1
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Eruchalu CN, Etheridge JC, Hammaker AC, Kader S, Abelson JS, Harvey J, Farr D, Stopenski SJ, Nahmias JT, Elsaadi A, Campbell SJ, Foote DC, Ivascu FA, Montgomery KB, Zmijewski P, Byrd SE, Kimbrough MK, Smith S, Postlewait LM, Dodwad SJM, Adams SD, Markesbery KC, Meister KM, Woeste MR, Martin RCG, Callahan ZM, Marks JA, Patel P, Anstadt MJ, Nasim BW, Willis RE, Patel JA, Newcomb MR, Stahl CC, Yafi MA, Sutton JM, George BC, Quillin RC, Cho NL, Cortez AR. Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium. Ann Surg 2024; 279:172-179. [PMID: 36928294 DOI: 10.1097/sla.0000000000005848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.
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Affiliation(s)
- Chukwuma N Eruchalu
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James C Etheridge
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA
| | - Austin C Hammaker
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jonathan S Abelson
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Jeffry T Nahmias
- Department of Surgery, University of California Irvine, Orange, CA
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Samuel J Campbell
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Darci C Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
| | | | | | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Samuel E Byrd
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | | | - Sasha D Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | | | | | | | | | | | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL
| | | | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jitesh A Patel
- Department of Surgery, University of Kentucky, Lexington, KY
| | | | | | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M Sutton
- Department of Surgery, Medical University of South Carolina, Division of Oncologic and Endocrine Surgery, Charleston, SC
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | - Ralph C Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
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2
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Sisak S, Price AD, Foote DC, Montgomery KB, Lindeman B, Cho NL, Sheu NO, Postlewait LM, Smith SR, Markesbery KC, Meister KM, Kader S, Abelson JS, Anstadt MJ, Patel PP, Marks JA, Callahan ZM, Kimbrough MK, Byrd SE, Stopenski SJ, Nahmias JT, Patel JA, Wilt W, Dodwad SJM, Adams SD, Willis RE, Farr D, Harvey J, Woeste MR, Martin RCG, Al Yafi M, Sutton JM, Cortez AR, Holm TM. A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents. Surgery 2024; 175:107-113. [PMID: 37953151 PMCID: PMC10906110 DOI: 10.1016/j.surg.2023.05.048] [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: 02/06/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.
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Affiliation(s)
- Stephanie Sisak
- Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Department of Surgery, Cincinnati, OH
| | - Adam D Price
- Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Department of Surgery, Cincinnati, OH
| | - Darci C Foote
- Beaumont Health, Department of Surgery, Royal Oak, MI; University of Michigan, Department of Surgery, Ann Arbor, MI
| | | | - Brenessa Lindeman
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL
| | - Nancy L Cho
- Brigham and Women's Hospital, Department of Surgery, Boston, MA
| | - Nora O Sheu
- Brigham and Women's Hospital, Department of Surgery, Boston, MA
| | | | | | | | | | - Sarah Kader
- Lahey Hospital and Medical Center, Department of Surgery, Burlington, MA
| | | | | | - Purvi P Patel
- Loyola University, Department of Surgery, Maywood, IL
| | - Joshua A Marks
- Thomas Jefferson University, Department of Surgery, Philadelphia, PA
| | | | | | - Samuel E Byrd
- University of Arkansas for Medical Sciences, Department of Surgery, Little Rock, AR
| | | | - Jeffry T Nahmias
- University of California at Irvine, Department of Surgery, Orange, CA
| | - Jitesh A Patel
- University of Kentucky, Department of Surgery, Lexington, KY
| | - Wesley Wilt
- University of Kentucky, Department of Surgery, Lexington, KY
| | | | - Sasha D Adams
- McGovern Medical School at UTHealth, Department of Surgery, Houston, TX
| | - Ross E Willis
- University of Texas Health Science Center at San Antonio, Department of Surgery, San Antonio, TX
| | - Deborah Farr
- University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX
| | - Jalen Harvey
- University of Texas Southwestern Medical Center, Department of Surgery, Dallas, TX
| | | | | | - Motaz Al Yafi
- University of Toledo, Department of Surgery, Toledo, OH
| | - Jeffrey M Sutton
- Medical University of South Carolina, Division of Oncologic and Endocrine Surgery, Department of Surgery, Charleston, SC
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Department of Surgery, Cincinnati, OH; University of San Francisco, Department of Surgery, San Francisco, CA
| | - Tammy M Holm
- Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Department of Surgery, Cincinnati, OH.
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3
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Winer LK, Kader S, Abelson JS, Hammaker AC, Eruchalu CN, Etheridge JC, Cho NL, Foote DC, Ivascu FA, Smith S, Postlewait LM, Greenwell K, Meister KM, Montgomery KB, Zmijewski P, Byrd SE, Kimbrough MK, Stopenski SJ, Nahmias JT, Harvey J, Farr D, Callahan ZM, Marks JA, Stahl CC, Al Yafi M, Sutton JM, Elsaadi A, Campbell SJ, Dodwad SJM, Adams SD, Woeste MR, Martin RC, Patel P, Anstadt MJ, Nasim BW, Willis RE, Patel JA, Newcomb MR, George BC, Quillin RC, Cortez AR. Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium. Ann Surg 2023; 278:1-7. [PMID: 36994704 PMCID: PMC10896185 DOI: 10.1097/sla.0000000000005847] [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: 03/31/2023]
Abstract
OBJECTIVE To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.
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Affiliation(s)
- Leah K. Winer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Austin C. Hammaker
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | | | - Nancy L. Cho
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Darci C. Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | | | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Samuel E. Byrd
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K. Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | | | - Joshua A. Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M. Sutton
- Division of Oncologic and Endocrine Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center School of Medicine Lubbock, TX
| | - Samuel J. Campbell
- Texas Tech University Health Sciences Center School of Medicine Lubbock, TX
| | | | - Sasha D. Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | | | | | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL
| | | | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E. Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jitesh A. Patel
- Department of Surgery, University of Kentucky, Lexington, KY
| | | | - Brian C. George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | - Ralph C. Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Alexander R. Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
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4
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Puzio TJ, Adams SD, Kao LS. Invited Commentary: Targeting Many or a Few? A Commentary on Redefining Multimorbidity in Older Surgical Patients. J Am Coll Surg 2023; 236:1022-1023. [PMID: 36919931 DOI: 10.1097/xcs.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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5
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Kregel HR, Puzio TJ, Adams SD. Frailty in the Geriatric Trauma Patient: a Review on Assessments, Interventions, and Lessons from Other Surgical Subspecialties. Curr Trauma Rep 2022. [DOI: 10.1007/s40719-022-00241-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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6
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Kregel HR, Murphy PB, Attia M, Meyer DE, Morris RS, Onyema EC, Adams SD, Wade CE, Harvin JA, Kao LS, Puzio TJ. The Geriatric Nutritional Risk Index as a predictor of complications in geriatric trauma patients. J Trauma Acute Care Surg 2022; 93:195-199. [PMID: 35293374 PMCID: PMC9329178 DOI: 10.1097/ta.0000000000003588] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients. METHODS This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI <82), moderate risk (GNRI 82-91), low risk (GNRI 92-98), and no risk (GNRI >98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes. RESULTS A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home. CONCLUSIONS Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Heather R. Kregel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | | | - Mina Attia
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
| | - David E. Meyer
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Rachel S. Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ezenwa C. Onyema
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | - Sasha D. Adams
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Charles E. Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - John A. Harvin
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Lillian S. Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Thaddeus J. Puzio
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
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7
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Hammaker AC, Dodwad SJM, Salyer CE, Adams SD, Foote DC, Ivascu FA, Kader S, Abelson JS, Al Yafi M, Sutton JM, Smith S, Postlewait LM, Stopenski SJ, Nahmias JT, Harvey J, Farr D, Callahan ZM, Marks JA, Elsaadi A, Campbell SJ, Stahl CC, Hanseman DJ, Patel P, Woeste MR, Martin RCG, Patel JA, Newcomb MR, Greenwell K, Meister KM, Etheridge JC, Cho NL, Thrush CR, Kimbrough MK, Nasim BW, Willis RE, George BC, Quillin RC, Cortez AR. A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation. Surgery 2022; 172:906-912. [PMID: 35788283 DOI: 10.1016/j.surg.2022.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.
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Affiliation(s)
- Austin C Hammaker
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH. https://twitter.com/HammakerAustin
| | - Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX. https://twitter.com/shahofsurgery
| | - Christen E Salyer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH. https://twitter.com/salyerchristen
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX. https://twitter.com/SashaTrauma
| | - Darci C Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
| | | | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jonathan S Abelson
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA. https://twitter.com/jabelsonmd
| | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, Medical University of South Carolina, Charleston, SC. https://twitter.com/J_M_Sutton
| | | | | | | | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA. https://twitter.com/jnahmias1
| | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX. https://twitter.com/JHarvMD20
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX. https://twitter.com/DVFelaine
| | - Zachary M Callahan
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA. https://twitter.com/zmcallahan
| | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ali Elsaadi
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Samuel J Campbell
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | | | - Dennis J Hanseman
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL. https://twitter.com/pppatelmd
| | | | | | - Jitesh A Patel
- Department of Surgery, University of Kentucky, Lexington, KY. https://twitter.com/Patel_Wildcat
| | | | | | | | | | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, MA. https://twitter.com/NancyLCho
| | - Carol R Thrush
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR. https://twitter.com/kimbrough_katie
| | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI. https://twitter.com/bcgeorge
| | - Ralph C Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH.
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8
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Affiliation(s)
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School, Houston, Texas
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9
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Hatton GE, Kregel HR, Pedroza C, Puzio TJ, Adams SD, Wade CE, Kao LS, Harvin JA. Age-related Opioid Exposure in Trauma: A Secondary Analysis of the Multimodal Analgesia Strategies for Trauma (MAST) Randomized Trial. Ann Surg 2021; 274:565-571. [PMID: 34506311 PMCID: PMC8783293 DOI: 10.1097/sla.0000000000005065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Evaluate the effect of age on opioid consumption after traumatic injury. SUMMARY BACKGROUND DATA Older trauma patients receive fewer opioids due to decreased metabolism and increased complications, but adequacy of pain control is unknown. We hypothesized that older trauma patients require fewer opioids to achieve adequate pain control. METHODS A secondary analysis of the multimodal analgesia strategies for trauma Trial evaluating the effectiveness of 2 multimodal pain regimens in 1561 trauma patients aged 16 to 96 was performed. Older patients (≥55 years) were compared to younger patients. Median daily oral morphine milligram equivalents (MME) consumption, average numeric rating scale pain scores, complications, and death were assessed. Multivariable analyses were performed. RESULTS Older patients (n = 562) had a median age of 68 years (interquartile range 61-78) compared to 33 (24-43) in younger patients. Older patients had lower injury severity scores (13 [9-20] vs 14 [9-22], P = 0.004), lower average pain scores (numeric rating scale 3 [1-4] vs 4 [2-5], P < 0.001), and consumed fewer MME/day (22 [10-45] vs 52 [28-78], P < 0.001). The multimodal analgesia strategies for trauma multi-modal pain regimen was effective at reducing opioid consumption at all ages. Additionally, on multivariable analysis including pain score adjustment, each decade age increase after 55 years was associated with a 23% reduction in MME/day consumed. CONCLUSIONS Older trauma patients required fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control.
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Affiliation(s)
- Gabrielle E Hatton
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Heather R Kregel
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas
| | - Thaddeus J Puzio
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Sasha D Adams
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Charles E Wade
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
| | - John A Harvin
- Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at UTHealth, Houston, Texas
- Center for Translational Injury Research, Houston, Texas
- Center for Clinical Research and Evidence Based Medicine, McGovern Medical School at UTHealth, Houston, Texas
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Hatton GE, Mollett PJ, Du RE, Wei S, Korupolu R, Wade CE, Adams SD, Kao LS. High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury. J Spinal Cord Med 2021; 44:775-781. [PMID: 32043943 PMCID: PMC8477933 DOI: 10.1080/10790268.2020.1722936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
CONTEXT/OBJECTIVE Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN Cohort study. SETTING Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS Adult Acute Cervical SCI Patients, 2011-2018. INTERVENTIONS HVtV. OUTCOME MEASURES VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55-2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.
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Affiliation(s)
- Gabrielle E. Hatton
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA,Corresponding to: Gabrielle E. Hatton, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin Street Suite 471, Houston, TX77030, USA; Ph: 713-500-4330, fax: 713-500-0714.
| | - Patrick J. Mollett
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Reginald E. Du
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,McGovern Medical School at the University of Texas Health Science Center, HoustonTexas, USA
| | - Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Sasha D. Adams
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
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11
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Harvin JA, Adams SD, Dodwad SJM, Isbell KD, Pedroza C, Green C, Tyson JE, Taub EA, Meyer DE, Moore LJ, Albarado R, McNutt MK, Kao LS, Wade CE, Holcomb JB. Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial. Trauma Surg Acute Care Open 2021; 6:e000777. [PMID: 34423135 PMCID: PMC8323393 DOI: 10.1136/tsaco-2021-000777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 11/03/2022] Open
Abstract
Background Although widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL. Methods Eligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed. Results Of 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses. Conclusion The findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma. Level of evidence Level II.
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Affiliation(s)
- John A Harvin
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sasha D Adams
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shah-Jahan M Dodwad
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kayla D Isbell
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles Green
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jon E Tyson
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ethan A Taub
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura J Moore
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rondel Albarado
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - John B Holcomb
- Center for Injury Science, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Donthula D, Conner CR, Truong VTT, Green C, Jiang C, Wandling MW, Komak S, Huzar TF, Adams SD, Freet DJ, Wainwright DJ, Wade CE, Kao LS, Harvin JA. Impact of Opioid-Minimizing Pain Protocols after Burn Injury. J Burn Care Res 2021; 42:1146-1151. [PMID: 34302482 DOI: 10.1093/jbcr/irab143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre (01/01/2018 to 07/31/2019) and Post (01/01/2020 to 06/30/2020) implementation of the protocols (08/01/2019 to 12/31/2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain-specific MME, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated 3 different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effects were estimated using Bayesian generalized linear models.There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174). The Post group had significantly lower total MME (Post 110 MME [32, 325] versus Pre 230 [60, 840], p<0.001), MME/day (Post 33 MME/day [15, 54] versus Pre 52 [27, 80], p<0.001), and domain-specific total MME. No difference in average normalized pain scores was seen.Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.
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Affiliation(s)
- Deepanjli Donthula
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Christopher R Conner
- the Department of Neurosurgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Van Thi Thanh Truong
- the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles Green
- the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Chuantao Jiang
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Michael W Wandling
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Spogmai Komak
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Todd F Huzar
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Sasha D Adams
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Daniel J Freet
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - David J Wainwright
- the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Charles E Wade
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - Lillian S Kao
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
| | - John A Harvin
- Center for Translational Injury Research, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Department of Surgery, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the Center for Clinical Research and Evidence-Based Medicine, the McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,the John S. Dunn Burn Center at Memorial Hermann Hospital-Texas Medical Center
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13
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Ghneim M, Albrecht J, Brasel K, Knight A, Liveris A, Watras J, Michetti CP, Haan J, Lightwine K, Winfield RD, Adams SD, Podbielski J, Armen S, Zacko JC, Nasrallah FS, Schaffer KB, Dunn JA, Smoot B, Schroeppel TJ, Stillman Z, Cooper Z, Stein DM. Factors associated with receipt of intracranial pressure monitoring in older adults with traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000733. [PMID: 34395918 PMCID: PMC8311332 DOI: 10.1136/tsaco-2021-000733] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines. METHODS We analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression. RESULTS Our sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2). DISCUSSION Worsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Mira Ghneim
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Jennifer Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ariel Knight
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Anna Liveris
- Department of Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
- Department of Surgery, Albert Einstein School, Bronx, New York, USA
| | - Jill Watras
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | | | - James Haan
- Department of Trauma Services, Ascension Via Christi, Wichita, Kansas, USA
| | - Kelly Lightwine
- Department of Trauma Services, Ascension Via Christi, Wichita, Kansas, USA
| | | | - Sasha D Adams
- Department of Surgery, McGovern Medical School, Houston, Texas, USA
| | | | - Scott Armen
- Departments of Surgery and Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - J Christopher Zacko
- Departments of Surgery and Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Julie A Dunn
- Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
| | - Brittany Smoot
- Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
| | - Thomas J Schroeppel
- Trauma and Acute Care Surgery, University of Colorado Health - South, Colorado Springs, Colorado, USA
| | - Zachery Stillman
- UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Deborah M Stein
- Department of Surgery, University of California, San Francisco, CA, USA
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Ho VP, Adams SD, O'Connell KM, Cocanour CS, Arbabi S, Powelson EB, Cooper Z, Stein DM. Making your geriatric and palliative programs a strength: TQIP guideline implementation and the VRC perspective. Trauma Surg Acute Care Open 2021; 6:e000677. [PMID: 34337156 PMCID: PMC8286789 DOI: 10.1136/tsaco-2021-000677] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/05/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Older patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program's best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification. METHODS We discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions. RESULTS We describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen. DISCUSSION Specialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes.Level of evidence V.
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Affiliation(s)
- Vanessa P Ho
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Sasha D Adams
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | | | - Saman Arbabi
- Surgery, University of Washington, Seattle, Washington, USA
| | - Elisabeth B Powelson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Drake SA, Conway SH, Yang Y, Cheatham LS, Wolf DA, Adams SD, Wade CE, Holcomb JB. When falls become fatal-Clinical care sequence. PLoS One 2021; 16:e0244862. [PMID: 33406164 PMCID: PMC7787527 DOI: 10.1371/journal.pone.0244862] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 12/17/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This study encompassed fall-related deaths, including those who died prior to medical care, that were admitted to multiple healthcare institutions, regardless of whether they died at home, in long-term care, or in hospice. The common element was that all deaths resulted directly or indirectly from injuries sustained during a fall, regardless of the temporal relationship. This comprehensive approach provides an unusual illustration of the clinical sequence of fall-related deaths. Understanding this pathway lays the groundwork for identification of gaps in healthcare needs. DESIGN This is a retrospective study of 2014 fall-related deaths recorded by one medical examiner's office (n = 511) within a larger dataset of all trauma related deaths (n = 1848). Decedent demographic characteristics and fall-related variables associated with the deaths were coded and described. RESULTS Of those falling, 483 (94.5%) were from heights less than 10 feet and 394 (77.1%) were aged 65+. The largest proportion of deaths (n = 267, 52.3%) occurred post-discharge from an acute care setting. Of those who had a documented prior fall, 216 (42.3%) had a history of one fall while 31 (6.1%) had ≥2 falls prior to their fatal incident. For the 267 post-acute care deaths, 440 healthcare admissions were involved in their care. Of 267 deaths occurring post-acute care, 129 (48.3%) were readmitted within 30 days. Preventability, defined as opportunities for improvement in care that may have influenced the outcome, was assessed. Of the 1848 trauma deaths, 511 (27.7%) were due to falls of which 361 (70.6%) were determined to be preventable or potentially preventable. CONCLUSION Our data show that readmissions and repeated falls are frequent events in the clinical sequence of fall fatalities. Efforts to prevent fall-related readmissions should be a top priority for improving fall outcomes and increasing the quality of life among those at risk of falling.
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Affiliation(s)
- Stacy A. Drake
- Texas A&M University, College of Nursing, College Station, Texas, United States of America
| | - Sadie H. Conway
- The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Yijiong Yang
- The University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, Texas, United States of America
| | - Latarsha S. Cheatham
- The University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, Texas, United States of America
| | - Dwayne A. Wolf
- Harris County Institute of Forensic Sciences, Houston, Texas, United States of America
| | - Sasha D. Adams
- Center for Translational Injury Research, Houston, Texas, United States of America
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Charles E. Wade
- Center for Translational Injury Research, Houston, Texas, United States of America
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - John B. Holcomb
- Department of Surgery, University of Alabama, Birmingham, Alabama, United States of America
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Forth KE, Wirfel KL, Adams SD, Rianon NJ, Lieberman Aiden E, Madansingh SI. A Postural Assessment Utilizing Machine Learning Prospectively Identifies Older Adults at a High Risk of Falling. Front Med (Lausanne) 2020; 7:591517. [PMID: 33392218 PMCID: PMC7772994 DOI: 10.3389/fmed.2020.591517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 08/04/2020] [Accepted: 11/12/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Falls are the leading cause of accidental death in older adults. Each year, 28.7% of US adults over 65 years experience a fall resulting in over 300,000 hip fractures and $50 billion in medical costs. Annual fall risk assessments have become part of the standard care plan for older adults. However, the effectiveness of these assessments in identifying at-risk individuals remains limited. This study characterizes the performance of a commercially available, automated method, for assessing fall risk using machine learning. Methods: Participants (N = 209) were recruited from eight senior living facilities and from adults living in the community (five local community centers in Houston, TX) to participate in a 12-month retrospective and a 12-month prospective cohort study. Upon enrollment, each participant stood for 60 s, with eyes open, on a commercial balance measurement platform which uses force-plate technology to capture center-of-pressure (60 Hz frequency). Linear and non-linear components of the center-of-pressure were analyzed using a machine-learning algorithm resulting in a postural stability (PS) score (range 1–10). A higher PS score indicated greater stability. Participants were contacted monthly for a year to track fall events and determine fall circumstances. Reliability among repeated trials, past and future fall prediction, as well as survival analyses, were assessed. Results: Measurement reliability was found to be high (ICC(2,1) [95% CI]=0.78 [0.76–0.81]). Individuals in the high-risk range (1-3) were three times more likely to fall within a year than those in low-risk (7–10). They were also an order of magnitude more likely (12/104 vs. 1/105) to suffer a spontaneous fall i.e., a fall where no cause was self-reported. Survival analyses suggests a fall event within 9 months (median) for high risk individuals. Conclusions: We demonstrate that an easy-to-use, automated method for assessing fall risk can reliably predict falls a year in advance. Objective identification of at-risk patients will aid clinicians in providing individualized fall prevention care.
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Affiliation(s)
| | - Kelly L Wirfel
- Department of Internal Medicine, Division of Diabetes, Endocrinology and Metabolism, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nahid J Rianon
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Internal Medicine, Division of Geriatric and Palliative Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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Cherla DV, Viso CP, Holihan JL, Bernardi K, Moses ML, Mueck KM, Olavarria OA, Flores-Gonzalez JR, Balentine CJ, Ko TC, Adams SD, Pedroza C, Kao LS, Liang MK. The Effect of Financial Conflict of Interest, Disclosure Status, and Relevance on Medical Research from the United States. J Gen Intern Med 2019; 34:429-434. [PMID: 30604124 PMCID: PMC6420588 DOI: 10.1007/s11606-018-4784-0] [Citation(s) in RCA: 20] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/31/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Financial interactions between industry and healthcare providers are reportable. Substantial discrepancies have been detected between industry and self-report of these conflicts of interest (COIs). OBJECTIVE Our aim was to determine if authors who fail to disclose reportable COI are more likely to publish findings that are favorable to industry than authors with no COI. DESIGN In this blinded, observational study of medical and surgical primary research articles in PubMed, 590 articles were reviewed. MAIN MEASURES Reportable financial relationships between authors and industry were evaluated. COIs were considered to have relevance if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, defined as an impression favorable to the product(s) discussed by an article and determined by 3 independent, blinded clinicians for each article. Primary analysis compared Incomplete Self-Disclosure to No COI. Two-level multivariable mixed-effects ordered logistic regression was used to assess factors associated with favorability. KEY RESULTS A 69% discordance rate existed between industry and self-report in COI disclosure. When authors failed to disclose COI, their conclusions were more likely to favor industry partners than authors without COI (favorable ratings 73% versus 62%, RR 1.18, p = < 0.001). On univariate (any COI 74% versus no COI 62%, RR 1.11, p = < 0.001) and multivariable analyses, any COI was associated with favorability. CONCLUSIONS All financial COIs (disclosed or undisclosed, relevant or not relevant, research or non-research) influence whether studies report findings favorable to industry sponsors.
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Affiliation(s)
- Deepa V Cherla
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cristina P Viso
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Karla Bernardi
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Department of Surgery, General Surgery Clinical Research Fellow, Houston, TX, USA.
| | - Maya L Moses
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Krislynn M Mueck
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Oscar A Olavarria
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan R Flores-Gonzalez
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Courtney J Balentine
- Department of Surgery & Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tien C Ko
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Claudia Pedroza
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mike K Liang
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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Lei R, Swartz MD, Harvin JA, Cotton BA, Holcomb JB, Wade CE, Adams SD. Stop the Bleed Training empowers learners to act to prevent unnecessary hemorrhagic death. Am J Surg 2019; 217:368-372. [DOI: 10.1016/j.amjsurg.2018.09.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/25/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
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Cherla DV, Viso CP, Olavarria OA, Bernardi K, Holihan JL, Mueck KM, Flores-Gonzalez J, Liang MK, Adams SD. The Impact of Financial Conflict of Interest on Surgical Research: An Observational Study of Published Manuscripts. World J Surg 2018; 42:2757-2762. [PMID: 29426969 DOI: 10.1007/s00268-018-4532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Substantial discrepancies exist between industry-reported and self-reported conflicts of interest (COI). Although authors with relevant, self-reported financial COI are more likely to write studies favorable to industry sponsors, it is unknown whether undisclosed COI have the same effect. We hypothesized that surgeons who fail to disclose COI are more likely to publish findings that are favorable to industry than surgeons with no COI. METHODS PubMed was searched for articles in multiple surgical specialties. Financial COI reported by surgeons and industry were compared. COI were considered to be relevant if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, which was defined as an impression favorable to the product(s) discussed by an article and was determined by 3 independent, blinded clinicians for each article. Primary analysis compared incomplete self-disclosure to no COI. Ordered logistic multivariable regression modeling was used to assess factors associated with favorability. RESULTS Overall, 337 articles were reviewed. There was a high rate of discordance in the reporting of COI (70.3%). When surgeons failed to disclose COI, their conclusions were significantly more likely to favor industry than surgeons without COI (RR 1.2, 95% CI 1.1-1.4, p < 0.001). On multivariable analysis, any COI (regardless of relevance, disclosure, or monetary amount) were significantly associated with favorability. CONCLUSIONS Any financial COI (disclosed or undisclosed, relevant or not relevant) significantly influence whether studies report findings favorable to industry. More attention must be paid to improving research design, maximizing transparency in medical research, and insisting that surgeons disclose all COI, regardless of perceived relevance.
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Affiliation(s)
- Deepa V Cherla
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cristina P Viso
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Oscar A Olavarria
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Karla Bernardi
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA.
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Julie L Holihan
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Krislynn M Mueck
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Juan Flores-Gonzalez
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
| | - Mike K Liang
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sasha D Adams
- Department of Surgery, University of Texas Health Science Center at Houston, 5656 Kelley St, Houston, TX, 77026, USA
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George MJ, Adams SD, McNutt MK, Love JD, Albarado R, Moore LJ, Wade CE, Cotton BA, Holcomb JB, Harvin JA. The effect of damage control laparotomy on major abdominal complications: A matched analysis. Am J Surg 2017; 216:56-59. [PMID: 29157889 DOI: 10.1016/j.amjsurg.2017.10.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 09/12/2017] [Accepted: 10/30/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Damage control laparotomy (DCL) for trauma is thought to be associated with increased abdominal complications. The purpose of this study is to determine the effect of DCL on abdominal complications by comparing two groups of trauma patients: DCL patients who were prospectively adjudicated to potentially being closed at the primary laparotomy (potential DEF or pDEF) and those who underwent definitive laparotomy (DEF). METHODS The pDEF group was matched to DEF patients according to mechanism of injury, abdominal injury severity, operating room transfusions, and performance of a colon resection. The primary outcome was major abdominal complications (MAC), a composite variable. RESULTS No statistically significant difference in the primary outcome, major abdominal complications, were seen (pDEF 19% versus DEF 56%, p = 0.066). The pDEF group was more likely to have a fascial dehiscence (38% versus 0%, p = 0.018), and to be re-opened after fascial closure (38% versus 0%, p = 0.018). CONCLUSION Damage control laparotomy was associated with clinically but not statistically significant increase in rates of MAC. Increased numbers of patients to analyze in this fashion is needed.
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Affiliation(s)
- Mitchell J George
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Sasha D Adams
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Michelle K McNutt
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Joseph D Love
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Rondel Albarado
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Laura J Moore
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Charles E Wade
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Bryan A Cotton
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - John B Holcomb
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - John A Harvin
- Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
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Choi TJ, Schnettgoecke BT, Dodwad SN, Wade CE, Holcomb JB, Adams SD. “Unnecessary Imaging” in the Elderly Is Necessary. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Harvin JA, Kao LS, Liang MK, Adams SD, McNutt MK, Love JD, Moore LJ, Wade CE, Cotton BA, Holcomb JB. Decreasing the Use of Damage Control Laparotomy in Trauma: A Quality Improvement Project. J Am Coll Surg 2017; 225:200-209. [PMID: 28445796 DOI: 10.1016/j.jamcollsurg.2017.04.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 01/17/2017] [Revised: 03/10/2017] [Accepted: 04/10/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Our institution has published damage control laparotomy (DCL) rates of 30% and documented the substantial morbidity associated with the open abdomen. The purpose of this quality improvement (QI) project was to decrease the rate of DCL at a busy, Level I trauma center in the US. STUDY DESIGN A prospective cohort of all emergent trauma laparotomies from November 2013 to October 2015 (QI group) was followed. The QI intervention was multifaceted and included audit and feedback for every DCL case. Morbidity and mortality of the QI patients were compared with those from a published control (control group: emergent laparotomy from January 2011 to October 2013). RESULTS A significant decrease was observed immediately on beginning the QI project, from a 39% DCL rate in the control period to 23% in the QI group (p < 0.001). This decrease was sustained over the 2-year study period. There were no differences in demographics, Injury Severity Score, or transfusions between the groups. No differences organ/space infection (control 16% vs QI 12%; p = 0.15), fascial dehiscence (6% vs 8%; p = 0.20), unplanned relaparotomy (11% vs 10%; p = 0.58), or mortality (9% vs 10%; p = 0.69) were observed. The reduction in use resulted in a decrease of 68 DCLs over the 2-year period. There was a further reduction in the rate of DCL to 17% after completion of the QI project. CONCLUSIONS A QI initiative rapidly changed the use of DCL and improved quality of care by decreasing resource use without an increase morbidity or mortality. This decrease was sustained during the QI period and further improved upon after its completion.
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Affiliation(s)
- John A Harvin
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, the University of Texas McGovern Medical School, Houston, TX.
| | - Lillian S Kao
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX
| | - Mike K Liang
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX
| | - Sasha D Adams
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, the University of Texas McGovern Medical School, Houston, TX
| | - Michelle K McNutt
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX
| | - Joseph D Love
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX
| | - Laura J Moore
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, the University of Texas McGovern Medical School, Houston, TX
| | - Charles E Wade
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, the University of Texas McGovern Medical School, Houston, TX
| | - Bryan A Cotton
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, the University of Texas McGovern Medical School, Houston, TX
| | - John B Holcomb
- Department of Surgery, the University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, the University of Texas McGovern Medical School, Houston, TX
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Abstract
National health care expenditures constitute a continuously expanding component of the US economy. Health care resources are distributed unequally among the population, and geriatric patients are disproportionately represented. Characterizing this group of individuals that accounts for the largest percentage of US health spending may facilitate the introduction of targeted interventions in key high-impact areas. Changing demographics, an increasing incidence of chronic disease and progressive disability, rapid technological advances, and systemic market failures in the health care sector combine to drive cost. A multidisciplinary approach will become increasingly necessary to balance the delicate relationship between our constrained supply and increasing demand.
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Affiliation(s)
- Preston B Rich
- Division of Acute Care Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, Campus Box #7228, Chapel Hill, NC 27599-7228, USA.
| | - Sasha D Adams
- Division of Acute Care Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, Campus Box #7228, Chapel Hill, NC 27599-7228, USA
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Phillips MR, Machta RM, Adams SD, McLean SE, Charles AG. Are Geriatric Patients at Increased Risk of Appendiceal Perforation? J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lu RP, Ni A, Lin FC, Ortiz-Pujols SM, Adams SD, Monroe DM, Whinna HC, Cairns BA, Key NS. Major burn injury is not associated with acute traumatic coagulopathy. J Trauma Acute Care Surg 2013; 74:1474-9. [PMID: 23694874 DOI: 10.1097/ta.0b013e3182923193] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The pathophysiology and time course of coagulopathy after major burns are inadequately understood. Our study objectives were to determine whether acute traumatic coagulopathy (ATC) is seen in burn patients at admission and to determine the changes in international normalized ratio (INR), activated partial thromboplastin time (aPTT), platelet count (PLT), and hemoglobin (Hgb) in the first 7 days after injury. METHODS We conducted a retrospective study of patients with burn injury of at least 15% total body surface area who presented to the University of North Carolina. Data on patient demographics, injury characteristics, and laboratory data (INR, aPTT, PLT, and Hgb) at admission and within the first 7 days after injury were recorded. We defined ATC as INR of 1.3 or greater, aPTT of 1.5 or greater times the mean normal limit, and normal PLT at admission. RESULTS We studied the hematologic profile of 102 patients with burn injury of 15% to 100% total body surface area but did not identify a single patient with ATC at admission. The screening hematologic profile at admission was not influenced by burn severity. In the first 7 days after injury, the INR and aPTT were relatively preserved, while the PLT quickly recovered to baseline after an early decline and the Hgb remained stable at around 10 g/dL; all these changes occurred during the time when the burn patients had received large amounts of fluid resuscitation. CONCLUSION The screening hematologic profile of burn patients at admission is normal, and the standard screening assays do not suggest the existence of ATC at admission. While this is a relatively small study, it provides evidence to suggest that ATC is unique to trauma patients. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Rommel P Lu
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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Lu RP, Lin FC, Ortiz-Pujols SM, Adams SD, Whinna HC, Cairns BA, Key NS. Blood utilization in patients with burn injury and association with clinical outcomes (CME). Transfusion 2012; 53:2212-21; quiz 2211. [PMID: 23278449 DOI: 10.1111/trf.12057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uncontrolled bleeding is an important cause of increased transfusion in burn victims; however, description of blood utilization patterns in the burn population is lacking. STUDY DESIGN AND METHODS We conducted a single-institution, retrospective cohort study to measure blood utilization in 89 consecutive burn patients with 15% to 65% total body surface area (TBSA) burn within 60 days of injury. We also evaluated the relationship of blood product utilization with clinical variables including anticoagulant usage and mortality. RESULTS We determined that: 1) the predictors for increased red blood cells (RBCs) and plasma transfusions were high TBSA burn and the use of argatroban anticoagulation (for suspected heparin-induced thrombocytopenia [HIT]); 2) TBSA burn and patient age were independent predictors of mortality, but not RBC or plasma transfusion; and 3) the incidence of symptomatic venous thromboembolic events is not uncommon (11.2%), although HIT is rare (1.1%). CONCLUSION Despite concerns about adverse correlation between increased number of transfusions and mortality in other clinical settings, we did not find this association in our study. However, we demonstrated that the type and intensity of anticoagulation carries substantial risk for increased RBC as well as plasma usage.
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Affiliation(s)
- Rommel P Lu
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Biostatistics and North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Ward JL, Delano BA, Adams SD, Mercer EE, Mercer DW. Laparotomy attenuates lipopolysaccharide-induced gastric bleeding in the rat. Dig Dis Sci 2010; 55:902-10. [PMID: 19390968 DOI: 10.1007/s10620-009-0800-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 03/17/2009] [Indexed: 12/16/2022]
Abstract
Lipopolysaccharide (LPS) increases systemic inflammation and causes duodenogastric reflux of bile and gastric bleeding. Laparotomy prevents gastric injury from the luminal irritant bile, but its effects on LPS-induced gastric injury are unknown. We hypothesized that laparotomy would diminish inflammation and attenuate gastric bleeding caused by LPS. In the rat, laparotomy, done either before or after administration of LPS, attenuated LPS-induced bile reflux, gastric bleeding, and cyclooxygenase-2, but not inducible nitric oxide synthase, expression when compared to controls given LPS. Laparotomy also blunted LPS-induced changes in serum cytokine production. These data suggest that laparotomy has gastroprotective effects by preventing LPS-induced bile reflux and gastric bleeding and by a mechanism mediated, at least in part by cyclooxygenase-2.
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Affiliation(s)
- Jeremy L Ward
- Department of Surgery, University of Texas Health Science Center at Houston, 6431 Fannin Street, Suite 4.264, Houston, TX, 77030, USA.
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Suliburk JW, Ward JL, Helmer KS, Adams SD, Zuckerbraun BS, Mercer DW. Ketamine-induced hepatoprotection: the role of heme oxygenase-1. Am J Physiol Gastrointest Liver Physiol 2009; 296:G1360-9. [PMID: 19372106 PMCID: PMC2697945 DOI: 10.1152/ajpgi.00038.2009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lipopolysaccharide (LPS) causes hepatic injury that is mediated, in part, by upregulation of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2). Ketamine has been shown to prevent these effects. Because upregulation of heme oxygenase-1 (HO-1) has hepatoprotective effects, as does carbon monoxide (CO), an end product of the HO-1 catalytic reaction, we examined the effects of HO-1 inhibition on ketamine-induced hepatoprotection and assessed whether CO could attenuate LPS-induced hepatic injury. One group of rats received ketamine (70 mg/kg ip) or saline concurrently with either the HO-1 inhibitor tin protoporphyrin IX (50 micromol/kg ip) or saline. Another group of rats received inhalational CO (250 ppm over 1 h) or room air. All rats were given LPS (20 mg/kg ip) or saline 1 h later and euthanized 5 h after LPS or saline. Liver was collected for iNOS, COX-2, and HO-1 (Western blot), NF-kappaB and PPAR-gamma analysis (EMSA), and iNOS and COX-2 mRNA analysis (RT-PCR). Serum was collected to measure alanine aminotransferase as an index of hepatocellular injury. HO-1 inhibition attenuated ketamine-induced hepatoprotection and downregulation of iNOS and COX-2 protein. CO prevented LPS-induced hepatic injury and upregulation of iNOS and COX-2 proteins. Although CO abolished the ability of LPS to diminish PPAR-gamma activity, it enhanced NF-kappaB activity. These data suggest that the hepatoprotective effects of ketamine are mediated primarily by HO-1 and its end product CO.
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Affiliation(s)
- James W. Suliburk
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeremy L. Ward
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenneth S. Helmer
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sasha D. Adams
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David W. Mercer
- Department of Surgery, The University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Vercruysse GA, Adams SD, Feliciano DV. Computed tomographic evidence of hepatic portal venous gas after blunt abdominal trauma does not necessitate surgery. Am Surg 2008; 74:335-337. [PMID: 18453300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery.
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Affiliation(s)
- Gary A Vercruysse
- Department of Surgery, Emory University, Atlanta, Georgia 30303, USA.
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Vercruysse GA, Adams SD, Feliciano DV. Computed Tomographic Evidence of Hepatic Portal Venous Gas after Blunt Abdominal Trauma Does Not Necessitate Surgery. Am Surg 2008. [DOI: 10.1177/000313480807400412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery.
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Affiliation(s)
| | - Sasha D. Adams
- University of Texas Medical School at Houston, Houston, Texas
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Harting MT, Jimenez F, Adams SD, Mercer DW, Cox CS. QS398. Acute, Regional Inflammatory Response After Traumatic Brain Injury: Implications for Cellular Therapy. J Surg Res 2008. [DOI: 10.1016/j.jss.2007.12.654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Clostridium difficile is the most common cause of nosocomial infectious diarrhea in adults. The purpose of this review is to increase awareness that infection from C. difficile is not always indolent, but with fulminant colitis, it can be lethal. The epidemiology, pathogenesis and treatment of C. difficile infection are discussed, with special emphasis on management of fulminant colitis. RECENT FINDINGS Clostridium difficile causes fulminant colitis in 3-8% of patients. Early predictors of disease include immunosuppression, hypotension, hypoalbuminemia, and a pronounced leukocytosis. In patients with fulminant colitis, early colectomy before vasopressor therapy is required and may improve survival. SUMMARY The incidence and virulence of C. difficile infection are increasing. Antibiotic use and length of hospital stay correlate strongly with infection. Oral or intravenous metronidazole is the recommended first-line therapy, with discontinuation of systemic antibiotics if possible. Forty percent of patients may have a prolonged course and 20% will relapse despite adequate therapy. Fulminant colitis develops in 3-8% of patients; diagnosis can be difficult with diarrhea absent in 20% of the subgroup. Once diagnosed, subtotal colectomy with ileostomy is usually required. In patients with a marked leukocytosis or bandemia, surgery is advisable because the leukocytosis frequently precedes hypotension and the requirement for vasopressor therapy, which carries a poor prognosis.
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Affiliation(s)
- Sasha D Adams
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas 77030, USA
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Abstract
UNLABELLED Matrix metalloproteinases (MMPs) degrade the extracellular matrix and contribute to LPS-induced gastric injury. MMPs are closely modulated by their activators, membrane type-MMP (MT-MMPs) and their endogenous inhibitors, the tissue inhibitors of metalloproteinases (TIMPs). As LPS-induced gastric injury is mediated in part by iNOS, and NO modulates MMP production in vitro, we hypothesized that NOS inhibition would similarly modulate LPS-induced gastric MMP production. Therefore, the purpose of these studies was to compare the effects of selective and nonselective NOS inhibition on LPS-induced gastric MMP production. METHODS Sprague-Dawley rats were given either the nonselective NOS inhibitor NG-nitro-L-arginine methyl ester (L-NAME; 5 mg/kg, s.c.), a selective iNOS inhibitor, aminoguanidine (45 mg/kg, i.p.) or L-N-iminoethyl-lysine (L-NIL; 10 mg/kg, i.p.), or vehicle 15 min before saline or LPS (20 mg/kg, i.p.) and killed 24 h after LPS administration. Stomachs were assessed for macroscopic injury (computed planimetry), and gastric mucosal MMP production was assessed by gelatin zymography, in situ zymography, and Western analysis for MMP-2, MT1-MMP, and TIMP-2. (n > or = 4/group; ANOVA). RESULTS Aminoguanidine treatment decreased LPS-induced macroscopic gastric injury as well as MMP-2 and MT1-MMP protein production while having no effect on TIMP-2 protein levels. L-NIL similarly attenuated the induction of MMP-2 and MT1-MMP by LPS. L-NAME failed to attenuate LPS induced gastric injury or MT1-MMP protein induction and increased MMP-2 levels. L-NAME similarly had no effect on gastric TIMP-2 production. CONCLUSIONS Selective iNOS inhibition decreases gastric MMP-2 activity after LPS administration, whereas nonselective inhibition increases MMP-2 levels. The ability of selective iNOS inhibition to ameliorate LPS-induced gastric injury may be due in part to its inhibition of active MMP-2 production, whereas nonselective NOS inhibitors increase MMP-2 levels and maintain gastric injury after LPS administration.
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Affiliation(s)
- Emily K Robinson
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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Berger MJ, Adams SD, Tigges BM, Sprague SL, Wang XJ, Collins DP, McKenna DH. Differentiation of umbilical cord blood-derived multilineage progenitor cells into respiratory epithelial cells. Cytotherapy 2006; 8:480-7. [PMID: 17050253 DOI: 10.1080/14653240600941549] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [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: 10/24/2022]
Abstract
BACKGROUND Umbilical cord blood (UCB) has been examined for the presence of stem cells capable of differentiating into cell types of all three embryonic layers (i.e. endo-, ecto- and mesoderm). The few groups reporting success have typically confirmed endodermal potential using hepatic differentiation. We report differentiation of human UCB-derived multipotent stem cells, termed multilineage progenitor cells (MLPC), into respiratory epithelial cells (i.e. type II alveolar cells). METHODS Using a cell separation medium (PrepaCyte-MLPC; BioE Inc.) and plastic adherence, MLPC were isolated from four of 16 UCB units (American Red Cross) and expanded. Cultures were grown to 80% confluence in mesenchymal stromal cell growth medium (MSCGM; Cambrex BioScience) prior to addition of small airway growth medium (SAGM; Cambrex BioScience), an airway maintenance medium. Following a 3-8-day culture, cells were characterized by light microscopy, transmission electron microscopy, immunofluorescence and reverse transcriptase (RT)-PCR. RESULTS MLPC were successfully differentiated into type II alveolar cells (four of four mixed lines; two of two clonal lines). Differentiated cells were characterized by epithelioid morphology with lamellar bodies. Both immunofluorescence and RT-PCR confirmed the presence of surfactant protein C, a protein highly specific for type II cells. DISCUSSION MLPC were isolated, expanded and then differentiated into respiratory epithelial cells using an off-the-shelf medium designed for maintenance of fully differentiated respiratory epithelial cells. To the best of our knowledge, this is the first time human non-embryonic multipotent stem cells have been differentiated into type II alveolar cells. Further studies to evaluate the possibilities for both research and therapeutic applications are necessary.
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Affiliation(s)
- M J Berger
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Knowles SM, Adams SD. Who owns my DNA?: the national and international intellectual property law on human embryonic tissue and cloning. Cumberland Law Rev 2003; 32:475-86. [PMID: 12645552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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Adams SD, Barracchini KC, Simonis TB, Stroncek D, Marincola FM. High throughput HLA sequence-based typing (SBT) utilizing the ABI Prism 3700 DNA Analyzer. Tumori 2001; 87:S40-3. [PMID: 11401225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
AIMS AND BACKGROUND The genetic complexity of the human major histocompatibility complex (MHC) has required the development of various molecular typing methods. The purpose of this paper is to compare the results of two of these molecular methods: sequenced based typing (SBT) and polymerase chain reaction (PCR) using sequence specific primers (PCR-SSP). METHODS The SBT method described utilizes an ABI Prism 3700 DNA Analyzer, which has been designed fro high throughput production of sequence data through highly automated operation with significant walk-away time. The ABI Prism 3700 DNA Analyzer is a 96-capillary electrophoresis instrument with the capability of running four 96-well plates black to back in a sixteen-hour period. Potentially, data from this machine can produce Class I sequences for A or B loci for 64 samples in this time frame. The SBT method encompassed exons 2, 3, and 4 with forward and reverse sequence orientation reactions using the PE Biosystems HLA-A and HLA-B Sequenced Based Typing Kits (PE Applied Biopsystems/Perkin-Elmer, Foster City, CA, USA). Most SBT methods previously employed only gather data from exons 2 and 3 which distinguishes most of the polymorphism necessary to identify the majority of alleles in the HLA region. However, in an effort to discern numerous null alleles in the HLA region, exon 4 data is also included. The PCR-SSP method utilized consists of one 96 well tray, with 95 primer mixes and one negative control, per sample designed to produce an intermediate/high resolution HLA-A, B typing. RESULTS Data from one 96-well capillary run on the ABI Prism 3700 DNA Analyzer, which consists of results from 16 samples for HLA-A or HLA-B loci, was compared to data derived from sixteen HLA-A and HLA-B PCR-SSP typings. 75% of loci tested achieved a higher resolution HLA typing by the SBT method. DISCUSSION The ability to provide allele level HLA typing results can have significant functional implications for the bone marrow transplant community and numerous vaccine studies.
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Affiliation(s)
- S D Adams
- Department of Transfusion Medicine, Warren G Magnuson Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-1184, USA
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Affiliation(s)
- A F Morey
- Department of Surgery (Urology Service), Tripler Army Medical Center, Honolulu, Hawaii 96859-5000
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Adams SD. Traveler's diarrhea in a West-Pac-deployed Navy/Marine Corps population. Mil Med 1991; 156:A7. [PMID: 1900105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Adams SD, Killien M, Larson E. In-line filtration and infusion phlebitis. Heart Lung 1986; 15:134-40. [PMID: 3512490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Ludwig EG, Adams SD. Patient cooperation in a rehabilitation center: assumption of the client role. J Health Soc Behav 1968; 9:328-336. [PMID: 5706546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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