KB, Gardener A, Anton S, Efron PA, Moldawer LL, Moore FA, Brakenridge SC, Mohr AM. Chronic Critical Illness in Patients With Sepsis is Associated With Persistent Anemia, Inflammation, and Impaired Functional Outcomes. Am Surg 2023; 89:2563-2571. [PMID: 35593749 PMCID: PMC9675873 DOI: 10.1177/00031348221104252] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Survivors of sepsis will progress towards rapid recovery (RAP) or enter a state of persistent organ dysfunction and chronic critical illness (CCI). Independently, anemia is known to be a significant factor in functional recovery of hospitalized patients. This study aims to analyze long-term hemoglobin levels and functional outcomes following RAP and CCI. METHODS A prospective, cohort study was performed in septic patients who were stratified into RAP (N = 54) with ICU length of stay < 14 days or CCI (N = 63) with ICU length of stay > 14 days. CBC and plasma inflammatory markers were measured on the day of enrollment, weekly until day 42, then at 3 and 6 months. Functional outcomes using Zubrod scale, gait speed test, and total short physical performance battery (SPPB) were assessed at 3, 6, and 12 months. RESULTS Mean age was 59 years (range: 20-83) and 62% were male. Hemoglobin was significantly decreased at 3 and 6 months in CCI compared to RAP (8.9* and 9.2* vs 10.4 and 11.1 g/dL), despite receiving significantly more red blood cell transfusions. CCI patients had persistent elevation of CRP, IL-6 and TNF-α. CCI patients had worse functional outcome with a significantly higher Zubrod score, and lower SPPB, and gait speed score at 3, 6, and 12 months. CONCLUSION Despite receiving more pRBC transfusions, CCI patients had a persistent anemia that was associated with chronic systemic inflammation and poor functional outcomes six months following sepsis. Alleviating prolonged inflammation could improve persistent anemia and functional outcomes in CCI patients.
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Affiliation(s)
- Ethan D Carmichael
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Camille G Apple
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Kolenkode B Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Anna Gardener
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Stephen Anton
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Lyle L Moldawer
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Frederick A Moore
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Scott C Brakenridge
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
| | - Alicia M Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, FL, USA
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20
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Barrios EL, Polcz VE, Hensley SE, Sarosi GA, Mohr AM, Loftus TJ, Upchurch GR, Sumfest JM, Efron PA, Dunleavy K, Bible L, Terracina KP, Al-Mansour MR, Gravina N. A narrative review of ergonomic problems, principles, and potential solutions in surgical operations. Surgery 2023:S0039-6060(23)00177-0. [PMID: 37202309 DOI: 10.1016/j.surg.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions. METHODS pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature. RESULTS Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation. CONCLUSION Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons.
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Affiliation(s)
- Evan L Barrios
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Valerie E Polcz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Sara E Hensley
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Jill M Sumfest
- Gatorcare Health Management Corporation, University of Florida, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Kim Dunleavy
- Department of Physical Therapy, University of Florida, Gainesville, FL
| | - Letitia Bible
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Krista P Terracina
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Mazen R Al-Mansour
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Nicole Gravina
- Department of Psychology, University of Florida, Gainesville, FL.
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21
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Balch JA, Chen UI, Liesenfeld O, Starostik P, Loftus TJ, Efron PA, Brakenridge SC, Sweeney TE, Moldawer LL. Defining critical illness using immunological endotypes in patients with and without of sepsis: A cohort study. Res Sq 2023:rs.3.rs-2874506. [PMID: 37214996 PMCID: PMC10197751 DOI: 10.21203/rs.3.rs-2874506/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Background: Sepsis is a heterogenous syndrome with limited therapeutic options. Identifying characteristic gene expression patterns, or endotypes, in septic patients may lead to targeted interventions. We investigated whether patients admitted to a surgical ICU with sepsis and with high risk of mortality express similar endotypes to non-septic, but still critically ill patients using two multiplex transcriptomic metrics obtained both on admission to a surgical intensive care unit (ICU) and at set intervals. Methods: We analyzed transcriptomic data from 522 patients in two single-site, prospective, observational cohorts admitted to surgical ICUs over a 5-year period ending in July 2020 . Using an FDA-cleared analytical platform (nCounter FLEX ® , NanoString, Inc.), we assessed a previously validated 29-messenger RNA transcriptomic classifier for likelihood of 30-day mortality (IMX-SEV-3) and a 33-messenger RNA transcriptomic endotype classifier. Clinical outcomes included all-cause (in-hospital, 30-, 90-day) mortality, development of chronic critical illness (CCI), and secondary infections. Univariate and multivariate analyses were performed to assess for true effect and confounding. Results: Sepsis was associated with a significantly higher predicted and actual hospital mortality. At enrollment, the predominant endotype for both septic and non-septic patients was adaptive , though with significantly different distributions. Inflammopathic and coagulopathic septic patients, as well as inflammopathic non-septic patients, showed significantly higher frequencies of secondary infections compared to those with adaptive endotypes (p<0.01). Endotypes changed during ICU hospitalization in 57.5% of patients. Patients who remained adaptive had overall better prognosis, while those who remained inflammopathic or coagulopathic had worse overall outcomes. For severity metrics, patients admitted with sepsis and a high predicted likelihood of mortality showed an inflammopathic (49.6%) endotype and had higher rates of cumulative adverse outcomes (67.4%). Patients at low mortality risk, whether septic or non-septic, almost uniformly presented with an adaptive endotype (100% and 93.4%, respectively). Conclusion : Critically ill surgical patients express different and evolving immunological endotypes depending upon both their sepsis status and severity of their clinical course. Future studies will elucidate whether endotyping critically ill, septic patients can identify individuals for targeted therapeutic interventions to improve patient management and outcomes.
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Munley JA, Kelly LS, Gillies GS, Kannan KB, Pons EE, Bible LE, Efron PA, Mohr AM. EFFECTS OF TRAUMA PLASMA-DERIVED EXOSOMES ON HEMATOPOIETIC PROGENITOR CELLS. Shock 2023; 59:591-598. [PMID: 36772985 PMCID: PMC10065931 DOI: 10.1097/shk.0000000000002094] [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: 02/12/2023]
Abstract
ABSTRACT Background: Severe trauma disrupts bone marrow function resulting in persistent anemia and immunosuppression. Exosomes are extracellular vesicles implicated in disease, cellular functions, and immunomodulation. The effects of trauma plasma-derived exosomes on bone marrow hematopoiesis are unstudied; we hypothesized that trauma plasma-derived exosomes suppress bone marrow hematopoietic progenitor cell (HPC) growth and contribute to increased inflammatory cytokines and HPC mobilization. Methods: Plasma was collected from a prospective, cohort study of trauma patients (n = 15) with hip and/or femur fractures and an ISS > 15 and elective total hip arthroplasty (THA) patients (n = 15). Exosomes were isolated from both groups using the Invitrogen Total Exosome Isolation Kit. Healthy bone marrow was cultured with 2% plasma, 50 μg, 100 μg, or 200 μg of exosomal protein and HPC (granulocyte, erythrocyte, monocyte, megakaryocyte colony-forming units [CFU-GEMM], erythroid burst-forming units [BFU-E], and macrophage colony-forming units [CFU-GM]) growth assessed. After culturing healthy bone marrow stroma with 100 μg of exosomal protein, expression of cytokines and factors influencing HPC mobilization were assessed by qPCR. Differences were compared using the ANOVA, with significance defined as P < 0.05. Results: The only demographic difference was age; trauma patients were significantly younger than THA (mean 44 vs. 63 years). In vitro exposure to trauma plasma significantly decreased growth of all HPCs. In vitro exposure to 100 μg or 200 μg of trauma exosomal protein significantly decreased growth of BFU-E and CFU-GM, whereas 50 μg had no effect. Culture of trauma exosomal protein with bone marrow stromal cells resulted in increased expression of IFN-γ, IL-1α, TNF-α, G-CSF, CXCR4, SDF-1, and VCAM-1 in bone marrow stroma. Conclusions: Both plasma and plasma-derived exosomes from trauma patients adversely affect bone marrow function. Plasma-derived exosomes may contribute to altered hematopoiesis after severe trauma; analysis of exosomal content may improve our understanding of altered bone marrow function.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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23
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Nyren MQ, Filiberto AC, Underwood PW, Abbott KL, Balch JA, Efron PA, George BC, Shickel B, Upchurch GR, Sarosi GA, Loftus TJ. A simulation curriculum for laparoscopic common bile duct exploration, balloon sphincterotomy, and endobiliary stenting: Associations with resident performance and autonomy in the operating room. Surgery 2023; 173:950-956. [PMID: 36517292 DOI: 10.1016/j.surg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration is safe and effective for managing choledocholithiasis, but laparoscopic common bile duct exploration is rarely performed, which threatens surgical trainee proficiency. This study tests the hypothesis that prior operative or simulation experience with laparoscopic common bile duct exploration is associated with greater resident operative performance and autonomy without adversely affecting patient outcomes. METHODS This longitudinal cohort study included 33 consecutive patients undergoing laparoscopic common bile duct exploration in cases involving postgraduate years 3, 4, and 5 general surgery residents at a single institution during the implementation of a laparoscopic common bile duct exploration simulation curriculum. For each of the 33 cases, resident performance and autonomy were rated by residents and attendings, the resident's prior operative and simulation experience were recorded, and patient outcomes were ascertained from electronic health records for comparison among 3 cohorts: prior operative experience, prior simulation experience, and no prior experience. RESULTS Operative approach was similar among cohorts. Overall morbidity was 6.1% and similar across cohorts. The operative performance scores were higher in prior experience cohorts according to both residents (3.0 [2.8-3.0] vs 2.0 [2.0-3.0]; P = .01) and attendings (3.0 [3.0-4.0]; P < .001). The autonomy scores were higher in prior experience cohorts according to both residents (2.0 [2.0-3.0] vs 2.0 [2.0-2.0]; P = .005) and attendings (2.5 [2.0-3.0] vs 2.0 [1.0-2.0]; P = .001). Prior simulation and prior operative experience had similar associations with performance and autonomy. CONCLUSION Simulation experience with laparoscopic common bile duct exploration was associated with greater resident operative performance and autonomy, with effects that mimic prior operative experience. This illustrates the potential for simulation-based training to improve resident operative performance and autonomy for laparoscopic common bile duct exploration.
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Affiliation(s)
- Molly Q Nyren
- College of Medicine, University of Florida, Gainesville, FL
| | | | | | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | | | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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24
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Balch JA, Loftus TJ, Efron PA, Mohr AM, Upchurch GR, Smith RS. Survival and neurologic outcomes following aortic occlusion for trauma and hemorrhagic shock in a hybrid operating room. World J Emerg Surg 2023; 18:21. [PMID: 36959585 PMCID: PMC10035182 DOI: 10.1186/s13017-023-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Outcomes following aortic occlusion for trauma and hemorrhagic shock are poor, leading some to question the clinical utility of aortic occlusion in this setting. This study evaluates neurologically intact survival following resuscitative endovascular balloon occlusion of the aorta (REBOA) versus resuscitative thoracotomy at a center with a dedicated trauma hybrid operating room with angiographic capabilities. METHODS This retrospective cohort analysis compared patients who underwent zone 1 aortic occlusion via resuscitative thoracotomy (n = 13) versus REBOA (n = 13) for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock (systolic blood pressure less than 90 mmHg despite volume resuscitation) at a level 1 trauma center with a dedicated trauma hybrid operating room. The primary outcome was survival to hospital discharge. The secondary outcome was neurologic status at hospital discharge, assessed by Glasgow Coma Scale (GCS) scores. RESULTS Overall median age was 40 years, 27% had penetrating injuries, and 23% had pre-hospital closed-chest cardiopulmonary resuscitation. In both cohorts, median injury severity scores and head-abbreviated injury scores were 26 and 2, respectively. The resuscitative thoracotomy cohort had lower systolic blood pressure on arrival (0 [0-75] vs. 76 [65-99], p = 0.009). Hemorrhage control (systolic blood pressure 100 mmHg without ongoing vasopressor or transfusion requirements) was obtained in 77% of all REBOA cases and 8% of all resuscitative thoracotomy cases (p = 0.001). Survival to hospital discharge was greater in the REBOA cohort (54% vs. 8%, p = 0.030), as was discharge with GCS 15 (46% vs. 0%, p = 0.015). CONCLUSIONS Among patients undergoing aortic occlusion for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock at a center with a dedicated, trauma hybrid operating room, nearly half of all patients managed with REBOA had neurologically intact survival. The high death rate in resuscitative thoracotomy and differences in patient cohorts limit direct comparison.
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Affiliation(s)
- Jeremy A Balch
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Philip A Efron
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - R Stephen Smith
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA.
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Maegele M, Aletti F, Efron PA, Relja B, Orfanos SE. NEW INSIGHTS INTO THE PATHOPHYSIOLOGY OF TRAUMA AND HEMORRHAGE. Shock 2023; 59:6-9. [PMID: 36867756 DOI: 10.1097/shk.0000000000001954] [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: 03/05/2023]
Abstract
ABSTRACT Circulatory shock from trauma and hemorrhage remains a clinical challenge with mortality still high within the first hours after impact. It represents a complex disease involving the impairment of a number of physiological systems and organs and the interaction of different pathological mechanisms. Multiple external and patient-specific factors may further modulate and complicate the clinical course. Recently, novel targets and models with complex multiscale interaction of data from different sources have been identified which offer new windows of opportunity. Future works needs to consider patient-specific conditions and outcomes to mount shock research onto the next higher level of precision and personalized medicine.
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Affiliation(s)
- Marc Maegele
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Institute for Research in Operative Medicine, University Witten-Herdecke, Cologne, Germany
| | - Federico Aletti
- Instituto de Ciência e Tecnologia, Universidade Federal de São Paulo, São José dos Campos, Brazil
| | - Philip A Efron
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Laboratory of Inflammation Biology and Surgical Science, UF Health Critical Care Organization, Florida
| | - Borna Relja
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stylianos E Orfanos
- 1st Department of Critical Care Medicine, National and Kapodistrian University of Athens, Medical School, Greece
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Balch JA, Ruppert MM, Shickel B, Ozrazgat-Baslanti T, Tighe PJ, Efron PA, Upchurch GR, Rashidi P, Bihorac A, Loftus TJ. Building an automated, machine learning-enabled platform for predicting post-operative complications. Physiol Meas 2023; 44:024001. [PMID: 36657179 PMCID: PMC9910093 DOI: 10.1088/1361-6579/acb4db] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 12/29/2022] [Accepted: 01/19/2023] [Indexed: 01/21/2023]
Abstract
Objective. In 2019, the University of Florida College of Medicine launched theMySurgeryRiskalgorithm to predict eight major post-operative complications using automatically extracted data from the electronic health record.Approach. This project was developed in parallel with our Intelligent Critical Care Center and represents a culmination of efforts to build an efficient and accurate model for data processing and predictive analytics.Main Results and Significance. This paper discusses how our model was constructed and improved upon. We highlight the consolidation of the database, processing of fixed and time-series physiologic measurements, development and training of predictive models, and expansion of those models into different aspects of patient assessment and treatment. We end by discussing future directions of the model.
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Affiliation(s)
- Jeremy A Balch
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
| | - Matthew M Ruppert
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Benjamin Shickel
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Tezcan Ozrazgat-Baslanti
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Patrick J Tighe
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
| | - Parisa Rashidi
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States of America
| | - Azra Bihorac
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Tyler J Loftus
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States of America
- Department of Surgery, University of Florida, Gainesville, Florida, United States of America
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27
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Nyren MQ, Filiberto AC, Underwood PW, Abbott KL, Balch JA, Mas FD, Cobianchi L, Efron PA, George BC, Shickel B, Upchurch GR, Sarosi GA, Loftus TJ. Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback. World J Emerg Surg 2023; 18:13. [PMID: 36747289 PMCID: PMC9901129 DOI: 10.1186/s13017-023-00480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. METHODS Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). RESULTS Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p < .001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p = .009) and attendings (69% vs. 32%, p < .01). CONCLUSIONS Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations.
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Affiliation(s)
- Molly Q. Nyren
- grid.15276.370000 0004 1936 8091University of Florida College of Medicine, Gainesville, FL USA
| | - Amanda C. Filiberto
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Patrick W. Underwood
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Kenneth L. Abbott
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Jeremy A. Balch
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Francesca Dal Mas
- grid.7240.10000 0004 1763 0578Department of Management, Ca’ Foscari University of Venice, Venice, Italy
| | - Lorenzo Cobianchi
- grid.8982.b0000 0004 1762 5736Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy ,grid.419425.f0000 0004 1760 3027IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Philip A. Efron
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Brian C. George
- grid.214458.e0000000086837370Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Benjamin Shickel
- grid.15276.370000 0004 1936 8091Department of Biomedical Engineering, University of Florida, Gainesville, FL USA
| | - Gilbert R. Upchurch
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - George A. Sarosi
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
| | - Tyler J. Loftus
- grid.430508.a0000 0004 4911 114XDepartment of Surgery, University of Florida Health, PO Box 100286, Gainesville, FL 32610 USA
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Barrios EL, Polcz VE, Moldawer LL, Rincon JC, Efron PA, Larson SD. VARIABLES INFLUENCING THE DIFFERENTIAL HOST RESPONSE TO BURNS IN PEDIATRIC AND ADULT PATIENTS. Shock 2023; 59:145-154. [PMID: 36730790 PMCID: PMC9957807 DOI: 10.1097/shk.0000000000002042] [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: 02/04/2023]
Abstract
ABSTRACT Burn injury is a significant source of morbidity and mortality in the pediatric population. Although 40,000 pediatric patients in the United States are admitted to the hospital with burn wounds annually, significant differences exist in the management and treatment of these patients, even among highly specialized burn centers. Some aspects of pediatric burn research, such as metabolic changes and nutritional support after burn injury, have been studied extensively; however, in many aspects of burn care, pediatric research lags behind the study of adult populations. This review compares and contrasts a wide array of physiologic and immune responses between children and adults after burn injury. Such a review elucidates where robust research has been conducted, where adult research is applicable to pediatric patients, and where additional pediatric burn research needs to be conducted.
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Affiliation(s)
- Evan L Barrios
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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29
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Abstract
BACKGROUND Trauma is associated with widespread inflammation, neuroendocrine activation, and an inadequate bone marrow response to anemia. During late-stage erythropoiesis, erythroid progenitors/erythroblasts form clusters on the surface of specialized bone marrow macrophages where they are supported through terminal differentiation and enucleation. We hypothesized that these erythroblastic islands (EBIs) are adversely impacted by severe trauma. METHODS Male Sprague-Dawley rats (n = 8/group) were subjected to either multiple injuries (PT) (lung contusion, hemorrhagic shock, cecectomy, and bifemoral pseudofractures), PT plus 2 hours of daily chronic restraint stress (PT/CS), or naive controls. Bone marrow was harvested on days 2 and 7. Nuclear-stained, enriched bone marrow EBIs were fixed and stained for CD71, VCAM-1, and CD163, and confocal images were obtained at 20 times magnification. Numbers of erythroid cells/EBI and ratio of reticulocytes/EBI were counted by a blinded observer. Differences were compared using analysis of variance, with significance defined as p < 0.05. RESULTS PT and PT/CS had significantly reduced numbers of erythroid cells per EBI on day 2 when compared with naive (PT: 5.9 ± 1.0 cells [ p < 0.05], PT/CS: 6.8 ± 0.8 cells [ p < 0.05] vs. naive: 8.5 ± 0.8 cells). On day 7, the number of erythroid cells/EBI increased following PT (8.3 ± 0.4 cells) but remained reduced following PT/CS (5.9 ± 0.5 cells [ p < 0.05]). This correlated with an increased proportion of reticulocytes/EBI on day 7 following PT, which was not present following PT/CS (PT: 54% [ p < 0.05] vs. PT/CS: 28%). CONCLUSION Late-stage erythropoiesis was altered following multicompartmental PT early after injury, and these alterations persisted with the addition of daily chronic stress. Alterations in EBI structure and function after severe trauma and critical illness may serve as a promising new area of study to improve mechanistic understanding of persistent anemia after trauma.
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Affiliation(s)
- Lauren S Kelly
- From the Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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30
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Loftus TJ, Ruppert MM, Shickel B, Ozrazgat-Baslanti T, Balch JA, Hu D, Javed A, Madbak F, Skarupa DJ, Guirgis F, Efron PA, Tighe PJ, Hogan WR, Rashidi P, Upchurch GR, Bihorac A. Overtriage, Undertriage, and Value of Care after Major Surgery: An Automated, Explainable Deep Learning-Enabled Classification System. J Am Coll Surg 2023; 236:279-291. [PMID: 36648256 PMCID: PMC9993068 DOI: 10.1097/xcs.0000000000000471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND In single-institution studies, overtriaging low-risk postoperative patients to ICUs has been associated with a low value of care; undertriaging high-risk postoperative patients to general wards has been associated with increased mortality and morbidity. This study tested the reproducibility of an automated postoperative triage classification system to generating an actionable, explainable decision support system. STUDY DESIGN This longitudinal cohort study included adults undergoing inpatient surgery at two university hospitals. Triage classifications were generated by an explainable deep learning model using preoperative and intraoperative electronic health record features. Nearest neighbor algorithms identified risk-matched controls. Primary outcomes were mortality, morbidity, and value of care (inverted risk-adjusted mortality/total direct costs). RESULTS Among 4,669 ICU admissions, 237 (5.1%) were overtriaged. Compared with 1,021 control ward admissions, overtriaged admissions had similar outcomes but higher costs ($15.9K [interquartile range $9.8K to $22.3K] vs $10.7K [$7.0K to $17.6K], p < 0.001) and lower value of care (0.2 [0.1 to 0.3] vs 1.5 [0.9 to 2.2], p < 0.001). Among 8,594 ward admissions, 1,029 (12.0%) were undertriaged. Compared with 2,498 control ICU admissions, undertriaged admissions had longer hospital length-of-stays (6.4 [3.4 to 12.4] vs 5.4 [2.6 to 10.4] days, p < 0.001); greater incidence of hospital mortality (1.7% vs 0.7%, p = 0.03), cardiac arrest (1.4% vs 0.5%, p = 0.04), and persistent acute kidney injury without renal recovery (5.2% vs 2.8%, p = 0.002); similar costs ($21.8K [$13.3K to $34.9K] vs $21.9K [$13.1K to $36.3K]); and lower value of care (0.8 [0.5 to 1.3] vs 1.2 [0.7 to 2.0], p < 0.001). CONCLUSIONS Overtriage was associated with low value of care; undertriage was associated with both low value of care and increased mortality and morbidity. The proposed framework for generating automated postoperative triage classifications is reproducible.
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Affiliation(s)
- Tyler J Loftus
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL
| | - Matthew M Ruppert
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL
| | - Benjamin Shickel
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL
| | - Tezcan Ozrazgat-Baslanti
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL
| | - Jeremy A Balch
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL
- Biomedical Engineering (Balch, Rashidi), University of Florida, Gainesville, FL
- Computer and Information Science and Engineering (Balch, Rashidi), University of Florida, Gainesville, FL
- Electrical and Computer Engineering (Balch, Rashidi), University of Florida, Gainesville, FL
| | - Die Hu
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL
| | - Adnan Javed
- Departments of Emergency Medicine (Javed, Guirgis), University of Florida College of Medicine, Jacksonville, FL
- Critical Care Medicine (Javed), University of Florida College of Medicine, Jacksonville, FL
| | - Firas Madbak
- Surgery (Madbak, Skarupa), University of Florida College of Medicine, Jacksonville, FL
| | - David J Skarupa
- Surgery (Madbak, Skarupa), University of Florida College of Medicine, Jacksonville, FL
| | - Faheem Guirgis
- Departments of Emergency Medicine (Javed, Guirgis), University of Florida College of Medicine, Jacksonville, FL
| | - Philip A Efron
- Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL
| | - Patrick J Tighe
- Anesthesiology (Tighe), University of Florida Health, Gainesville, FL
- Orthopedics (Tighe), University of Florida Health, Gainesville, FL
- Information Systems/Operations Management (Tighe), University of Florida Health, Gainesville, FL
| | - William R Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine (Hogan), University of Florida, Gainesville, FL
| | - Parisa Rashidi
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Biomedical Engineering (Balch, Rashidi), University of Florida, Gainesville, FL
- Computer and Information Science and Engineering (Balch, Rashidi), University of Florida, Gainesville, FL
- Electrical and Computer Engineering (Balch, Rashidi), University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL
| | - Azra Bihorac
- From the University of Florida Intelligent Critical Care Center, Gainesville, FL (Loftus, Ruppert, Shickel, Ozrazgat-Baslanti, Balch, Hu, Rashidi, Bihorac)
- Departments of Surgery (Loftus, Balch, Hu, Efron, Upchurch, Bihorac), University of Florida Health, Gainesville, FL
- Medicine (Ruppert, Shickel, Ozrazgat-Baslanti, Bihorac), University of Florida Health, Gainesville, FL
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Polcz VE, Rincon JC, Hawkins RB, Barrios EL, Efron PA, Moldawer LL, Larson SD. TRAINED IMMUNITY: A POTENTIAL APPROACH FOR IMPROVING HOST IMMUNITY IN NEONATAL SEPSIS. Shock 2023; 59:125-134. [PMID: 36383390 PMCID: PMC9957873 DOI: 10.1097/shk.0000000000002054] [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: 11/17/2022]
Abstract
ABSTRACT Sepsis, a dysregulated host immune response to infection, is one of the leading causes of neonatal mortality worldwide. Improved understanding of the perinatal immune system is critical to improve therapies to both term and preterm neonates at increased risk of sepsis. Our narrative outlines the known and unknown aspects of the human immune system through both the immune tolerant in utero period and the rapidly changing antigen-rich period after birth. We will highlight the key differences in innate and adaptive immunity noted through these developmental stages and how the unique immune phenotype in early life contributes to the elevated risk of overwhelming infection and dysregulated immune responses to infection upon exposure to external antigens shortly after birth. Given an initial dependence on neonatal innate immune host responses, we will discuss the concept of innate immune memory, or "trained immunity," and describe several potential immune modulators, which show promise in altering the dysregulated immune response in newborns and improving resilience to sepsis.
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Affiliation(s)
- Valerie E Polcz
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Kelly LS, Munley JA, Kannan KB, Pons EE, Coldwell PS, Bible LE, Parvataneni HK, Hagen JE, Efron PA, Mohr AM. Anemia Recovery after Trauma: A Longitudinal Study. Surg Infect (Larchmt) 2023; 24:39-45. [PMID: 36579920 PMCID: PMC9894600 DOI: 10.1089/sur.2022.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Post-injury inflammation and its correlation with anemia recovery after severe trauma is poorly described. Severe injury induces a systemic inflammatory response associated with critical illness and organ dysfunction, including disordered hematopoiesis, and anemia. This study sought to characterize the resolution of post-injury inflammation and anemia to identify risk factors associated with persistence of anemia. Patients and Methods: This single-institution study prospectively enrolled 73 trauma patients with an injury severity score >15, hemorrhagic shock, and a lower extremity long bone orthopedic injury. Blood was obtained at enrollment and after 14 days, one, three, and six months. Analytes were compared using Mann-Whitney U tests with correction for multiple comparisons. Results: Median age was 45 years and Injury Severity Score (ISS) was 27, with anemia rates of 97% at two weeks, 80% at one month, 52% at three months, and 30% at six months. Post-injury elevations in erythropoietin, interleukin-6, and C-reactive protein resolved by one month, three months, and six months, respectively. Median granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF)-α concentrations remained elevated throughout the six-month follow-up period. Patients with persistent anemia had longer intensive care unit and hospital lengths of stay, more infectious complications, and received more packed red blood cell transfusions compared to those with early anemia recovery. Conclusions: Severe trauma is associated with a prolonged inflammatory response, which is associated with increased transfusion requirements, lengths of stay, and persistent anemia. Further analysis is needed to identify correlations between prolonged inflammation and clinical outcomes after discharge.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Hari K. Parvataneni
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer E. Hagen
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
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Loftus TJ, Ruppert MM, Ozrazgat-Baslanti T, Balch JA, Shickel B, Hu D, Efron PA, Tighe PJ, Hogan WR, Rashidi P, Upchurch GR, Bihorac A. Postoperative Overtriage to an Intensive Care Unit Is Associated With Low Value of Care. Ann Surg 2023; 277:179-185. [PMID: 35797553 PMCID: PMC9817331 DOI: 10.1097/sla.0000000000005460] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We test the hypothesis that for low-acuity surgical patients, postoperative intensive care unit (ICU) admission is associated with lower value of care compared with ward admission. BACKGROUND Overtriaging low-acuity patients to ICU consumes valuable resources and may not confer better patient outcomes. Associations among postoperative overtriage, patient outcomes, costs, and value of care have not been previously reported. METHODS In this longitudinal cohort study, postoperative ICU admissions were classified as overtriaged or appropriately triaged according to machine learning-based patient acuity assessments and requirements for immediate postoperative mechanical ventilation or vasopressor support. The nearest neighbors algorithm identified risk-matched control ward admissions. The primary outcome was value of care, calculated as inverse observed-to-expected mortality ratios divided by total costs. RESULTS Acuity assessments had an area under the receiver operating characteristic curve of 0.92 in generating predictions for triage classifications. Of 8592 postoperative ICU admissions, 423 (4.9%) were overtriaged. These were matched with 2155 control ward admissions with similar comorbidities, incidence of emergent surgery, immediate postoperative vital signs, and do not resuscitate order placement and rescindment patterns. Compared with controls, overtraiged admissions did not have a lower incidence of any measured complications. Total costs for admission were $16.4K for overtriage and $15.9K for controls ( P =0.03). Value of care was lower for overtriaged admissions [2.9 (2.0-4.0)] compared with controls [24.2 (14.1-34.5), P <0.001]. CONCLUSIONS Low-acuity postoperative patients who were overtriaged to ICUs had increased total costs, no improvements in outcomes, and received low-value care.
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Affiliation(s)
- Tyler J. Loftus
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Jeremy A. Balch
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
| | - Benjamin Shickel
- Department of Biomedical Engineering, University of
Florida, Gainesville, FL, USA
| | - Die Hu
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Philip A. Efron
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
| | - Patrick J. Tighe
- Departments of Anesthesiology, Orthopedics, and Information
Systems/Operations Management, University of Florida Health, Gainesville, FL,
USA
| | - William R. Hogan
- Department of Health Outcomes & Biomedical Informatics,
College of Medicine, University of Florida, Gainesville, FL, USA
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and
Information Science and Engineering, and Electrical and Computer Engineering,
University of Florida, Gainesville, Florida, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | | | - Azra Bihorac
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
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Balch JA, Loftus TJ, Efron PA, Mohr AM, Upchurch GR, Smith RS. Survival and neurologic outcomes following aortic occlusion for trauma and hemorrhagic shock in a hybrid operating room. Res Sq 2023:rs.3.rs-2459030. [PMID: 36711502 PMCID: PMC9882656 DOI: 10.21203/rs.3.rs-2459030/v1] [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] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Outcomes following aortic occlusion for trauma and hemorrhagic shock are poor, leading some to question the clinical utility of aortic occlusion in this setting. This study evaluates neurologically intact survival following resuscitative endovascular balloon occlusion of the aorta (REBOA) vs. resuscitative thoracotomy at a center with a dedicated trauma hybrid operating room with angiographic capabilities. Methods: This retrospective cohort analysis compared patients who underwent zone 1 aortic occlusion via resuscitative thoracotomy (n=13) vs. REBOA (n=13) for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock (systolic blood pressure less than 90 mmHg despite volume resuscitation) at a level 1 trauma center with a dedicated, trauma hybrid operating room. The primary outcome was survival to hospital discharge. The secondary outcome was neurologic status at hospital discharge, assessed by Glasgow Coma Scale (GCS) scores. Results: Overall median age was 40 years, 27% had penetrating injuries, and 23% had pre-hospital closed-chest cardiopulmonary resuscitation. In both cohorts, median Injury Severity Scores and head Abbreviated Injury Scores were 26 and 2, respectively. The resuscitative thoracotomy cohort had lower systolic blood pressure on arrival (0 [0-75] vs. 76 [65-99], p=0.009). Hemorrhage control (systolic blood pressure 100 mmHg without ongoing vasopressor or transfusion requirements) was obtained in 77% of all REBOA cases and 8% of all resuscitative thoracotomy cases (p=0.001). Survival to hospital discharge was greater in the REBOA cohort (54% vs. 8%, p=0.030), as was discharge with GCS 15 (46% vs. 0%, p=0.015). Conclusions: Among patients undergoing aortic occlusion for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock at a center with a dedicated, trauma hybrid operating room, nearly half of all patients managed with REBOA had neurologically intact survival. The high death rate in resuscitative thoracotomy and differences in patient cohorts limit direct comparison.
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Munley JA, Kelly LS, Pons EE, Kannan KB, Coldwell PS, Whitley EM, Gillies GS, Efron PA, Nagpal R, Mohr AM. Multicompartmental traumatic injury and the microbiome: Shift to a pathobiome. J Trauma Acute Care Surg 2023; 94:15-22. [PMID: 36203239 PMCID: PMC9805505 DOI: 10.1097/ta.0000000000003803] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 02/07/2023]
Abstract
BACKGROUND Previous animal models have demonstrated altered gut microbiome after mild traumatic injury; however, the impact of injury severity and critical illness is unknown. We hypothesized that a rodent model of severe multicompartmental injuries and chronic stress would demonstrate microbiome alterations toward a "pathobiome" characterized by an overabundance of pathogenic organisms, which would persist 1 week after injury. METHODS Male Sprague-Dawley rats (n = 8 per group) were subjected to either multiple injuries (PT) (lung contusion, hemorrhagic shock, cecectomy, and bifemoral pseudofractures), PT plus daily chronic restraint stress for 2 hours (PT/CS), or naive controls. Fecal microbiome was measured on days 0, 3, and 7 using high-throughput 16S rRNA sequencing and Quantitative Insights Into Microbial Ecology 2 bioinformatics analysis. Microbial α diversity was assessed using Chao1 and Shannon indices, and β diversity with principle coordinate analysis. Intestinal permeability was evaluated by plasma occludin; ileum and descending colon tissues were reviewed for injury. Analyses were performed in GraphPad (GraphPad Software, La Jolla, CA) and R (R Foundation for Statistical Computing, Vienna, Austria), with significance defined as p < 0.05. RESULTS There were significant alterations in β diversity at day 3 and between all groups. By day 3, both PT and PT/CS demonstrated significantly depleted bacterial diversity (Chao1) ( p = 0.01 and p = 0.001, respectively) versus naive, which persisted up to day 7 in PT/CS only ( p = 0.001). Anaerostipes and Rothia dominated PT and Lactobacillus bloomed in PT/CS cohorts by day 7. Plasma occludin was significantly elevated in PT/CS compared with naive ( p = 0.04), and descending colon of both PT and PT/CS showed significantly higher injury compared with naive ( p = 0.005, p = 0.006). CONCLUSIONS Multiple injuries with and without chronic stress induces significant alterations in microbiome diversity and composition within 3 days; these changes are more prominent and persist for 1 week postinjury with stress. This rapid and persistent transition to a "pathobiome" phenotype represents a critical phenomenon that may influence outcomes after severe trauma and critical illness.
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Affiliation(s)
- Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Preston S. Coldwell
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | | | - Gwendolyn S. Gillies
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Ravinder Nagpal
- Department of Nutrition & Integrative Physiology, Florida State University College of Health and Human Sciences, Tallahassee, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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36
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Munley JA, Nagpal R, Hanson NC, Mirzaie A, Laquian L, Mohr AM, Efron PA, Arnaoutakis DJ, Cooper MA. Chronic Mesenteric Ischemia Intestinal Dysbiosis Resolves after Revascularization. J Vasc Surg Cases Innov Tech 2022; 9:101084. [PMID: 36970136 PMCID: PMC10033993 DOI: 10.1016/j.jvscit.2022.101084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Chronic mesenteric ischemia (CMI) is a debilitating condition arising from intestinal malperfusion from mesenteric artery stenosis or occlusion. Mesenteric revascularization has been the standard of care but can result in substantial morbidity and mortality. Most of the perioperative morbidity has been secondary to postoperative multiple organ dysfunction, potentially from ischemia-reperfusion injury. The intestinal microbiome is a dense community of microorganisms in the gastrointestinal tract that help regulate pathways ranging from nutritional metabolism to the immune response. We hypothesized that patients with CMI will have microbiome perturbations that contribute to this inflammatory response and could potentially normalize in the postoperative period. Methods We performed a prospective study of patients with CMI who had undergone mesenteric bypass and/or stenting from 2019 to 2020. Stool samples were collected at three time points: preoperatively at the clinic, perioperatively within 14 days after surgery, and postoperatively at the clinic at >30 days after revascularization. Stool samples from healthy controls were used for comparison. The microbiome was measured using 16S rRNA sequencing on an Illumina-MiSeq sequence platform and analyzed using the QIIME2 (quantitative insights into microbial ecology 2)-DADA2 bioinformatics pipeline with the Silva database. Beta-diversity was analyzed using a principal coordinates analysis and permutational analysis of variance. Alpha-diversity (microbial richness and evenness) was compared using the nonparametric Mann-Whitney U test. Microbial taxa unique to CMI patients vs controls were identified using linear discriminatory analysis effect size analysis. P < .05 was considered statistically significant. Results Eight patients with CMI had undergone mesenteric revascularization (25% men; average age, 71 years). Nine healthy controls were also analyzed (78% men; average age, 55 years). Bacterial alpha-diversity (number of operational taxonomic units) was dramatically reduced preoperatively compared with that of the controls (P = .03). However, revascularization partially restored the species richness and evenness in the perioperative and postoperative phases. Beta-diversity was only different between the perioperative and postoperative groups (P = .03). Further analyses revealed increased abundance of Bacteroidetes and Clostridia taxa preoperatively and perioperatively compared with the controls, which was reduced during the postoperative period. Conclusions The results from the present study have shown that patients with CMI have intestinal dysbiosis that resolves after revascularization. The intestinal dysbiosis is characterized by the loss of alpha-diversity, which is restored perioperatively and maintained postoperatively. This microbiome restoration demonstrates the importance of intestinal perfusion to sustain gut homeostasis and suggests that microbiome modulation could be a possible intervention to ameliorate acute and subacute postoperative outcomes in these patients.
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37
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Rincon JC, Efron PA, Moldawer LL. Immunopathology of chronic critical illness in sepsis survivors: Role of abnormal myelopoiesis. J Leukoc Biol 2022; 112:1525-1534. [PMID: 36193662 PMCID: PMC9701155 DOI: 10.1002/jlb.4mr0922-690rr] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 02/01/2023] Open
Abstract
Sepsis remains the single most common cause of mortality and morbidity in hospitalized patients requiring intensive care. Although earlier detection and improved treatment bundles have reduced in-hospital mortality, long-term recovery remains dismal. Sepsis survivors who experience chronic critical illness often demonstrate persistent inflammation, immune suppression, lean tissue wasting, and physical and functional cognitive declines, which often last in excess of 1 year. Older patients and those with preexisting comorbidities may never fully recover and have increased mortality compared with individuals who restore their immunologic homeostasis. Many of these responses are shared with individuals with advanced cancer, active autoimmune diseases, chronic obstructive pulmonary disease, and chronic renal disease. Here, we propose that this resulting immunologic endotype is secondary to a persistent maladaptive reprioritization of myelopoiesis and pathologic activation of myeloid cells. Driven in part by the continuing release of endogenous alarmins from chronic organ injury and muscle wasting, as well as by secondary opportunistic infections, ongoing myelopoiesis at the expense of lymphopoiesis and erythropoiesis leads to anemia, recurring infections, and lean tissue wasting. Early recognition and intervention are required to interrupt this pathologic activation of myeloid populations.
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Affiliation(s)
- Jaimar C Rincon
- Sepsis and Critical Illness Research Center, Laboratory of Inflammation Biology and Surgical Science, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Philip A Efron
- Sepsis and Critical Illness Research Center, Laboratory of Inflammation Biology and Surgical Science, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lyle L Moldawer
- Sepsis and Critical Illness Research Center, Laboratory of Inflammation Biology and Surgical Science, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
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38
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Loftus TJ, Ruppert MM, Shickel B, Ozrazgat-Baslanti T, Balch JA, Efron PA, Upchurch GR, Rashidi P, Tignanelli C, Bian J, Bihorac A. Federated learning for preserving data privacy in collaborative healthcare research. Digit Health 2022; 8:20552076221134455. [PMID: 36325438 PMCID: PMC9619858 DOI: 10.1177/20552076221134455] [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: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
Generalizability, external validity, and reproducibility are high priorities for artificial intelligence applications in healthcare. Traditional approaches to addressing these elements involve sharing patient data between institutions or practice settings, which can compromise data privacy (individuals' right to prevent the sharing and disclosure of information about themselves) and data security (simultaneously preserving confidentiality, accuracy, fidelity, and availability of data). This article describes insights from real-world implementation of federated learning techniques that offer opportunities to maintain both data privacy and availability via collaborative machine learning that shares knowledge, not data. Local models are trained separately on local data. As they train, they send local model updates (e.g. coefficients or gradients) for consolidation into a global model. In some use cases, global models outperform local models on new, previously unseen local datasets, suggesting that collaborative learning from a greater number of examples, including a greater number of rare cases, may improve predictive performance. Even when sharing model updates rather than data, privacy leakage can occur when adversaries perform property or membership inference attacks which can be used to ascertain information about the training set. Emerging techniques mitigate risk from adversarial attacks, allowing investigators to maintain both data privacy and availability in collaborative healthcare research. When data heterogeneity between participating centers is high, personalized algorithms may offer greater generalizability by improving performance on data from centers with proportionately smaller training sample sizes. Properly applied, federated learning has the potential to optimize the reproducibility and performance of collaborative learning while preserving data security and privacy.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of
Florida, Gainesville, FL, USA,University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA
| | - Matthew M Ruppert
- University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA,Department of Medicine, University of
Florida, Gainesville, FL, USA
| | - Benjamin Shickel
- University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA,Department of Biomedical Engineering,
University of
Florida, Gainesville, FL, USA
| | - Tezcan Ozrazgat-Baslanti
- University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA,Department of Medicine, University of
Florida, Gainesville, FL, USA
| | - Jeremy A Balch
- Department of Surgery, University of
Florida, Gainesville, FL, USA,University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of
Florida, Gainesville, FL, USA
| | | | - Parisa Rashidi
- University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA,Departments of Biomedical Engineering, Computer and Information
Science and Engineering, and Electrical and Computer Engineering,
University of
Florida, Gainesville, FL, USA
| | | | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics,
University of
Florida, Gainesville, FL, USA
| | - Azra Bihorac
- Department of Surgery, University of
Florida, Gainesville, FL, USA,University of Florida, Intelligent Critical Care Center,
Gainesville, FL, USA,Azra Bihorac, University of Florida,
Intelligent Critical Care Center, Gainesville, FL, USA.
; Twitter: @AzraBihorac
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Kelly LS, Kannan KB, Munley JA, Pons EE, Parvataneni HK, Hagen JE, Efron PA, Mohr AM. Bone Marrow Adipokine Expression Was Associated With Decreased Erythroid Colony Growth After Trauma. Am Surg 2022:31348221135772. [DOI: 10.1177/00031348221135772] [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: 11/15/2022]
Abstract
Background Proinflammatory and immunomodulatory adipokines are linked to inflammation in critically ill patients but are poorly studied after injury. We hypothesized that trauma would induce systemic adipokine release and influence erythroid suppression. Methods Blood and bone marrow (BM) were collected from trauma patients (ISS > 15, n = 90) and compared to patients undergoing elective hip replacement (n = 37). Plasma adipokine levels were measured, and BM was assayed for adipokine transcription and erythroid progenitor growth potential. Differences were detected using t-tests and correlations using simple linear regression. Results Trauma patients exhibited decreased adiponectin (1.8* vs 3.4 mg/mL) and increased leptin (7.8* vs 4.6 ng/mL) and resistin (3.1* vs 2.5 ng/mL), with sex- and age-specific differences. They also showed increased BM visfatin transcription. Adipokine transcription negatively correlated with erythroid progenitor growth. Conclusion Adipose tissue activity is linked to inflammatory responses after injury, with variability by age and sex. Bone marrow adipose tissue may influence erythroid recovery after trauma.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, USA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jennifer A. Munley
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, USA
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, USA
| | - Hari K. Parvataneni
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jennifer E. Hagen
- Department of Orthopedic Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, USA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, USA
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40
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Filiberto AC, Efron PA, Frantz A, Bihorac A, Upchurch GR, Loftus TJ. Personalized decision-making for acute cholecystitis: Understanding surgeon judgment. Front Digit Health 2022; 4:845453. [PMID: 36339515 PMCID: PMC9632988 DOI: 10.3389/fdgth.2022.845453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 08/30/2022] [Indexed: 12/07/2022] Open
Abstract
Background There is sparse high-level evidence to guide treatment decisions for severe, acute cholecystitis (inflammation of the gallbladder). Therefore, treatment decisions depend heavily on individual surgeon judgment, which is highly variable and potentially amenable to personalized, data-driven decision support. We test the hypothesis that surgeons' treatment recommendations misalign with perceived risks and benefits for laparoscopic cholecystectomy (surgical removal) vs. percutaneous cholecystostomy (image-guided drainage). Methods Surgery attendings, fellows, and residents applied individual judgement to standardized case scenarios in a live, web-based survey in estimating the quantitative risks and benefits of laparoscopic cholecystectomy vs. percutaneous cholecystostomy for both moderate and severe acute cholecystitis, as well as the likelihood that they would recommend cholecystectomy. Results Surgeons predicted similar 30-day morbidity rates for laparoscopic cholecystectomy and percutaneous cholecystostomy. However, a greater proportion of surgeons predicted low (<50%) likelihood of full recovery following percutaneous cholecystostomy compared with cholecystectomy for both moderate (30% vs. 2%, p < 0.001) and severe (62% vs. 38%, p < 0.001) cholecystitis. Ninety-eight percent of all surgeons were likely or very likely to recommend cholecystectomy for moderate cholecystitis; only 32% recommended cholecystectomy for severe cholecystitis (p < 0.001). There were no significant differences in predicted postoperative morbidity when respondents were stratified by academic rank or self-reported ability to predict complications or make treatment recommendations. Conclusions Surgeon recommendations for severe cholecystitis were discordant with perceived risks and benefits of treatment options. Surgeons predicted greater functional recovery after cholecystectomy but less than one-third recommended cholecystectomy. These findings suggest opportunities to augment surgical decision-making with personalized, data-driven decision support.
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Affiliation(s)
- Amanda C. Filiberto
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Philip A. Efron
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Amanda Frantz
- Department of Anesthesiology, University of Florida Health, Gainesville, FL, United States
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL, United States
- Intelligent Critical Care Center, University of Florida Health, Gainesville, FL, United States
| | - Gilbert R. Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Tyler J. Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
- Intelligent Critical Care Center, University of Florida Health, Gainesville, FL, United States
- Correspondence: Tyler J. Loftus
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41
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Loftus TJ, Shickel B, Balch JA, Tighe PJ, Abbott KL, Fazzone B, Anderson EM, Rozowsky J, Ozrazgat-Baslanti T, Ren Y, Berceli SA, Hogan WR, Efron PA, Moorman JR, Rashidi P, Upchurch GR, Bihorac A. Phenotype clustering in health care: A narrative review for clinicians. Front Artif Intell 2022; 5:842306. [PMID: 36034597 PMCID: PMC9411746 DOI: 10.3389/frai.2022.842306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 12/23/2021] [Accepted: 07/26/2022] [Indexed: 01/03/2023] Open
Abstract
Human pathophysiology is occasionally too complex for unaided hypothetical-deductive reasoning and the isolated application of additive or linear statistical methods. Clustering algorithms use input data patterns and distributions to form groups of similar patients or diseases that share distinct properties. Although clinicians frequently perform tasks that may be enhanced by clustering, few receive formal training and clinician-centered literature in clustering is sparse. To add value to clinical care and research, optimal clustering practices require a thorough understanding of how to process and optimize data, select features, weigh strengths and weaknesses of different clustering methods, select the optimal clustering method, and apply clustering methods to solve problems. These concepts and our suggestions for implementing them are described in this narrative review of published literature. All clustering methods share the weakness of finding potential clusters even when natural clusters do not exist, underscoring the importance of applying data-driven techniques as well as clinical and statistical expertise to clustering analyses. When applied properly, patient and disease phenotype clustering can reveal obscured associations that can help clinicians understand disease pathophysiology, predict treatment response, and identify patients for clinical trial enrollment.
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Affiliation(s)
- Tyler J. Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, United States,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States,Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States,*Correspondence: Tyler J. Loftus
| | - Benjamin Shickel
- Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States,Department of Medicine, University of Florida Health, Gainesville, FL, United States
| | - Jeremy A. Balch
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Patrick J. Tighe
- Departments of Anesthesiology, Orthopedics, and Information Systems/Operations Management, University of Florida Health, Gainesville, FL, United States
| | - Kenneth L. Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Brian Fazzone
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Erik M. Anderson
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Jared Rozowsky
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Tezcan Ozrazgat-Baslanti
- Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States,Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States,Department of Medicine, University of Florida Health, Gainesville, FL, United States
| | - Yuanfang Ren
- Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States,Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States,Department of Medicine, University of Florida Health, Gainesville, FL, United States
| | - Scott A. Berceli
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - William R. Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Philip A. Efron
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - J. Randall Moorman
- Department of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Parisa Rashidi
- Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States,Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States,Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States
| | - Gilbert R. Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Azra Bihorac
- Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States,Intelligent Critical Care Center, University of Florida, Gainesville, FL, United States,Department of Medicine, University of Florida Health, Gainesville, FL, United States
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42
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Brakenridge SC, Chen UI, Loftus T, Ungaro R, Dirain M, Kerr A, Zhong L, Bacher R, Starostik P, Ghita G, Midic U, Darden D, Fenner B, Wacker J, Efron PA, Liesenfeld O, Sweeney TE, Moldawer LL. Evaluation of a Multivalent Transcriptomic Metric for Diagnosing Surgical Sepsis and Estimating Mortality Among Critically Ill Patients. JAMA Netw Open 2022; 5:e2221520. [PMID: 35819783 PMCID: PMC9277492 DOI: 10.1001/jamanetworkopen.2022.21520] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/19/2022] [Indexed: 02/02/2023] Open
Abstract
Importance Rapid and accurate discrimination of sepsis and its potential severity currently require multiple assays with slow processing times that are often inconclusive in discerning sepsis from sterile inflammation. Objective To analyze a whole-blood, multivalent, host-messenger RNA expression metric for estimating the likelihood of bacterial infection and 30-day mortality and compare performance of the metric with that of other diagnostic and prognostic biomarkers and clinical parameters. Design, Setting, and Participants This prospective diagnostic and prognostic study was performed in the surgical intensive care unit (ICU) of a single, academic health science center. The analysis included 200 critically ill adult patients admitted with suspected sepsis (cohort A) or those at high risk for developing sepsis (cohort B) between July 1, 2020, and July 30, 2021. Exposures Whole-blood sample measurements of a custom 29-messenger RNA transcriptomic metric classifier for likelihood of bacterial infection (IMX-BVN-3) or 30-day mortality (severity) (IMX-SEV-3) in a clinical-diagnostic laboratory setting using an analysis platform (510[k]-cleared nCounter FLEX; NanoString, Inc), compared with measurement of procalcitonin and interleukin 6 (IL-6) plasma levels, and maximum 24-hour sequential organ failure assessment (SOFA) scores. Main Outcomes and Measures Estimated sepsis and 30-day mortality performance. Results Among the 200 patients included (124 men [62.0%] and 76 women [38.0%]; median age, 62.5 [IQR, 47.0-72.0] years), the IMX-BVN-3 bacterial infection classifier had an area under the receiver operating characteristics curve (AUROC) of 0.84 (95% CI, 0.77-0.90) for discriminating bacterial infection at ICU admission, similar to procalcitonin (0.85 [95% CI, 0.79-0.90]; P = .79) and significantly better than IL-6 (0.67 [95% CI, 0.58-0.75]; P < .001). For estimating 30-day mortality, the IMX-SEV-3 metric had an AUROC of 0.81 (95% CI, 0.66-0.95), which was significantly better than IL-6 levels (0.57 [95% CI, 0.37-0.77]; P = .006), marginally better than procalcitonin levels (0.65 [95% CI, 0.50-0.79]; P = .06), and similar to the SOFA score (0.76 [95% CI, 0.62-0.91]; P = .48). Combining IMX-BVN-3 and IMX-SEV-3 with procalcitonin or IL-6 levels or SOFA scores did not significantly improve performance. Among patients with sepsis, IMX-BVN-3 scores decreased over time, reflecting the resolution of sepsis. In 11 individuals at high risk (cohort B) who subsequently developed sepsis during their hospital course, IMX-BVN-3 bacterial infection scores did not decline over time and peaked on the day of documented infection. Conclusions and Relevance In this diagnostic and prognostic study, a novel, multivalent, transcriptomic metric accurately estimated the presence of bacterial infection and risk for 30-day mortality in patients admitted to a surgical ICU. The performance of this single transcriptomic metric was equivalent to or better than multiple alternative diagnostic and prognostic metrics when measured at admission and provided additional information when measured over time.
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Affiliation(s)
- Scott C. Brakenridge
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
- Division of Burn, Trauma & Critical Care Surgery, Department of Surgery, University of Washington, Seattle
| | - Uan-I Chen
- Inflammatix, Inc, Burlingame, California
| | - Tyler Loftus
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Ricardo Ungaro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Marvin Dirain
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Austin Kerr
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Luer Zhong
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Rhonda Bacher
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Petr Starostik
- Molecular Pathology Laboratory at Rocky Point, Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville
- Clinical and Diagnostic Laboratories, Health Science Center, UF (University of Florida) Health Shands Hospital, Gainesville
| | - Gabriella Ghita
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Uros Midic
- Inflammatix, Inc, Burlingame, California
| | - Dijoia Darden
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Brittany Fenner
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | | | - Philip A. Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
| | | | | | - Lyle L. Moldawer
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville
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Ozrazgat-Baslanti T, Loftus TJ, Mohandas R, Wu Q, Brakenridge S, Brumback B, Efron PA, Anton S, Moore FA, Moldawer LL, Segal MS, Bihorac A. Clinical Trajectories of Acute Kidney Injury in Surgical Sepsis: A Prospective Observational Study. Ann Surg 2022; 275:1184-1193. [PMID: 33196489 PMCID: PMC8116352 DOI: 10.1097/sla.0000000000004360] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To characterize endothelial function, inflammation, and immunosuppression in surgical patients with distinct clinical trajectories of AKI and to determine the impact of persistent kidney injury and renal non-recovery on clinical outcomes, resource utilization, and long-term disability and survival. SUMMARY OF BACKGROUND DATA AKI is associated with increased healthcare costs and mortality. Trajectories that account for duration and recovery of AKI have not been described for sepsis patients, who are uniquely vulnerable to renal dysfunction. METHODS This prospective observational study included 239 sepsis patients admitted and enrolled between January 2015 and July 2017. Kidney Disease: Improving Global Outcomes (KDIGO) and Acute Disease Quality Initiative (ADQI) criteria were used to classify subjects as having no AKI, rapidly reversed AKI, persistent AKI with renal recovery, or persistent AKI without renal recovery. Serial biomarker profiles, clinical outcomes, resource utilization, and long-term physical performance status and survival were compared among AKI trajectories. RESULTS Sixty-two percent of the study population developed AKI. Only one-third of AKI episodes rapidly reversed within 48 hours; the remaining had persistent AKI, among which 57% did not have renal recovery by discharge. One-year survival and proportion of subjects fully active 1 year after sepsis was lowest among patients with persistent AKI compared with other groups. Long-term mortality hazard rates were 5-fold higher for persistent AKI without renal recovery compared with no AKI. CONCLUSIONS Among critically ill surgical sepsis patients, persistent AKI and the absence of renal recovery are associated with distinct early and sustained immunologic and endothelial biomarker signatures and decreased long-term physical function and survival.
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Affiliation(s)
- Tezcan Ozrazgat-Baslanti
- Departments of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine (Prisma), University of Florida, Gainesville, FL, USA
| | - Tyler J. Loftus
- Departments of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Rajesh Mohandas
- Departments of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Quran Wu
- Departments of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Scott Brakenridge
- Departments of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Babette Brumback
- Department of Biostatistics, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Philip A. Efron
- Departments of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Stephen Anton
- Department of Aging and Geriatric Research, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Frederick A. Moore
- Departments of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Lyle L. Moldawer
- Departments of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Mark S. Segal
- Departments of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Azra Bihorac
- Departments of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine (Prisma), University of Florida, Gainesville, FL, USA
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Kerr AW, Efron PA, Larson SD, Rincon JC. T-Cell Activation and LPS: A Dangerous Duo for Organ Dysfunction. J Leukoc Biol 2022; 112:219-220. [PMID: 35481682 DOI: 10.1002/jlb.3ce0122-019r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/09/2022] Open
Abstract
Lipopolysaccharide (LPS), one of the main components of cell membranes in gram-negative bacteria, is commonly used to promote inflammation-induced organ dysfunction. In the TLR4/LPS pathway, LPS binding protein and CD14 enable lipid A of LPS to be recognized by the TLR4-MD2 receptor complex. The intracellular domain of the TLR4/LPS complex stimulates MyD88-dependent/independent and TRIF-dependent pathways, which in turn activate NF-B and IRF3, leading to subsequent production of pro-inflammatory mediators. LPS has been demonstrated to induce microcirculatory disturbances via promotion of leukocyte adhesion to the vascular endothelium and the release of reactive oxygen species (ROS), damaging the vessels and causing vascular dysfunction. Thus, LPS is frequently used as a systemic model of inflammation as LPS administration increases circulating pro-inflammatory mediators, which triggers leukocyte adhesion and leads to multi-organ failure and death.
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Affiliation(s)
- Austin W Kerr
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Philip A Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Shawn D Larson
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Jaimar C Rincon
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
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45
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Balch JA, Efron PA, Bihorac A, Loftus TJ. Gamification for Machine Learning in Surgical Patient Engagement. Front Surg 2022; 9:896351. [PMID: 35656082 PMCID: PMC9152738 DOI: 10.3389/fsurg.2022.896351] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Patients and their surgeons face a complex and evolving set of choices in the process of shared decision making. The plan of care must be tailored to individual patient risk factors and values, though objective estimates of risk can be elusive, and these risk factors are often modifiable and can alter the plan of care. Machine learning can perform real-time predictions of outcomes, though these technologies are limited by usability and interpretability. Gamification, or the use of game elements in non-game contexts, may be able to incorporate machine learning technology to help patients optimize their pre-operative risks, reduce in-hospital complications, and hasten recovery. This article proposes a theoretical mobile application to help guide decision making and provide evidence-based, tangible goals for patients and surgeons with the goal of achieving the best possible operative outcome that aligns with patient values.
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Affiliation(s)
- Jeremy A. Balch
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Philip A. Efron
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL, United States
- Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States
| | - Tyler J. Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL, United States
- Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, FL, United States
- Correspondence: Tyler J. Loftus
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Knewitz DK, Kirkpatrick SL, Jenkins PD, Al-Mansour M, Rosenthal MD, Efron PA, Loftus TJ. Preoperative computed tomography for acutely incarcerated ventral or inguinal hernia. Surgery 2022; 172:193-197. [PMID: 35304009 DOI: 10.1016/j.surg.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/29/2021] [Accepted: 01/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The utility of preoperative computed tomography for urgent abdominal wall hernia repair is unclear. This study tests the hypothesis that there is no difference in patient outcomes for acutely incarcerated ventral or inguinal hernias diagnosed by preoperative computed tomography versus clinical assessment alone. METHODS This retrospective cohort analysis included 270 adult patients undergoing urgent repair of ventral or inguinal hernia. Demographics, risk factors for complications, operative management strategies, and 1-year outcomes were compared between patients with (n = 179) versus without (n = 91) preoperative computed tomography. RESULTS Among 179 preoperative computed tomography scans, 15 (8.4%) were ordered by surgeons, and all others were ordered by referring providers. The computed tomography and no computed tomography groups had similar age (58 vs 58 years, P = .77), body mass index (30.7 vs 30.6 kg/m2, P = .30), American Society of Anesthesiologists class (3.0 vs 3.0, P = .39), incidence of the systemic inflammatory response syndrome (19.0% vs 20.9%, P = .75), and incidence of recurrent hernia (16.8% vs 19.8%, P = .61). The interval between admission and incision was longer in the computed tomography group (11.2 hours vs 6.6 hours, P < .001). The computed tomography and no computed tomography groups had similar duration of surgery (125 minutes in both groups, P = .88), proportions of patients with biologic mesh (21.2% vs 17.6%, P = .52) and synthetic mesh (35.2% vs 46.2%, P = .09) placement, and 1-year outcomes including incidence of superficial (8.4% vs 6.6%, P = .81) and deep or organ/space surgical site infection (5.0% vs 6.6%, P = .59), mesh explant for infection (2.2% vs 3.3%, P = .69), reoperation for recurrent hernia (3.9% vs 1.1%, P = .27), and mortality (7.8% vs 4.4%, P = .44). CONCLUSION The performance of preoperative computed tomography was associated with a longer interval between admission and incision and no differences in mesh placement, mesh type, or 1-year patient outcomes. These results support the safety of performing urgent repair of acutely incarcerated ventral or inguinal hernias based on clinical assessment alone.
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Affiliation(s)
| | | | | | - Mazen Al-Mansour
- Department of Surgery, University of Florida Health, Gainesville, FL
| | | | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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47
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Apple CG, Kelly LS, Kannan KB, Ungaro RF, Moore FA, Brakenridge SC, Moldawer LL, Efron PA, Mohr AM. Ineffective Erythropoietin Response to Anemia in Sepsis. Surg Infect (Larchmt) 2022; 23:142-149. [PMID: 34958257 PMCID: PMC8892986 DOI: 10.1089/sur.2021.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 02/01/2023] Open
Abstract
Background: To determine whether degree of anemia at sepsis onset is predictive of inflammatory cytokine trajectory, erythropoietin response, and recovery. Patients and Methods: Critically ill patients with sepsis were stratified into three groups based on initial hemoglobin (Hgb): Hgb <8 g/dL (severe); 8-10 g/dL (moderate); and >10 g/dL (mild). Granulocyte colony stimulating factor (G-CSF), interferon (IFN)-γ, tumor necrosis factor (TNF)-α, C-reactive protein (CRP), erythropoietin (EPO), and Zubrod scores were measured serially. Results: Thirty-four percent had severe anemia (Hgb, 7.2 ± 0.7g/dL), 35% had moderate anemia (Hgb, 9.1 ± 0.6g/dL), and 31% had mild anemia (Hgb, 11.3 ± 1.1g/dL). All groups experienced persistently high EPO levels without resolution of anemia. IFN-γ and CRP was persistently elevated in all groups. At three, six, and 12 months, the severe anemia group had higher Zubrod scores. Conclusions: Degree of anemia at sepsis onset was not associated with a difference in proinflammatory cytokine trajectory but was associated with a worse functional outcome. Despite initial elevated EPO levels, it did not correlate with resolution of anemia.
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Affiliation(s)
- Camille G. Apple
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Ricardo F. Ungaro
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Frederick A. Moore
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Scott C. Brakenridge
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Lyle L. Moldawer
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida, USA.,Address correspondence to: Dr. Alicia M. Mohr, Department of Surgery, University of Florida, 1600 SW Archer Road, Box 100108, Gainesville, FL 32610, USA
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48
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Rani A, Barter J, Kumar A, Stortz JA, Hollen M, Nacionales D, Moldawer LL, Efron PA, Foster TC. Influence of age and sex on microRNA response and recovery in the hippocampus following sepsis. Aging (Albany NY) 2022; 14:728-746. [PMID: 35094981 PMCID: PMC8833110 DOI: 10.18632/aging.203868] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 12/07/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
Sepsis, defined as a dysregulated host immune response to infection, is a common and dangerous clinical syndrome. The excessive host inflammatory response can induce immediate and persistent cognitive decline, which can be worse in older individuals. Sex-specific differences in the outcome of infectious diseases and sepsis appear to favor females. We employed a murine model to examine the influence of age and sex on the brain's microRNA (miR) response following sepsis. Young and old mice of both sexes underwent cecal ligation and puncture (CLP) with daily restraint stress. Expression of hippocampal miR was examined in age- and sex-matched controls at 1 and 4 days post-CLP. Few miR were modified in a similar manner across age or sex and these few miR were generally associated with neuroprotection against inflammation. Similar to previous work examining transcription, young females exhibited a better recovery of the miR profile from day 1 to day 4, relative to young males and old females. For young males and all female groups, the initial response mainly involved a decrease in miR expression. In contrast, old males exhibited only upregulated miR on day 1 and day 4 and many of the miR upregulated on day 1 and day 4 were linked to neurodegeneration, increased neuroinflammation, and cognitive impairment. The results emphasize age and sex differences in epigenetic mechanisms that likely contribute to susceptibility or resilience to cognitive impairment due to sepsis.
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Affiliation(s)
- Asha Rani
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32611, USA
| | - Jolie Barter
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32611, USA
| | - Ashok Kumar
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32611, USA
| | - Julie A Stortz
- Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - McKenzie Hollen
- Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - Dina Nacionales
- Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - Thomas C Foster
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32611, USA.,Genetics and Genomics Program, University of Florida, Gainesville, FL 32611, USA
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Mankowski RT, Laitano O, Darden D, Kelly L, Munley J, Loftus TJ, Mohr AM, Efron PA, Thomas RM. Sepsis-Induced Myopathy and Gut Microbiome Dysbiosis: Mechanistic Links and Therapeutic Targets. Shock 2022; 57:15-23. [PMID: 34726875 PMCID: PMC9373856 DOI: 10.1097/shk.0000000000001843] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
ABSTRACT Sepsis is currently defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. The skeletal muscle system is among the host organ systems compromised by sepsis. The resulting neuromuscular dysfunction and impaired regenerative capacity defines sepsis-induced myopathy and manifests as atrophy, loss of strength, and hindered regeneration after injury. These outcomes delay recovery from critical illness and confer increased vulnerability to morbidity and mortality. The mechanisms underlying sepsis-induced myopathy, including the potential contribution of peripheral organs, remain largely unexplored. The gut microbiome is an immunological and homeostatic entity that interacts with and controls end-organ function, including the skeletal muscle system. Sepsis induces alterations in the gut microbiota composition, which is globally termed a state of "dysbiosis" for the host compared to baseline microbiota composition. In this review, we critically evaluate existing evidence and potential mechanisms linking sepsis-induced myopathy with gut microbiota dysbiosis.
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Affiliation(s)
- Robert T. Mankowski
- Department of Aging and Geriatric Research, University of Florida, Gainesville, FL
| | - Orlando Laitano
- Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, FL
| | - Dijoia Darden
- Department of Surgery, University of Florida, Gainesville, FL
| | - Lauren Kelly
- Department of Surgery, University of Florida, Gainesville, FL
| | - Jennifer Munley
- Department of Surgery, University of Florida, Gainesville, FL
| | - Tyler J. Loftus
- Department of Surgery, University of Florida, Gainesville, FL
| | - Alicia M. Mohr
- Department of Surgery, University of Florida, Gainesville, FL
| | - Philip A. Efron
- Department of Surgery, University of Florida, Gainesville, FL
| | - Ryan M. Thomas
- Department of Surgery, University of Florida, Gainesville, FL
- Department of Molecular Genetics and Microbiology; University of Florida College of Medicine; Gainesville, FL
- Section of General Surgery, North Florida/South Georgia Veterans Health System; Gainesville, FL
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50
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Kelly LS, Apple CG, Darden DB, Kannan KB, Pons EE, Fenner BP, Parvataneni HK, Hagen JE, Brakenridge SC, Efron PA, Mohr AM. Transcriptomic Changes Within Human Bone Marrow After Severe Trauma. Shock 2022; 57:24-30. [PMID: 34172608 PMCID: PMC8678139 DOI: 10.1097/shk.0000000000001826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Severe trauma is associated with severe systemic inflammation and neuroendocrine activation that is associated with erythroid progenitor growth suppression and refractory anemia. Although distinct transcriptional profiles have been detected in numerous tissue types after trauma, no study has yet characterized this within the bone marrow. This study sought to identify a unique bone marrow transcriptomic response following trauma. METHODS In a prospective observational cohort study, bone marrow was obtained from severely injured trauma patients with a hip or femur fracture (n = 52), elective hip replacement patients (n = 33), and healthy controls (n = 11). RNA was isolated from bone marrow using a Purelink RNA mini kit. Direct quantification of mRNA copies was performed by NanoString Technologies on a custom gene panel. RESULTS Trauma patients displayed an upregulation of genes encoding receptors known to have inhibitory downstream effects on erythropoiesis, including ferroportin, interleukin-6 (IL-6) receptor, transforming growth factor-beta (TGF-β) receptor, and IL-10, as well as genes involved in innate immunity including toll-like receptor 4 (TLR4)-mediated signaling factors. In contrast, hip replacement patients had downregulated transcription of IL-1β, IL-6, TGF-β, tumor necrosis factor alpha, and the HAMP gene with no change in TLR4-mediated signaling factors. CONCLUSIONS A unique transcriptomic response within the bone marrow was identified following severe trauma compared to elective hip replacement. These transcriptomic differences were related to the innate immune response as well as known inhibitors of erythropoiesis. Although confined to just one time point, this differential transcriptional response may be linked to refractory anemia and inflammation after injury.
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Affiliation(s)
- Lauren S. Kelly
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Camille G. Apple
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Dijoia B. Darden
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Kolenkode B. Kannan
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Erick E. Pons
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Brittany P. Fenner
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Hari K. Parvataneni
- Department of Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Jennifer E. Hagen
- Department of Orthopaedic Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Scott C. Brakenridge
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Philip A. Efron
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - Alicia M. Mohr
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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