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Martino AM, Yeates EO, Grigorian A, Chinn J, Young H, Colin Escobar J, Glavis-Bloom J, Anavim A, Yaghmai V, Nguyen NT, Dolich M, Schubl SD, Goodman LF, Guner YS, Nahmias J. Comparing Accuracy of Night Radiology Interpretations for Pediatric Trauma: Radiology Residents Versus Attending Teleradiologists. Am Surg 2024:31348241248794. [PMID: 38655777 DOI: 10.1177/00031348241248794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background: Overnight radiology coverage for pediatric trauma patients (PTPs) is addressed with a combination of on-call radiology residents (RRs) and/or attending teleradiologists (ATs); however, the accuracy of these two groups has not been investigated for PTPs. We aimed to compare the accuracy of RRs vs AT interpretations of computed tomography (CT) scans for PTPs. Methods: Pediatric trauma patients (<18 years old) at a single level-I adult/level-II pediatric trauma center were studied in a retrospective analysis (3/2019-5/2020). Computed tomography scans interpreted by both RRs and ATs were included. Radiology residents were compared to ATs for time to interpretation (TTI) and accuracy compared to faculty attending radiologist interpretation, using the validated RADPEER scoring system. Additionally, RR and AT accuracies were compared to a previously studied adult cohort during the same time-period. Results: 42 PTPs (270 interpretations) and 1053 adults (8226 interpretations) were included. Radiology residents had similar rates of discrepancy (13.3% vs 13.3%), major discrepancy (4.4% vs 4.4%), missed findings (9.6% vs 12.6%), and overcalls (3.7% vs .7%) vs ATs (all P > .05). Mean TTI was shorter for RRs (55.9 vs 90.4 minutes, P < .001). Radiology residents had a higher discrepancy rate for PTPs (13.3% vs 7.5%, P = .01) than adults. Attending teleradiologists had a similar discrepancy rate for PTPs and adults (13.3% vs 8.9%, P = .07). Discussion: When interpreting PTP CT imaging, RRs had similar discrepancy rates but faster TTI than ATs. Radiology residents had a higher discrepancy rate for PTP CTs than RR interpretation of adult patients, indicating both RRs and ATs need more focused training in the interpretation of PTP studies.
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Affiliation(s)
- Alice M Martino
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Eric O Yeates
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Justine Chinn
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Hayley Young
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Jessica Colin Escobar
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Justin Glavis-Bloom
- Department of Radiology, University of California Irvine Medical Center, Orange, CA, USA
| | - Arash Anavim
- Department of Radiology, University of California Irvine Medical Center, Orange, CA, USA
| | - Vahid Yaghmai
- Department of Radiology, University of California Irvine Medical Center, Orange, CA, USA
| | - Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Matthew Dolich
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Laura F Goodman
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
- Department of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
- Department of Pediatric Surgery, Children's Hospital of Orange County, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
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2
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Coulon PG, Prakash S, Dhanushkodi NR, Srivastava R, Zayou L, Tifrea DF, Edwards RA, Figueroa CJ, Schubl SD, Hsieh L, Nesburn AB, Kuppermann BD, Bahraoui E, Vahed H, Gil D, Jones TM, Ulmer JB, BenMohamed L. High frequencies of alpha common cold coronavirus/SARS-CoV-2 cross-reactive functional CD4 + and CD8 + memory T cells are associated with protection from symptomatic and fatal SARS-CoV-2 infections in unvaccinated COVID-19 patients. Front Immunol 2024; 15:1343716. [PMID: 38605956 PMCID: PMC11007208 DOI: 10.3389/fimmu.2024.1343716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/08/2024] [Indexed: 04/13/2024] Open
Abstract
Background Cross-reactive SARS-CoV-2-specific memory CD4+ and CD8+ T cells are present in up to 50% of unexposed, pre-pandemic, healthy individuals (UPPHIs). However, the characteristics of cross-reactive memory CD4+ and CD8+ T cells associated with subsequent protection of asymptomatic coronavirus disease 2019 (COVID-19) patients (i.e., unvaccinated individuals who never develop any COVID-19 symptoms despite being infected with SARS-CoV-2) remains to be fully elucidated. Methods This study compares the antigen specificity, frequency, phenotype, and function of cross-reactive memory CD4+ and CD8+ T cells between common cold coronaviruses (CCCs) and SARS-CoV-2. T-cell responses against genome-wide conserved epitopes were studied early in the disease course in a cohort of 147 unvaccinated COVID-19 patients who were divided into six groups based on the severity of their symptoms. Results Compared to severely ill COVID-19 patients and patients with fatal COVID-19 outcomes, the asymptomatic COVID-19 patients displayed significantly: (i) higher rates of co-infection with the 229E alpha species of CCCs (α-CCC-229E); (ii) higher frequencies of cross-reactive functional CD134+CD137+CD4+ and CD134+CD137+CD8+ T cells that cross-recognized conserved epitopes from α-CCCs and SARS-CoV-2 structural, non-structural, and accessory proteins; and (iii) lower frequencies of CCCs/SARS-CoV-2 cross-reactive exhausted PD-1+TIM3+TIGIT+CTLA4+CD4+ and PD-1+TIM3+TIGIT+CTLA4+CD8+ T cells, detected both ex vivo and in vitro. Conclusions These findings (i) support a crucial role of functional, poly-antigenic α-CCCs/SARS-CoV-2 cross-reactive memory CD4+ and CD8+ T cells, induced following previous CCCs seasonal exposures, in protection against subsequent severe COVID-19 disease and (ii) provide critical insights into developing broadly protective, multi-antigen, CD4+, and CD8+ T-cell-based, universal pan-Coronavirus vaccines capable of conferring cross-species protection.
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Affiliation(s)
- Pierre-Gregoire Coulon
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | - Swayam Prakash
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | - Nisha R. Dhanushkodi
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | - Ruchi Srivastava
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | - Latifa Zayou
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | - Delia F. Tifrea
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Robert A. Edwards
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Cesar J. Figueroa
- Department of Surgery, Divisions of Trauma, Burns and Critical Care, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Sebastian D. Schubl
- Department of Surgery, Divisions of Trauma, Burns and Critical Care, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Lanny Hsieh
- Department of Medicine, Division of Infectious Diseases and Hospitalist Program, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Anthony B. Nesburn
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | - Baruch D. Kuppermann
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
| | | | - Hawa Vahed
- Department of Vaccines and Immunotherapies, TechImmune, LLC, University Lab Partners, Irvine, CA, United States
| | - Daniel Gil
- Department of Vaccines and Immunotherapies, TechImmune, LLC, University Lab Partners, Irvine, CA, United States
| | - Trevor M. Jones
- Department of Vaccines and Immunotherapies, TechImmune, LLC, University Lab Partners, Irvine, CA, United States
| | - Jeffrey B. Ulmer
- Department of Vaccines and Immunotherapies, TechImmune, LLC, University Lab Partners, Irvine, CA, United States
| | - Lbachir BenMohamed
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, University of California Irvine, School of Medicine, Irvine, CA, United States
- Université Paul Sabatier, Infinity, Inserm, Toulouse, France
- Department of Vaccines and Immunotherapies, TechImmune, LLC, University Lab Partners, Irvine, CA, United States
- Institute for Immunology, The University of California Irvine, School of Medicine, Irvine, CA, United States
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3
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Donnelly MR, Barie PS, Schubl SD. Impact of the Coronavirus Disease 2019 Pandemic on Utilization of Emergency Medical Services in New York City. Surg Infect (Larchmt) 2024; 25:95-100. [PMID: 38294840 DOI: 10.1089/sur.2023.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Abstract
Background: This study evaluates trends in the utilization of emergency medical services (EMS) in New York City, the "epicenter" of the first "wave" of the coronavirus pandemic. We hypothesize that EMS call volumes decreased overall in New York City during the first year of the pandemic, specifically with respect to trauma/injury calls. Contrarily, we posit that calls for "sick" events increased given pervasive fear of virus transmission. Materials and Methods: Retrospective New York City EMS calls data (January 1, 2019 to December 31, 2020) were obtained from the NYC Open Data/EMS Incident Dispatch database. Total EMS calls, trauma/injury calls, and "sick" event calls were collected for New York City and for all five boroughs. Census data for each borough were used to weigh daily EMS calls per 100,000 individuals. Mann-Whitney U tests were used to compare pre-pandemic (2019 to March 2020) versus pandemic (April 2020 to December 2020) EMS call volumes, p = 0.05. Results: Median daily EMS calls per 100,000 individuals decreased 21.6% at the start of the pandemic across New York City (pre-pandemic, 3,262 calls; pandemic, 2,556 calls; p < 0.001) and similarly decreased when stratified by borough (all, p < 0.001). Median daily trauma/injury and sick event calls per 100,000 also decreased in New York City and the five boroughs from pre-pandemic to pandemic time periods (all, p < 0.001). Discussion and Conclusions: These data reflect an unprecedented window into EMS utilization during an infectious disease pandemic. As decreased EMS utilization for multiple conditions likely reflects delayed or impeded access to care, utilization data have important implications for provision of acute care services during possible future disruptions related to the pandemic.
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Affiliation(s)
- Megan R Donnelly
- Department of Surgery, UC Irvine Health, Orange, California, USA
| | - Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
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Delaplain PT, Santos J, Dvorak J, Mele TS, Gelbard RB, Guidry CA, Barie PS, Schubl SD. An Exploratory and Qualitative Analysis of Self-Reported Evaluations for Fever. Surg Infect (Larchmt) 2024; 25:116-124. [PMID: 38324100 DOI: 10.1089/sur.2023.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background: Despite the high prevalence of post-operative fever, a variety of approaches are taken as to the components of a fever evaluation, when it should be undertaken, and when empiric antibiotic agents should be started. Hypothesis: There is a lack of consensus surrounding many common components of a post-operative fever evaluation. Patients and Methods: The Surgical Infection Society membership was surveyed to determine practices surrounding evaluation of post-operative fever. Eight scenarios were posed in febrile (38.5°C), post-operative general surgery or trauma patients, with 19 possible components of work-up (physical examination, complete blood count [CBC], fungal biomarkers, lactate and procalcitonin [PCT] concentrations, cultures, imaging) and management (antibiotic agents). Each scenario was then re-considered for intensive care unit (ICU) patients (intubated/unstable hemodynamics). Agreement on a parameter (<1/4 or >3/4 of respondents) achieved consensus, positive or negative. Parameters between had equipoise; α was set at 0.05. Results: Among the examined scenarios, only CBC and physical examination received positive consensus across most scenarios. Blood/urine cultures, imaging, lactate, inflammatory biomarkers, and the empiric administration of antibiotic agents did not reach consensus; support was variable depending on the clinical scenario, illness severity, and the individual preferences of the answering clinician. The qualitative portion of the survey identified "fever threshold and duration," "clinical suspicion," and "physiologic manifestation" as the most important factors for deciding about the initiation of a fever evaluation and the potential empiric administration of antibiotic agents. Conclusions: There is consensus only for physical and examination routine laboratory work when initiating the evaluation of febrile post-operative patients. However, there are multiple components of a fever evaluation that individual respondents would select depending on the clinical scenario and severity of illness. Parameters demonstrating equipoise are potential candidates for formal guidance or pragmatic prospective trials.
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Affiliation(s)
- Patrick T Delaplain
- Boston Children's Hospital, Harvard Medical System, Boston, Massachusetts, USA
| | - Jeffrey Santos
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Justin Dvorak
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rondi B Gelbard
- Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christopher A Guidry
- Division of Trauma/Critical and Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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Eriksson EA, Waite A, Whitbeck SS, Bach JA, Bauman ZM, Cavlovic L, Dale K, DeVoe WB, Doben AR, Edwards JG, Forrester JD, Kaye AJ, Green J, Hsu J, Hufford A, Janowak C, Kartiko S, Moore EE, Patel B, Pieracci F, Sarani B, Schubl SD, Semon G, Thomas BW, Tung J, Van Lieshout EMM, White TW, Wijffels MME, Wullschleger ME. An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers (CWIS-CC2). J Trauma Acute Care Surg 2023:01586154-990000000-00535. [PMID: 37889926 DOI: 10.1097/ta.0000000000004158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
BACKGROUND Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS A survey was performed including all CWIS-CC evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each Chest Wall Injury Center (CWIC) care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS Data was collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US based trauma centers. Eighty percent (16/20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5/20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80%(8/10) with APPs and 70%(7/10) with care coordinators. Forty percent(8/20) of centers have dedicated rib fracture research support and 35%(7/20) have SSRF-related grants. Forty percent (8/20) of centers have marketing support and 30%(8/20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4(1-9) surgeons perform surgical stabilization of rib fractures (SSRF). In the majority of trauma centers the trauma surgeons perform SSRF. CONCLUSIONS Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal CWIC. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE IV Economic & Value-Based Evaluations.
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Affiliation(s)
| | - Amanda Waite
- Medical University of South Carolina, Department of Surgery
| | | | - John A Bach
- Riverside Methodist Hospital, Department of Surgery
| | | | | | - Kate Dale
- Gold Coast Health, Department of Surgery
| | | | - Andrew R Doben
- St Francis Hospital and Medical Center, Department of Surgery
| | - John G Edwards
- Sheffield Teaching Hospitals NHS Foundation, Department of Cardiothoracic Surgery
| | | | - Adam J Kaye
- Overland Park Regional Medical Center, Department of Surgery
| | | | - Jeremy Hsu
- Westmead Hospital University of Sydney, Department of Surgery
| | - Andrea Hufford
- Overland Park Regional Medical Center, Department of Surgery
| | | | - Susan Kartiko
- The George Washington University, Department of Surgery
| | | | | | | | - Babak Sarani
- The George Washington University, Department of Surgery
| | | | | | | | - Jamie Tung
- Stanford University, Department of Surgery
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Delaplain PT, Santos J, Barie PS, Dvorak J, Mele TS, Gelbard R, Guidry CA, Schubl SD. Self-Reported Diagnosis and Management of Surgical Site Infection Highlights Lack of Objective Measures and Treatment Guidance. Surg Infect (Larchmt) 2023; 24:598-605. [PMID: 37646635 DOI: 10.1089/sur.2023.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Background: There is little guidance regarding empiric therapy for superficial surgical site infections (SSIs). Management of incisions with signs of SSI lacks consensus and management is variable among individual surgeons. Methods: The Surgical Infection Society was surveyed regarding management of SSIs. Cases were provided with varying wound descriptions, initial wound class (WC), post-operative day, and presence of a prosthesis. Responses were in multiple-choice format; statistics: χ2; α = 0.05. Results: Seventy-eight members responded. For appearance scenarios, respondents believed that both mild erythema (55%) and clear drainage (64%) could be observed, whereas substantial (>3 cm) erythema or purulence should be treated with complete (22% and 50%) or partial (55% and 40%) opening of the incision. Degree of erythema did not influence administration of antibiotic agents, but purulence was more likely than clear drainage to be treated with antibiotics (38% vs. 6%; p < 0.001). There were no differences based on WC, except that clean cases were more likely than higher WC scenarios to be treated with gram-positive coverage alone (WC 1 [26%] vs. 2 [10%] vs. 3 [13%] vs. 4 [4%]; p < 0.001). Post-operative day (POD) three appeared to be an inflection point for more aggressive treatment of suspected incisional SSI, with fewer (POD 0 [86%] vs. POD day 3 [54%]; p < 0.001) reporting observation. Respondents were more likely to obtain imaging, start broad-spectrum antibiotic agents, and return to the operating room for purulence in the presence of a mesh. Conclusions: Presented with escalating possibility of SSI, respondents reported lower rates of observation, increased use of antibiotic agents, and increased surgical drainage. Many scenarios lack consensus regarding appropriate therapy. The complete elimination of SSIs is unlikely to be accomplished soon, and this study provides a framework for understanding how surgeons approach SSIs, and potential areas for further research or pragmatic guidance.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, Boston Children's Hospital, Harvard Medical System, Boston, Massachusetts, USA
| | - Jeffrey Santos
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York USA
| | - Justin Dvorak
- Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rondi Gelbard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher A Guidry
- Division of Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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7
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Santos J, Delaplain PT, Barie PS, Dvorak J, Mele TS, Gelbard R, Guidry CA, Schubl SD. Different Surgeon, Different Closure: Lack of Consensus on Appropriate Closure Technique for Various Case Scenarios. Surg Infect (Larchmt) 2023; 24:541-548. [PMID: 37462905 DOI: 10.1089/sur.2023.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ2 test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.
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Affiliation(s)
- Jeffrey Santos
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Patrick T Delaplain
- Department of Surgery, Boston Children's Hospital, Harvard Medical System, Boston, Massachusetts, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Justin Dvorak
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rondi Gelbard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher A Guidry
- Division of Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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8
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Hosseinian S, de Assis R, Khalil G, Luu M, Jain A, Horvath P, Nakajima R, Palma AM, Hoang A, Razzak E, Garcia N, Alger J, Kalantari M, Silzel EK, Jasinskas A, Zaldivar F, Schubl SD, Felgner PL, Khan S. Analysis and comparison of SARS-CoV-2 variant antibodies and neutralizing activity for 6 months after a booster mRNA vaccine in a healthcare worker population. Front Immunol 2023; 14:1166261. [PMID: 37266444 PMCID: PMC10229859 DOI: 10.3389/fimmu.2023.1166261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023] Open
Abstract
Introduction In the context of recurrent surges of SARS-CoV-2 infections, a detailed characterization of antibody persistence over a 6-month period following vaccine booster dose is necessary to crafting effective public health policies on repeat vaccination. Methods To characterize the SARS-CoV-2 antibody profile of a healthcare worker population over a 6-month period following mRNA vaccination and booster dose. 323 healthcare workers at an academic medical center in Orange County, California who had completed primary vaccination and booster dose against SARS-CoV-2 were recruited for the study. A total of 690 blood specimens over a 6-month period were collected via finger-stick blood and analyzed for the presence of antibodies against 9 SARS-CoV-2 antigens using a coronavirus antigen microarray. Results The primary outcome of this study was the average SARS-CoV-2 antibody level as measured using a novel coronavirus antigen microarray. Additional outcomes measured include levels of antibodies specific to SARS-CoV-2 variants including Delta, Omicron BA.1, and BA.2. We also measured SARS-CoV-2 neutralization capacity for a subset of the population to confirm correlation with antibody levels. Although antibodies against SARS-CoV-2 wane throughout the 6-month period following a booster dose, antibody levels remain higher than pre-boost levels. However, a booster dose of vaccine based on the original Wuhan strain generates approximately 3-fold lower antibody reactivity against Omicron variants BA.1 and BA.2 as compared to the vaccine strain. Despite waning antibody levels, neutralization activity against the vaccine strain is maintained throughout the 6-month period. Discussion In the context of recurrent surges of SARS-CoV-2 infections, our data indicate that breakthrough infections are likely driven by novel variants with different antibody specificity and not by time since last dose of vaccination, indicating that development of vaccinations specific to these novel variants is necessary to prevent future surges of SARS-CoV-2 infections.
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Affiliation(s)
- Sina Hosseinian
- School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Rafael de Assis
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
| | - Ghali Khalil
- School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Madeleine K. Luu
- School of Biological Sciences, University of California Irvine, Irvine, CA, United States
| | - Aarti Jain
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
| | - Peter Horvath
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA, United States
| | - Rie Nakajima
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
| | - Anton M. Palma
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA, United States
| | - Anthony Hoang
- School of Biological Sciences, University of California Irvine, Irvine, CA, United States
| | - Eisa Razzak
- School of Biological Sciences, University of California Irvine, Irvine, CA, United States
| | - Nicholas Garcia
- School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Joshua Alger
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA, United States
| | - Mina Kalantari
- Innovative Health Diagnostics, Irvine, CA, United States
| | - Emily K. Silzel
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
| | - Algis Jasinskas
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
| | - Frank Zaldivar
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
- Department of Pediatrics, University of California Irvine, Irvine, CA, United States
| | - Sebastian D. Schubl
- Department of Surgery, School of Medicine, University of California Irvine, Irvine, CA, United States
| | - Philip L. Felgner
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, United States
| | - Saahir Khan
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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9
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Schubl SD, Figueroa C, Palma AM, de Assis RR, Jain A, Nakajima R, Jasinskas A, Brabender D, Hosseinian S, Naaseh A, Hernandez Dominguez O, Runge A, Skochko S, Chinn J, Kelsey AJ, Lai KT, Zhao W, Horvath P, Tifrea D, Grigorian A, Gonzales A, Adelsohn S, Zaldivar F, Edwards R, Amin AN, Stamos MJ, Barie PS, Felgner PL, Khan S. Risk factors for SARS-CoV-2 seropositivity in a health care worker population during the early pandemic. BMC Infect Dis 2023; 23:330. [PMID: 37194021 PMCID: PMC10186297 DOI: 10.1186/s12879-023-08284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 04/27/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND While others have reported severe acute respiratory syndrome-related coronavirus 2(SARS-CoV-2) seroprevalence studies in health care workers (HCWs), we leverage the use of a highly sensitive coronavirus antigen microarray to identify a group of seropositive health care workers who were missed by daily symptom screening that was instituted prior to any epidemiologically significant local outbreak. Given that most health care facilities rely on daily symptom screening as the primary method to identify SARS-CoV-2 among health care workers, here, we aim to determine how demographic, occupational, and clinical variables influence SARS-CoV-2 seropositivity among health care workers. METHODS We designed a cross-sectional survey of HCWs for SARS-CoV-2 seropositivity conducted from May 15th to June 30th 2020 at a 418-bed academic hospital in Orange County, California. From an eligible population of 5,349 HCWs, study participants were recruited in two ways: an open cohort, and a targeted cohort. The open cohort was open to anyone, whereas the targeted cohort that recruited HCWs previously screened for COVID-19 or work in high-risk units. A total of 1,557 HCWs completed the survey and provided specimens, including 1,044 in the open cohort and 513 in the targeted cohort. Demographic, occupational, and clinical variables were surveyed electronically. SARS-CoV-2 seropositivity was assessed using a coronavirus antigen microarray (CoVAM), which measures antibodies against eleven viral antigens to identify prior infection with 98% specificity and 93% sensitivity. RESULTS Among tested HCWs (n = 1,557), SARS-CoV-2 seropositivity was 10.8%, and risk factors included male gender (OR 1.48, 95% CI 1.05-2.06), exposure to COVID-19 outside of work (2.29, 1.14-4.29), working in food or environmental services (4.85, 1.51-14.85), and working in COVID-19 units (ICU: 2.28, 1.29-3.96; ward: 1.59, 1.01-2.48). Amongst 1,103 HCWs not previously screened, seropositivity was 8.0%, and additional risk factors included younger age (1.57, 1.00-2.45) and working in administration (2.69, 1.10-7.10). CONCLUSION SARS-CoV-2 seropositivity is significantly higher than reported case counts even among HCWs who are meticulously screened. Seropositive HCWs missed by screening were more likely to be younger, work outside direct patient care, or have exposure outside of work.
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Affiliation(s)
- Sebastian D Schubl
- Department of Surgery, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Cesar Figueroa
- Department of Surgery, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Anton M Palma
- Institute for Clinical and Translational Sciences, University of California Irvine, Irvine, CA, USA
| | - Rafael R de Assis
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, USA
| | - Aarti Jain
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, USA
| | - Rie Nakajima
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, USA
| | - Algimantas Jasinskas
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, USA
| | - Danielle Brabender
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sina Hosseinian
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Ariana Naaseh
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | | | - Ava Runge
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Shannon Skochko
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Justine Chinn
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Adam J Kelsey
- Department of Pharmaceutical Sciences, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Kieu T Lai
- Department of Pharmaceutical Sciences, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Weian Zhao
- Department of Pharmaceutical Sciences, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Peter Horvath
- Institute for Clinical and Translational Sciences, University of California Irvine, Irvine, CA, USA
| | - Delia Tifrea
- Department of Pathology, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Areg Grigorian
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Abran Gonzales
- Department of Surgery, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Suzanne Adelsohn
- Department of Pathology, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Frank Zaldivar
- Institute for Clinical and Translational Sciences, University of California Irvine, Irvine, CA, USA
| | - Robert Edwards
- Department of Pathology, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Alpesh N Amin
- Department of Medicine, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Michael J Stamos
- School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Philip L Felgner
- Department of Physiology and Biophysics, University of California Irvine, Irvine, CA, USA
| | - Saahir Khan
- Division of Infectious Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, 1520 San Pablo St., Los Angeles, CA, 90033, USA.
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10
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Tay-Lasso E, Alaniz L, Grant W, Hovis G, Frank M, Kincaid C, Brynn S, Pieracci FM, Nahmias J, Barrios C, Rockne W, Chin T, Swentek L, Schubl SD. Prospective single-center paradigm shift of surgical stabilization of rib fractures with decreased length of stay and operative time with an intrathoracic approach. J Trauma Acute Care Surg 2023; 94:567-572. [PMID: 36301075 DOI: 10.1097/ta.0000000000003811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Intrathoracic surgical stabilization of rib fractures allows for a novel approach to rib fracture repair. This approach can help minimize muscle disruption, which may improve patient recovery compared with traditional extrathoracic plating. We hypothesized patients undergoing intrathoracic plating (ITP) to have a shorter length of stay (LOS) and intensive care unit (ICU) LOS compared with extrathoracic plating (ETP). METHODS A prospective observational paradigm shift study was performed from November 2017 until September 2021. Patients 18 and older who underwent surgical stabilization of rib fractures were included. Patients with ahead Abbreviated Injury Scale score ≥3 were excluded. Patients undergoing ETP (July 2017 to October 2019) were compared with ITP (November 2019 to September 2021) with Pearson χ 2 tests and Mann-Whitney U tests, with the primary outcome being LOS and ICU LOS. RESULTS Ninety-six patients were included, 59 (61%) underwent ETP and 37 (38%) underwent ITP. The most common mechanism of injury was motor vehicle collision (29%) followed by falls (23%). There were no differences between groups in age, comorbidities, insurance, discharge disposition and injury severity score (18 vs. 19, p = 0.89). Intrathoracic plating had a shorter LOS (10 days vs. 8 days, p = 0.04) when compared with ETP but no difference in ICU LOS (4 days vs. 3 days, p = 0.12) and ventilator days. Extrathoracic plating patients more commonly received epidural anesthesia (56% vs. 24%, p < 0.001) and intercostal nerve block (56% vs. 29%, p = 0.01) compared with ITP. However, there was no difference in median morphine equivalents between cohorts. Operative time was shorter for ITP with ETP (279 minutes vs. 188 minutes, p < 0.001) after adjusting for numbers of ribs fixed. CONCLUSION In this single-center study, patients who underwent ITP had a decreased LOS and operative time in comparison to ETP in patients with similar injury severity. Future prospective multicenter research is needed to confirm these findings and may lead to further adoption of this minimally invasive technique. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Erika Tay-Lasso
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, (E.T.-L., L.A., W.G., G.H., M.F., C.K., S.B., J.N., C.B., W.R., T.C., L.S., S.D.S.), University of California, Irvine, Orange, California; and Department of General Surgery, Emergency General Surgery, Trauma and Critical Care (F.M.P.), University of Colorado, School of Medicine, Aurora, Colorado
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11
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Mukherjee K, Schubl SD, Tominaga G, Cantrell S, Kim B, Haines KL, Kaups KL, Barraco R, Staudenmayer K, Knowlton LM, Shiroff AM, Bauman ZM, Brooks SE, Kaafarani H, Crandall M, Nirula R, Agarwal SK, Como JJ, Haut ER, Kasotakis G. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society. J Trauma Acute Care Surg 2023; 94:398-407. [PMID: 36730672 DOI: 10.1097/ta.0000000000003830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level IV.
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Affiliation(s)
- Kaushik Mukherjee
- From the Division of Acute Care Surgery, Loma Linda University Medical Center (K.M.), Loma Linda; University of California Irvine Medical Center (S.D.S.), Irvine; Scripps Memorial La Jolla (G.T.), San Diego, California; Division of Trauma and Critical Care Surgery, Department of Surgery (S.C., K.L.H., S.K.A., G.K.), Duke University Medical Center, Durham, North Carolina; The Mayo Clinic (B.K.), Rochester, Minnesota; University of California San Francisco-Fresno (K.L.K.), Fresno, California; Lehigh Valley Health Network (R.B.), Allentown, Pennsylvania; Stanford University Medical Center (K.S., L.M.K.), Palo Alto, California; University of Pennsylvania Medical Center (A.M.S.), Philadelphia, Pennsylvania; University of Nebraska Medical Center (Z.M.B.), Omaha, Nevada; Texas Tech University Health Sciences Center (S.E.B.), Lubbock, Texas; Massachusetts General Hospital (H.K.), Boston, Massachusetts; University of Florida College of Medicine (M.C.), Jacksonville, Florida; University of Utah Medical Center (R.N.), Salt Lake City, Utah; MetroHealth Cleveland Medical Center (J.J.C.), Cleveland, Ohio; Johns Hopkins Medical Center (E.R.H.), Baltimore, Maryland
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12
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Forrester JD, Bukur M, Dvorak JE, Faliks B, Hindin D, Kartiko S, Kheirbek T, Lin L, Manasa M, Martin TJ, Miskimins R, Patel B, Pieracci FM, Ritter KA, Schubl SD, Tung J, Huston JM. Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection. Surg Infect (Larchmt) 2022; 23:321-331. [PMID: 35522129 DOI: 10.1089/sur.2022.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.
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Affiliation(s)
- Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Marko Bukur
- Division of Acute Care Surgery, Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Justin E Dvorak
- Division of Trauma, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Bradley Faliks
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - David Hindin
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Susan Kartiko
- Center for Trauma and Critical Care, Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tareq Kheirbek
- Department of Surgery, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Leo Lin
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Morgan Manasa
- Department of General Surgery, University of California, Irvine, Irvine, California, USA
| | - Thomas J Martin
- Department of Surgery, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Richard Miskimins
- Division of Acute Care Surgery, Department of Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Bhavik Patel
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Kaitlin A Ritter
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Sebastian D Schubl
- Department of General Surgery, University of California, Irvine, Irvine, California, USA
| | - Jamie Tung
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Jared M Huston
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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13
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Sullivan BG, Grigorian A, Lekawa M, Dolich MO, Schubl SD, Barrios C, Joe VC, Borazjani B, Nahmias J. Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury. Pediatr Emerg Care 2022; 38:e1262-e1265. [PMID: 35482503 DOI: 10.1097/pec.0000000000002588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level. METHODS The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis. RESULTS The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001). CONCLUSIONS In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.
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Affiliation(s)
- Brittany G Sullivan
- From the Department of Surgery, University of California Irvine Medical Center, Orange, CA
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14
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Stopenski S, Binkley J, Schubl SD, Bauman ZM. Rib Fracture Management: A Review of Surgical Stabilization, Regional Analgesia, and Intercostal Nerve Cryoablation. Surgery in Practice and Science 2022. [DOI: 10.1016/j.sipas.2022.100089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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15
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Abstract
PURPOSE OF REVIEW Traumatic chest wall injuries and rib fractures remain a prevalent injury. Despite many advances, these injuries result in high morbidity and mortality. Surgical stabilization of rib fractures (SSRF) is increasing in utilization with expanding indications. Recent studies have demonstrated that many patients may benefit from surgical intervention. RECENT FINDINGS Over the past 20 years the indications and timing of SSRF has evolved. Once reserved mainly for the most extreme of injuries, expanding indications demonstrate that even minimally injured patients may benefit from intervention regarding pain control, respiratory complications, and overall mortality. SUMMARY SSRF has become more prevalent with improving outcomes for patients. Understanding the indications will help expand utilization and improve patient outcomes.
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Affiliation(s)
- Andrew R Doben
- Department of Surgery, Saint Francis Hospital and Medical Center, Hartford, Connecticut
| | - Sebastian D Schubl
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California
| | - Roman Dudaryk
- Department of Anesthesiology, University of Miami, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida, USA
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16
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Mehta VV, Grigorian A, Nahmias JT, Dolich M, Barrios C, Chin TL, Schubl SD, Lekawa M. Blunt Trauma Mortality: Does Trauma Center Level Matter? J Surg Res 2022; 276:76-82. [PMID: 35339783 DOI: 10.1016/j.jss.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/22/2022] [Accepted: 02/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Trauma centers have improved outcomes compared to nontrauma centers when caring for injured patients. A multicenter report found blunt trauma patients treated at American College of Surgeons' Level I trauma centers have improved survival compared to Level II centers. In a subsequent multicenter study, Level II centers had improved survival in all trauma patients. We sought to provide a more granular analysis by stratifying blunt mechanisms-to determine if there was a difference in mortality between Level I and Level II centers. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to an American College of Surgeons' Level I or II trauma center after blunt trauma. A multivariable logistic regression analysis was performed controlling for comorbidities and Trauma and Injury Severity Score. RESULTS From 734,473 patients with blunt trauma, 507,715 (69.1%) were treated at a Level I center and 226,758 (30.9%) at a Level II center. The Level I cohort was younger (median age, 53 versus 58, P = 0.01), with a higher median injury severity score (13 versus 10, P < 0.001) and with more patients presenting after a motor vehicle accident (MVA) (27.9% versus 22.4%, P < 0.001) and lower rates of falls (46.6% versus 54.5%, P < 0.001). After adjusting for covariates, there was no difference in mortality between Level I and Level II centers (P > 0.05). When stratifying by mechanisms, Level I centers had a decreased associated mortality for MVA (odds ratio = 0.94, CI: 0.88-0.99, P = 0.04) and bicycle accidents (odds ratio = 0.77, CI: 0.74-0.03, P = 0.01) but no difference in falls or pedestrians struck (P > 0.05). CONCLUSIONS Overall, blunt trauma patients presenting to a Level I center have no difference in mortality compared to a Level II center. However, when stratified by mechanism, those involved in MVA or bicycle accidents have a decreased associated risk of mortality. Future prospective studies examining variations in practice to account for these differences are warranted.
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Affiliation(s)
- Vishes V Mehta
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California.
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
| | - Jeffry T Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
| | - Matthew Dolich
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
| | - Cristobal Barrios
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
| | - Theresa L Chin
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange County, California
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17
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Christian AB, Grigorian A, Mo J, Yeates EO, Dolich M, Chin TL, Schubl SD, Kuza CM, Lekawa M, Nahmias J. Comparative Outcomes for Trauma Patients in Prison and the General Population. Am Surg 2022; 88:1954-1961. [PMID: 35282696 DOI: 10.1177/00031348221078984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma. METHODS The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality-the primary outcome. RESULTS From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409). DISCUSSION Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.
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Affiliation(s)
- A B Christian
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - A Grigorian
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - J Mo
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - E O Yeates
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - M Dolich
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - T L Chin
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - S D Schubl
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - C M Kuza
- Department of Anesthesia, 12223University of Southern California, Los Angeles, CA, USA
| | - M Lekawa
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
| | - J Nahmias
- Department of Surgery, 8788University of California Irvine, Orange, CA, USA
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18
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Delaplain PT, Kaafarani HMA, Benedict LAO, Guidry CA, Kim D, Loor MM, Machado-Aranda D, Mele TS, Mendoza AE, Morris-Stiff G, Rattan R, Upperman JS, Barie PS, Schubl SD. Different Surgeon, Different Duration: Lack of Consensus on the Appropriate Duration of Antimicrobial Prophylaxis and Therapy in Surgical Practice. Surg Infect (Larchmt) 2022; 23:232-247. [PMID: 35196154 DOI: 10.1089/sur.2021.323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background: The principles of antimicrobial stewardship promote the appropriate prescribing of agents with respect to efficacy, safety, duration, and cost. Antibiotic resistance often results from inappropriate use (e.g., indication, selection, duration). We evaluated practice variability in duration of antimicrobials in surgical infection treatment (Rx) or prophylaxis (Px). Hypothesis: There is lack of consensus regarding the duration of antibiotic Px and Rx for many common indications. Methods: A survey was distributed to the Surgical Infection Society (SIS) regarding the use of antimicrobial agents for a variety of scenarios. Standard descriptive statistics were used to compare survey responses. Heterogeneity among question responses were compared using the Shannon Index, expressed as natural units (nats). Results: Sixty-three SIS members responded, most of whom (67%) have held a leadership position within the SIS or contributed as an annual meeting moderator or discussant; 76% have been in practice for more than five years. Regarding peri-operative Px, more than 80% agreed that a single dose is adequate for most indications, with the exceptions of gangrenous cholecystitis (40% single dose, 38% pre-operative +24 hours) and inguinal hernia repair requiring a bowel resection (70% single dose). There was more variability regarding the use of antibiotic Px for various bedside procedures with respondents split between none needed (range, 27%-66%) versus a single dose (range, 31%-67%). Opinions regarding the duration of antimicrobial Rx for hospitalized patients who have undergone a source control operation or procedure varied widely based on indication. Only two of 20 indications achieved more than 60% consensus despite available class 1 evidence: seven days for ventilator-associated pneumonia (77%), and four plus one days for perforated appendicitis (62%). Conclusions: Except for peri-operative antibiotic Px, there is little consensus regarding antibiotic duration among surgical infection experts, despite class 1 evidence and several available guidelines. This highlights the need for further high-level research and better dissemination of guidelines.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - L Andrew O Benedict
- Critical Care and Acute Care Surgery, St. Luke's Hospital, Kansas City, Missouri, USA
| | - Christopher A Guidry
- Trauma/Critical & Acute Care Surgery Division, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dennis Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Department of Surgery, Michigan Medicine and Veteran's Affairs Healthcare System, Ann Arbor, Michigan, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio. USA
| | - Rishi Rattan
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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19
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Hasjim BJ, Grigorian A, Schubl SD, Lekawa M, Kim D, Bernal N, Nahmias J. Helmets Protect Pediatric Bicyclists From Head Injury and Do Not Increase Risk of Cervical Spine Injury. Pediatr Emerg Care 2022; 38:e360-e364. [PMID: 33181791 DOI: 10.1097/pec.0000000000002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs). METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age <16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2. RESULTS From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P < 0.001), Hispanic (17.5% vs 9.3%, P < 0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P < 0.001). Both groups had similar rates of complications and mortality (P > 0.05). The associated risk of a serious head (odds ratio = 3.17, P < 0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P > 0.05). CONCLUSIONS Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.
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Affiliation(s)
- Bima J Hasjim
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine
| | - Areg Grigorian
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine
| | - Sebastian D Schubl
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine
| | - Michael Lekawa
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine
| | - Dennis Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, LA County Harbor-UCLA Medical Center, Torrance, CA
| | - Nicole Bernal
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine
| | - Jeffry Nahmias
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine
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20
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Duffens A, Grigorian A, de Virgilio C, Chin T, Kim D, Lekawa M, Schubl SD, Nahmias J. Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries. Pediatr Emerg Care 2022; 38:e287-e291. [PMID: 33105460 DOI: 10.1097/pec.0000000000002263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Helicopter emergency medical services (HEMS) are used for 16% of pediatric trauma. National HEMS guidelines advised that triage criteria be standardized for pediatric patients. A national report found pediatric HEMS associated with decreased mortality compared with ground emergency medical services (GEMS) but did not control for transport time. We hypothesized that the rate of HEMS has decreased nationally and the mortality risk for HEMS to be similar when adjusting for transport time compared with GEMS. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years transported by HEMS or GEMS. A multivariable logistic regression was used. RESULTS From 25,647 patients, 4527 (17.7%) underwent HEMS. The rate of HEMS from scene decreased from 21.2% in 2014 to 18.2% in 2016. The rate of HEMS for minor trauma (Injury Severity Score <15) decreased from 14.9% in 2014 to 13.5% in 2016 and major trauma (Injury Severity Score > 15) from 38.4% in 2014 to 35.9% in 2016. After controlling for predictors of mortality and transport time, HEMS was associated with decreased risk of mortality for only those with major injuries transferred from scene (odds ratio, 0.48; 95% confidence interval, 0.26-0.88; P = 0.01) compared with GEMS. CONCLUSIONS The rate of HEMS in pediatric trauma has decreased. However, there is room for improvement as 14% of those with minor trauma are transported by HEMS. Given the similar risk of mortality compared with GEMS, further development of guidelines that avoid the unnecessary use of HEMS appears warranted. However, utilization of HEMS for transport of pediatric major trauma should continue.
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Affiliation(s)
- Ali Duffens
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Areg Grigorian
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | | | - Theresa Chin
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Dennis Kim
- Department of Surgery, Harbor-University of California, Los Angeles, Torrance, CA
| | - Michael Lekawa
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Sebastian D Schubl
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Jeffry Nahmias
- From the Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
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21
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Gohil SK, Quan KA, Madey KM, King-Adelsohn S, Tjoa T, Tifrea D, Crews BO, Monuki ES, Khan S, Schubl SD, Bittencourt CE, Detweiler N, Chang W, Willis L, Khusbu U, Saturno A, Rezk SA, Figueroa C, Jain A, Assis R, Felgner P, Edwards R, Hsieh L, Forthal D, Wilson WC, Stamos MJ, Huang SS. Infection prevention strategies are highly protective in COVID-19 units while main risks to healthcare professionals come from coworkers and the community. Antimicrob Resist Infect Control 2021; 10:163. [PMID: 34809702 PMCID: PMC8608236 DOI: 10.1186/s13756-021-01031-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 10/27/2021] [Indexed: 11/19/2022] Open
Abstract
Background Early evaluations of healthcare professional (HCP) COVID-19 risk occurred during insufficient personal protective equipment and disproportionate testing, contributing to perceptions of high patient-care related HCP risk. We evaluated HCP COVID-19 seropositivity after accounting for community factors and coworker outbreaks. Methods Prior to universal masking, we conducted a single-center retrospective cohort plus cross-sectional study. All HCP (1) seen by Occupational Health for COVID-like symptoms (regardless of test result) or assigned to (2) dedicated COVID-19 units, (3) units with a COVID-19 HCP outbreak, or (4) control units from 01/01/2020 to 04/15/2020 were offered serologic testing by an FDA-authorized assay plus a research assay against 67 respiratory viruses, including 11 SARS-CoV-2 antigens. Multivariable models assessed the association of demographics, job role, comorbidities, care of a COVID-19 patient, and geocoded socioeconomic status with positive serology. Results Of 654 participants, 87 (13.3%) were seropositive; among these 60.8% (N = 52) had never cared for a COVID-19 patient. Being male (OR 1.79, CI 1.05–3.04, p = 0.03), working in a unit with a HCP-outbreak unit (OR 2.21, CI 1.28–3.81, p < 0.01), living in a community with low owner-occupied housing (OR = 1.63, CI = 1.00–2.64, p = 0.05), and ethnically Latino (OR 2.10, CI 1.12–3.96, p = 0.02) were positively-associated with COVID-19 seropositivity, while working in dedicated COVID-19 units was negatively-associated (OR 0.53, CI = 0.30–0.94, p = 0.03). The research assay identified 25 additional seropositive individuals (78 [12%] vs. 53 [8%], p < 0.01). Conclusions Prior to universal masking, HCP COVID-19 risk was dominated by workplace and community exposures while working in a dedicated COVID-19 unit was protective, suggesting that infection prevention protocols prevent patient-to-HCP transmission. Article summary Prior to universal masking, HCP COVID-19 risk was dominated by workplace and community exposures while working in a dedicated COVID-19 unit was protective, suggesting that infection prevention protocols prevent patient-to-HCP transmission. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-01031-5.
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Affiliation(s)
- Shruti K Gohil
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA. .,Division of Infectious Diseases, Department of Medicine, Irvine School of Medicine, University of California, 100 Theory, Suite 120, Irvine, CA, 92617, USA.
| | - Kathleen A Quan
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA
| | - Keith M Madey
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA
| | | | - Tom Tjoa
- Division of Infectious Diseases, Department of Medicine, Irvine School of Medicine, University of California, 100 Theory, Suite 120, Irvine, CA, 92617, USA
| | - Delia Tifrea
- Pathology and Laboratory Medicine, UCI Health, Newport Beach, USA
| | - Bridgit O Crews
- Pathology and Laboratory Medicine, UCI Health, Newport Beach, USA
| | - Edwin S Monuki
- Pathology and Laboratory Medicine, UCI Health, Newport Beach, USA
| | - Saahir Khan
- Division of Infectious Diseases, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Sebastian D Schubl
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, USA
| | | | - Neil Detweiler
- Pathology and Laboratory Medicine, UCI Health, Newport Beach, USA
| | - Wayne Chang
- Division of Occupational and Environmental Medicine, Irvine School of Medicine, University of California, Irvine, USA
| | - Lynn Willis
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA
| | - Usme Khusbu
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA
| | - Antonella Saturno
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA
| | - Sherif A Rezk
- Pathology and Laboratory Medicine, UCI Health, Newport Beach, USA
| | - Cesar Figueroa
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, USA
| | - Aarti Jain
- Department of Physiology and Biophysics, University of California, Irvine, USA
| | - Rafael Assis
- Department of Physiology and Biophysics, University of California, Irvine, USA
| | - Philip Felgner
- Department of Physiology and Biophysics, University of California, Irvine, USA
| | - Robert Edwards
- Pathology and Laboratory Medicine, UCI Health, Newport Beach, USA
| | - Lanny Hsieh
- Division of Infectious Diseases, Department of Medicine, Irvine School of Medicine, University of California, 100 Theory, Suite 120, Irvine, CA, 92617, USA
| | - Donald Forthal
- Division of Infectious Diseases, Department of Medicine, Irvine School of Medicine, University of California, 100 Theory, Suite 120, Irvine, CA, 92617, USA
| | | | - Michael J Stamos
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, USA
| | - Susan S Huang
- Epidemiology and Infection Prevention Program, Irvine Health (UC Irvine Health), University of California, Irvine, USA.,Division of Infectious Diseases, Department of Medicine, Irvine School of Medicine, University of California, 100 Theory, Suite 120, Irvine, CA, 92617, USA
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22
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Yeates EO, Grigorian A, Inaba K, Dolich M, Schubl SD, Lekawa M, Schellenberg M, de Virgilio M, Nahmias J. Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool. J Surg Res 2021; 270:321-326. [PMID: 34731729 DOI: 10.1016/j.jss.2021.09.034] [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] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/14/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple tools predicting massive transfusion (MT) in trauma have been developed but utilize variables that are not immediately available. Additionally, they only differentiate blunt from penetrating trauma and do not account for the large range of blunt mechanisms and their difference in force. We aimed to develop a Blunt trauma Massive Transfusion (B-MaT) score that accounts for high-risk blunt mechanisms and predicts MT needs in blunt trauma patients (BTPs) prior to arrival. MATERIALS AND METHODS The adult 2017 Trauma Quality Improvement Program database was used to identify BTPs who were divided into 2 sets at random (derivation/validation). First, multiple logistic regression models were created to determine risk factors of MT (≥6 units of PRBCs within 4-hours or ≥10 units within 24-hours). Next, the weighted average and relative impact of each independent predictor was used to derive a B-MaT score. Finally, the area under the receiver-operating curve (AROC) was calculated. RESULTS Of 172,423 patients in the derivation-set, 1,160 (0.7%) required MT. Heart rate ≥ 120bpm, systolic blood pressure ≤ 90mmHg, and high-risk blunt mechanisms were identified as independent predictors for MT. B-MaT scores were derived ranging from 0 -9, with scores of 6, 7, and 9 yielding a MT rate of 11.7%, 19.4%, and 32.4%, respectively. The AROC was 0.86. The validation-set had an AROC of 0.85. CONCLUSIONS B-MaT is a novel scoring tool that predicts need for MT in BTPs and can be calculated prior to arrival. B-MaT warrants prospective validation to confirm its accuracy and assess its ability to improve patient outcomes and blood product allocation.
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Affiliation(s)
- Eric O Yeates
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Areg Grigorian
- Department of Surgery, University of California Irvine (UCI), Orange, California; Department of Surgery, University of Southern California (USC), Los Angeles, California
| | - Kenji Inaba
- Department of Surgery, University of Southern California (USC), Los Angeles, California
| | - Matthew Dolich
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Sebastian D Schubl
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Michael Lekawa
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California (USC), Los Angeles, California
| | | | - Jeffry Nahmias
- Department of Surgery, University of California Irvine (UCI), Orange, California.
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23
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Delaplain PT, Kaafarani HMA, Benedict LAO, Guidry CA, Kim D, Loor MM, Machado-Aranda D, Mele TS, Mendoza AE, Morris-Stiff G, Rattan R, Upperman JS, Barie PS, Schubl SD. Surgical Infections and the Future of Research: Re-Defining the Research Agenda for the Surgical Infection Society. Surg Infect (Larchmt) 2021; 22:1014-1020. [PMID: 34357820 DOI: 10.1089/sur.2021.176] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Infections represent a major component of surgical practice. Risk mitigation, seeking eradication and optimal patient outcomes, require a concerted, multifocal effort to understand disease and microbiology, prevent infections, and treat them. The present study was undertaken to re-define the Surgical Infection Society (SIS) research agenda for the next decade. Hypothesis: We utilized the expertise of the SIS membership to identify research questions regarding surgical infections, hypothesizing that consensus among participants could be used to re-define the future research agenda. Methods: Members of the SIS were surveyed using a modified Delphi. The three rounds of the survey were targeted at: question generation; question ranking; and reaching consensus. Each of the 15 questions to emerge was evaluated according to level of consensus, feasibility, and data availability. Results: One hundred twenty-four participants contributed. Initially, 226 questions were generated that were condensed to 35 unique questions for consideration in the subsequent two rounds. The 35 questions encompassed several research themes, with antibiotic prophylaxis (n = 8), prevention of surgical site infections (SSIs; n = 6), and improved diagnostics (n = 5) being most common. Standard deviation of importance scores was inversely proportional to the question rank, indicating greater consensus among higher ranking questions. All 15 questions had a feasibility score of greater than three (five-point Likert scale), and the majority (12/15) had a mean data availability score of less than three. In the final round of the survey, the top three topics for further research surrounded non-antimicrobial treatments, optimal treatment duration for bacteremia, and treatment duration for necrotizing soft tissue infections. Conclusions: Using a modified Delphi process, 15 research questions addressing surgical infections were identified. Such questions can assist the SIS and the SIS Foundation for Research and Education in prioritizing and enabling research efforts, and development of a strategic research plan for the next decade.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - L Andrew O Benedict
- Trauma, Critical Care and Acute Care Surgery, St. Luke's Hospital, Kansas City, Missouri, USA
| | - Christopher A Guidry
- Trauma/Critical & Acute Care Surgery Division, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dennis Kim
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Department of Surgery, Michigan Medicine and Veteran's Administration Healthcare System, Ann Arbor, Michigan, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Dept of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida, USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, Orange, California, USA
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24
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Prakash S, Srivastava R, Coulon PG, Dhanushkodi NR, Chentoufi AA, Tifrea DF, Edwards RA, Figueroa CJ, Schubl SD, Hsieh L, Buchmeier MJ, Bouziane M, Nesburn AB, Kuppermann BD, BenMohamed L. Genome-Wide B Cell, CD4 +, and CD8 + T Cell Epitopes That Are Highly Conserved between Human and Animal Coronaviruses, Identified from SARS-CoV-2 as Targets for Preemptive Pan-Coronavirus Vaccines. J Immunol 2021; 206:2566-2582. [PMID: 33911008 DOI: 10.4049/jimmunol.2001438] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/16/2021] [Indexed: 02/06/2023]
Abstract
Over the last two decades, there have been three deadly human outbreaks of coronaviruses (CoVs) caused by SARS-CoV, MERS-CoV, and SARS-CoV-2, which has caused the current COVID-19 global pandemic. All three deadly CoVs originated from bats and transmitted to humans via various intermediate animal reservoirs. It remains highly possible that other global COVID pandemics will emerge in the coming years caused by yet another spillover of a bat-derived SARS-like coronavirus (SL-CoV) into humans. Determining the Ag and the human B cells, CD4+ and CD8+ T cell epitope landscapes that are conserved among human and animal coronaviruses should inform in the development of future pan-coronavirus vaccines. In the current study, using several immunoinformatics and sequence alignment approaches, we identified several human B cell and CD4+ and CD8+ T cell epitopes that are highly conserved in 1) greater than 81,000 SARS-CoV-2 genome sequences identified in 190 countries on six continents; 2) six circulating CoVs that caused previous human outbreaks of the common cold; 3) nine SL-CoVs isolated from bats; 4) nine SL-CoV isolated from pangolins; 5) three SL-CoVs isolated from civet cats; and 6) four MERS strains isolated from camels. Furthermore, the identified epitopes: 1) recalled B cells and CD4+ and CD8+ T cells from both COVID-19 patients and healthy individuals who were never exposed to SARS-CoV-2, and 2) induced strong B cell and T cell responses in humanized HLA-DR1/HLA-A*02:01 double-transgenic mice. The findings pave the way to develop a preemptive multiepitope pan-coronavirus vaccine to protect against past, current, and future outbreaks.
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Affiliation(s)
- Swayam Prakash
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Ruchi Srivastava
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Pierre-Gregoire Coulon
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Nisha R Dhanushkodi
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Aziz A Chentoufi
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Delia F Tifrea
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California Irvine, Irvine, CA
| | - Robert A Edwards
- Department of Pathology and Laboratory Medicine, School of Medicine, University of California Irvine, Irvine, CA
| | - Cesar J Figueroa
- Division of Trauma, Burns, Critical Care, and Acute Care Surgery, Department of Surgery, School of Medicine, University of California Irvine, Irvine, CA
| | - Sebastian D Schubl
- Division of Trauma, Burns, Critical Care, and Acute Care Surgery, Department of Surgery, School of Medicine, University of California Irvine, Irvine, CA
| | - Lanny Hsieh
- Division of Infectious Diseases and Hospitalist Program, Department of Medicine, School of Medicine, University of California Irvine, Irvine, CA
| | - Michael J Buchmeier
- Center for Virus Research, Division of Infectious Disease, School of Medicine, University of California Irvine, Irvine, CA
| | | | - Anthony B Nesburn
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Baruch D Kuppermann
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA
| | - Lbachir BenMohamed
- Laboratory of Cellular and Molecular Immunology, Gavin Herbert Eye Institute, School of Medicine, University of California Irvine, Irvine, CA; .,Center for Virus Research, Division of Infectious Disease, School of Medicine, University of California Irvine, Irvine, CA.,Institute for Immunology, School of Medicine, University of California Irvine, Irvine, CA
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25
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Barie PS, Ho VP, Hunter CJ, Kaufman EJ, Narayan M, Pieracci FM, Schubl SD, Heffernan DS, Huston JM. Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic. Surg Infect (Larchmt) 2021; 22:818-827. [PMID: 33635145 DOI: 10.1089/sur.2020.421] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/13/2022] Open
Abstract
Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. Results: The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA.,Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Catherine J Hunter
- Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Elinore J Kaufman
- Department of Surgery, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mayur Narayan
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Fredric M Pieracci
- Department of Surgery, DenverHealth Medical Center, University of Colorado Anschutz School of Medicine, Denver, Colorado, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Daithi S Heffernan
- Department of Surgery, Providence Veterans Affairs Medical Center, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jared M Huston
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.,Department of Science Education, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Yeates EO, Grigorian A, Nahmias J, Dolich M, Lekawa M, Qazi A, Kong A, Schubl SD. Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality. J Surg Res 2021; 262:197-202. [PMID: 33607414 DOI: 10.1016/j.jss.2021.01.016] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/28/2020] [Accepted: 01/18/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF. MATERIALS AND METHODS The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed. RESULTS From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF. CONCLUSIONS The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.
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Affiliation(s)
- Eric O Yeates
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California.
| | - Areg Grigorian
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
| | - Jeffry Nahmias
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
| | - Matthew Dolich
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
| | - Michael Lekawa
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
| | - Alliya Qazi
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
| | - Allen Kong
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
| | - Sebastian D Schubl
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California
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Mele TS, Kaafarani HMA, Guidry CA, Loor MM, Machado-Aranda D, Mendoza AE, Morris-Stiff G, Rattan R, Schubl SD, Barie PS. Surgical Infection Society Research Priorities: A Narrative Review of Fourteen Years of Progress. Surg Infect (Larchmt) 2020; 22:568-582. [PMID: 33275862 DOI: 10.1089/sur.2020.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/12/2022] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) utilized a modified Delphi approach to define 15 specific priority research questions that remained unanswered in the field of surgical infections. The aim of the current study was to evaluate the scientific progress achieved during the ensuing period in answering each of the 15 research questions and to determine if additional research in these fields is warranted. Methods: For each of the questions, a literature search using the National Center for Biotechnology Information (NCBI) was performed by the Scientific Studies Committee of the SIS to identify studies that attempted to address each of the defined questions. This literature was analyzed and summarized. The data on each question were evaluated by a surgical infections expert to determine if the question was answered definitively or remains unanswered. Results: All 15 priority research questions were studied in the last 14 years; six questions (40%) were definitively answered and 9 questions (60%) remain unanswered in whole or in part, mainly because of the low quality of the studies available on this topic. Several of the 9 unanswered questions were deemed to remain research priorities in 2020 and warrant further investigation. These included, for example, the role of empiric antimicrobial agents in nosocomial infections, the use of inotropes/vasopressors versus volume loading to raise the mean arterial pressure, and the role of increased antimicrobial dosing and frequency in the obese patient. Conclusions: Several surgical infection-related research questions prioritized in 2006 remain unanswered. Further high-quality research is required to provide a definitive answer to many of these priority knowledge gaps. An updated research agenda by the SIS is warranted at this time to define research priorities for the future.
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Affiliation(s)
- Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Division of Acute Care Surgery, Michigan Medicine and Ann Arbor Veterans' Affairs Health System, Ann Arbor, Michigan, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- Division of Trauma Surgery and Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, California, USA
| | - Philip S Barie
- Division of Trauma Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Tay E, Grigorian A, Schubl SD, Lekawa M, de Virgilio C, Scolaro J, Kabutey NK, Nahmias J. Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures. Am Surg 2020; 87:747-752. [PMID: 33169619 DOI: 10.1177/0003134820952832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. RESULTS From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001). CONCLUSION The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.
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Affiliation(s)
- Erika Tay
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, CA, USA
| | - Sebastian D Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, CA, USA
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, CA, USA
| | | | - John Scolaro
- Department of Orthopedics, University of California, CA, USA
| | - Nii-Kabu Kabutey
- Department of Surgery, Division of Vascular Surgery, University of California, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, CA, USA
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Prakash S, Srivastava R, Coulon PG, Dhanushkodi NR, Chentoufi AA, Tifrea DF, Edwards RA, Figueroa CJ, Schubl SD, Hsieh L, Buchmeier MJ, Bouziane M, Nesburn AB, Kuppermann BD, BenMohamed L. Genome-Wide Asymptomatic B-Cell, CD4 + and CD8 + T-Cell Epitopes, that are Highly Conserved Between Human and Animal Coronaviruses, Identified from SARS-CoV-2 as Immune Targets for Pre-Emptive Pan-Coronavirus Vaccines. bioRxiv 2020. [PMID: 33024971 DOI: 10.1101/2020.09.27.316018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Over the last two decades, there have been three deadly human outbreaks of Coronaviruses (CoVs) caused by emerging zoonotic CoVs: SARS-CoV, MERS-CoV, and the latest highly transmissible and deadly SARS-CoV-2, which has caused the current COVID-19 global pandemic. All three deadly CoVs originated from bats, the natural hosts, and transmitted to humans via various intermediate animal reservoirs. Because there is currently no universal pan-Coronavirus vaccine available, two worst-case scenarios remain highly possible: (1) SARS-CoV-2 mutates and transforms into a seasonal "flu-like" global pandemic; and/or (2) Other global COVID-like pandemics will emerge in the coming years, caused by yet another spillover of an unknown zoonotic bat-derived SARS-like Coronavirus (SL-CoV) into an unvaccinated human population. Determining the antigen and epitope landscapes that are conserved among human and animal Coronaviruses as well as the repertoire, phenotype and function of B cells and CD4 + and CD8 + T cells that correlate with resistance seen in asymptomatic COVID-19 patients should inform in the development of pan-Coronavirus vaccines 1 . In the present study, using several immuno-informatics and sequence alignment approaches, we identified several human B-cell, CD4 + and CD8 + T cell epitopes that are highly conserved in: ( i ) greater than 81,000 SARS-CoV-2 human strains identified to date in 190 countries on six continents; ( ii ) six circulating CoVs that caused previous human outbreaks of the "Common Cold"; ( iii ) five SL-CoVs isolated from bats; ( iv ) five SL-CoV isolated from pangolins; ( v ) three SL-CoVs isolated from Civet Cats; and ( vi ) four MERS strains isolated from camels. Furthermore, we identified cross-reactive asymptomatic epitopes that: ( i ) recalled B cell, CD4 + and CD8 + T cell responses from both asymptomatic COVID-19 patients and healthy individuals who were never exposed to SARS-CoV-2; and ( ii ) induced strong B cell and T cell responses in "humanized" Human Leukocyte Antigen (HLA)-DR/HLA-A*02:01 double transgenic mice. The findings herein pave the way to develop a pre-emptive multi-epitope pan-Coronavirus vaccine to protect against past, current, and potential future outbreaks.
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Rockne WY, Grigorian A, Christian A, Nahmias J, Lekawa M, Dolich M, Chin T, Schubl SD. No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture. Am J Surg 2020; 221:1076-1081. [PMID: 33010876 DOI: 10.1016/j.amjsurg.2020.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs. METHODS The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed. RESULTS 14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529). CONCLUSIONS Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.
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Affiliation(s)
- Wendy Y Rockne
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Ashton Christian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Michael Lekawa
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Matthew Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Theresa Chin
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - Sebastian D Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
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Chaudhry HH, Grigorian A, Lekawa ME, Dolich MO, Nguyen NT, Smith BR, Schubl SD, Nahmias JT. Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma. Am Surg 2020; 86:493-498. [PMID: 32684037 DOI: 10.1177/0003134820919724] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups. RESULTS From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, P < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, P = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications (P > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, P = .01), compared to LDR. There were no deaths in either group. CONCLUSIONS Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.
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Affiliation(s)
- Haris H Chaudhry
- 23331 Loma Linda University Adventist Health Sciences Center, Loma Linda, CA, USA
| | | | | | | | - Ninh T Nguyen
- 8788 University of California Irvine, Orange, CA, USA
| | - Brian R Smith
- 8788 University of California Irvine, Orange, CA, USA
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Abate M, Grigorian A, Nahmias J, Schubl SD, Kuncir E, Lekawa M. Differing Risk of Mortality in Trauma Patients With Stab Wounds to the Torso: Treating Hospital Matters. JAMA Surg 2020; 154:1070-1072. [PMID: 31433445 DOI: 10.1001/jamasurg.2019.2522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Miseker Abate
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange.,now with NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Eric Kuncir
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange
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Delaplain PT, Dosch AR, Kaafarani HMA, Barie PS, Schubl SD. Revisiting the Surgical Infection Society Delphi Analysis of the Research Agenda in Surgical Infections: Advancements and Unanswered Questions. Surg Infect (Larchmt) 2020; 22:258-265. [PMID: 32589512 DOI: 10.1089/sur.2020.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) used a modified Delphi process to enlist SIS member-experts to identify 15 research priorities in the field of surgical infectious diseases; it was intended to serve as a research road map for the next one to two decades. We sought to evaluate the progress made in each of these priority areas. Hypothesis: We examined the progress achieved with respect to the 15 research areas identified by the Delphi process at that time, hypothesizing that advances in knowledge would be achieved in most domains, if not all. Methods: Surgical Infection Society members were surveyed to determine whether each priority area question had been satisfactorily answered in the last 14 years; to assess the quality of evidence answering each question (1-3 scale); and to delineate whether there is a current unmet need for continued research in each area. Randomized controlled trials (RCTs) regarding these initiatives were also identified via literature search and their citations in the literature were tabulated. Results: Sixty-six members of the SIS responded to the survey. Thirteen of 15 research priority areas saw an increase in data perceived to be available as adjudged by experts, as well an increase in the number of RCTs addressing that topic. However, there were only six questions that were deemed by experts to be answered sufficiently, primarily regarding antibiotic duration for certain conditions and the impact of glycemic control on infection. The questions that remained unanswered related to nosocomial infections, sepsis/septic shock, prevention of SSI, and antimicrobial pharmacokinetics. For a majority of the questions that experts believed were not answered sufficiently (8/9), respondents opined that continued research into these areas was warranted. Conclusion: Whereas 40% (6/15) of the research questions prioritized by the SIS in 2006 were answered to the satisfaction of member-experts, there are many questions that remain unanswered despite an increase of available data. Revisiting these research priorities highlights advancements made in the field of surgical infections, but also helps identify the areas that would benefit from continued study. That a majority of questions remain unanswered underscores an opportunity for member-experts to collaborate on SIS-managed or -endorsed RCTs.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, Irvine, California, USA
| | - Austin R Dosch
- Department of Surgery, University of California, Irvine Medical Center, Irvine, California, USA
| | - Haytham M A Kaafarani
- Harvard Medical School & Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine Medical Center, Irvine, California, USA
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Yeates EO, Grigorian A, Schubl SD, Kuza CM, Joe V, Lekawa M, Borazjani B, Nahmias J. Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers. Am Surg 2020. [DOI: 10.1177/000313482008600433] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010–2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE ( P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.
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Affiliation(s)
- Eric O. Yeates
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Areg Grigorian
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Sebastian D. Schubl
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Catherine M. Kuza
- Department of Anesthesiology, University of Southern California Medical Center, Los Angeles, California
| | - Victor Joe
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Michael Lekawa
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Boris Borazjani
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Jeffry Nahmias
- Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
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Fan SM, Grigorian A, Smith BR, Kuza CM, Lekawa M, Schubl SD, Nguyen NT, Nahmias J. Geriatric patients undergoing appendectomy have increased risk of intraoperative perforation and/or abscess. Surgery 2020; 168:322-327. [PMID: 32461001 DOI: 10.1016/j.surg.2020.04.019] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/08/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The number of geriatric patients is expected to grow 3-fold over the next 30 years, and as many as 50% of the surgeries done in the United States may occur in geriatric patients. Geriatric patients often have increased comorbidities and more often present in a delayed manner for acute appendicitis. The aim of this study was to evaluate outcomes between geriatric patients and younger patients undergoing appendectomy, hypothesizing that geriatric patients will have a higher risk of abscess and/or perforation, conversion to open surgery, postoperative intra-abdominal abscess, and 30-day readmission. METHODS The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Procedure Targeted Appendectomy database was queried for patients with preoperative image findings consistent with acute appendicitis. Geriatric patients (age ≥65 years old) were compared with younger patients (age <65 years old). A multivariable logistic regression model was used for analysis. RESULTS From 21,586 patients undergoing appendectomy, 2,060 (9.5%) were geriatric patients. Compared with the younger cohort, geriatric patients were less likely to have leukocytosis (59.0% vs 65.8%, P < .001) and more likely to have a tumor and/or malignancy involving the appendix on final pathology (2.0% vs 0.8%, P < .001), an unplanned laparoscopic conversion to open surgery (4.2% vs 1.5%, P < .001), and 30-day readmission (7.0% vs 3.3%, P < .001). Geriatric patients had a longer median length of stay (2 vs 1 days, P < .001) and higher mortality rate (0.5% vs <0.1%, P < .001). After adjusting for covariates, there was an increased associated risk of intraoperative abscess and/or perforation (odds ratio 2.23, 2.01-2.48, P < .001) and postoperative intra-abdominal abscess (odds ratio 1.43, 1.12-1.83, P = .005) but no difference in associated risk for mortality (odds ratio 2.56, 0.79-8.25, P = .116), compared with the younger cohort. CONCLUSION Nearly 10% of laparoscopic appendectomies are done on geriatric patients with geriatric patients having a higher rate of conversion to open surgery and tumor and/or malignancy on final pathology. Geriatric patients have an associated increased risk of intraoperative perforation and/or abscess and postoperative intra-abdominal abscess but have similar risk for mortality compared with nongeriatric patients undergoing laparoscopic appendectomy.
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Affiliation(s)
- Shannon M Fan
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Brian R Smith
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Catherine M Kuza
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine, Orange, CA
| | | | - Ninh T Nguyen
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA.
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Dominguez OH, Grigorian A, Lekawa M, Schubl SD, Chin T, Kim DY, de Virgilio C, Nahmias J. Helicopter Transport Has Decreased Over Time and Transport From Scene or Hospital Matters. Air Med J 2020; 39:283-290. [PMID: 32690305 DOI: 10.1016/j.amj.2020.04.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Several reports have found helicopter emergency medical services (HEMS) to be associated with a lower risk of mortality compared with ground emergency medical services (GEMS); however, most studies did not control for transport time or stratify interfacility versus scene. We hypothesize that the HEMS transport rate has decreased nationally and that the risk of mortality for HEMS is similar to GEMS when adjusting for transport time and stratifying by scene or interfacility. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for adult patients transported by HEMS or GEMS. Multivariable logistic regression was used. RESULTS The HEMS transport rate decreased by 38.2% from 2010 to 2016 (P < .001). After controlling for known predictors of mortality and transport time, HEMS was associated with a decreased risk of mortality compared with GEMS for adult trauma patient transports (odds ratio = 0.74; 95% confidence interval [CI], 0.71-0.77; P < .001). Compared with GEMS, HEMS transports from the scene were associated with a decreased risk of mortality (OR = 0.63; 95% CI, 0.60-0.66; P < .001), whereas HEMS interfacility transfer was associated with an increased risk of mortality (OR = 1.22; 95% CI, 1.14-1.31; P < .001). CONCLUSION The rate of HEMS transports in trauma has decreased by nearly 40% over the past 7 years. Our results suggest that HEMS use for scene transports is beneficial for the survival of trauma patients.
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Affiliation(s)
- Oscar Hernandez Dominguez
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA.
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA
| | - Sebastian D Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA
| | - Theresa Chin
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA
| | - Dennis Y Kim
- Department of Surgery, University of California, Harbor-Los Angeles, Los Angeles, CA
| | - Christian de Virgilio
- Department of Surgery, University of California, Harbor-Los Angeles, Los Angeles, CA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA
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Bashir R, Grigorian A, Lekawa M, Joe V, Schubl SD, Chin TL, Kong A, Nahmias J. Octogenarians with blunt splenic injury: not all geriatrics are the same. Updates Surg 2020; 73:1533-1539. [PMID: 32306276 PMCID: PMC7223657 DOI: 10.1007/s13304-020-00765-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/11/2020] [Indexed: 11/29/2022]
Abstract
Geriatric trauma patients (GTP) (age ≥ 65 years) with blunt splenic injury (BSI) have up to a 6% failure rate of non-operative management (NOM). GTPs failing NOM have a similar mortality rate compared to GTPs managed successfully with NOM. However, it is unclear if this remains true in octogenarians (aged 80–89 years). We hypothesized that the failure rate for NOM in octogenarians would be similar to their younger geriatric cohort, patients aged 65–79 years; however risk of mortality in octogenarians who fail NOM would be higher than that of octogenarians managed successfully with NOM. The Trauma Quality Improvement Program (2010–2016) was queried for patients with BSI. Those undergoing splenectomy within 6 h were excluded to select for patients undergoing NOM. Patients aged 65–79 years (young GTPs) were compared to octogenarians. A multivariable logistic regression model was used to determine the risk for failed NOM and mortality. From 43,041 BSI patients undergoing NOM, 3660 (8.5%) were aged 65–79 years and 1236 (2.9%) were octogenarians. Both groups had a similar median Injury Severity Score (ISS) (p = 0.10) and failure rate of NOM (6.6% young GTPs vs. 6.8% octogenarians p = 0.82). From those failing NOM, octogenarians had similar units of blood products transfused (p > 0.05) and a higher mortality rate (40.5% vs. 18.2%, p < 0.001), compared to young GTPs. Independent risk factors for failing NOM in octogenarians included ≥ 1 unit of packed red blood cells (PRBC) (p = 0.039) within 24 h of admission. Octogenarians who failed NOM had a higher mortality rate compared to octogenarians managed successfully with NOM (40.5% vs 23.6% p = 0.001), which persisted in a multivariable logistic regression analysis (OR 2.25, CI 1.37–3.70, p < 0.001). Late failure of NOM ≥ 24 h (vs. early failure) was not associated with increased risk of mortality (p = 0.88), but ≥ 1 unit of PRBC transfused had higher risk (OR 1.88, CI 1.20–2.95, p = 0.006). Compared to young GTPs with BSI, octogenarians have a similar rate of failed NOM. Octogenarians with BSI who fail NOM have over a twofold higher risk of mortality compared to those managed successfully with NOM. PRBC transfusion increases risk for mortality. Therefore, clinicians should consider failure of NOM earlier in the octogenarian population to mitigate the risk of increased mortality.
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Affiliation(s)
- Rame Bashir
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Victor Joe
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Theresa L Chin
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Allen Kong
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
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Chou RL, Grigorian A, Nahmias J, Schubl SD, Delaplain PT, Barrios C. Racial Disparities in Adult Blunt Trauma Patients With Acute Respiratory Distress Syndrome. J Intensive Care Med 2020; 36:584-588. [PMID: 32253968 DOI: 10.1177/0885066620916170] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Study incidence and mortality for blunt trauma patients developing acute respiratory distress syndrome (ARDS) across race and insurance. DESIGN The National Trauma Data Bank (2007-2015) was queried for blunt trauma patients age >16. Covariates (age >65, injury severity score [ISS] >25, traumatic brain injury, lung injury, pneumonia, severe sepsis, hypotension on admission, and blood transfusion) were included in a multivariable logistic regression analysis. SETTING Despite progress in the treatment for ARDS, it remains a significant concern. Racial differences in response to trauma and ARDS have been inconsistently demonstrated. Since these prior studies, ARDS has been redefined by the Berlin Criteria, advances in care have been made, and health-care accessibility has changed. PATIENTS Adult blunt trauma patients with ISS > 15 and length of stay ≥ 3 days to examine patients at high risk of ARDS. MEASUREMENTS AND MAIN RESULTS There were 28 727 patients with ARDS. Most were white (76.2%), followed by blacks (11.5%), Hispanics (11.3%), and Asians (1.8%). Overall mortality was 20.5%. Compared to whites, blacks (odds ratio [OR]: 1.15, confidence interval [CI]: 1.10-1.20, P < .001) had higher risk of ARDS, being Hispanic was protective (OR: 0.80, CI: 0.76-0.83, P < .001). Asians with ARDS were at greater risk of death (OR: 1.31, CI: 1.07-1.61, P < .05) while being black was not associated with risk of death. Patients with private insurance had less diagnosed ARDS and those with ARDS had lower mortality than other insurances (OR: 0.86, CI: 0.79-0.92, P < .001). CONCLUSIONS Data from the National Trauma Data Bank (2007-2015) demonstrates racial and insurance disparities in the development of ARDS in blunt trauma patients. When compared to whites, blacks are at higher risk of developing ARDS while being Hispanic is protective. Likewise, Asians are at greatest risk of death and blacks have no difference in mortality when compared to whites. Patients with private insurance have lower risk of incidence and mortality.
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Affiliation(s)
- Raymond L Chou
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, 8788University of California-Irvine, Orange, CA, USA
| | - Areg Grigorian
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, 8788University of California-Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, 8788University of California-Irvine, Orange, CA, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, 8788University of California-Irvine, Orange, CA, USA
| | - Patrick T Delaplain
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, 8788University of California-Irvine, Orange, CA, USA
| | - Cristobal Barrios
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, 8788University of California-Irvine, Orange, CA, USA
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Yeates EO, Grigorian A, Schubl SD, Kuza CM, Joe V, Lekawa M, Borazjani B, Nahmias J. Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers. Am Surg 2020; 86:362-368. [PMID: 32391761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010-2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE (P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.
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Affiliation(s)
- Eric O Yeates
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Areg Grigorian
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Sebastian D Schubl
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Catherine M Kuza
- †Department of Anesthesiology, University of Southern California Medical Center, Los Angeles, California
| | - Victor Joe
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Michael Lekawa
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Boris Borazjani
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
| | - Jeffry Nahmias
- From the *Department of Trauma, Burns and Surgical Critical Care, University of California, Irvine Medical Center, Orange, California; and
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Delaplain PT, Grigorian A, Lekawa M, Mallicote M, Joe V, Schubl SD, Kuza CM, Dolich M, Nahmias J. Intracranial pressure monitoring associated with increased mortality in pediatric brain injuries. Pediatr Surg Int 2020; 36:391-398. [PMID: 31938835 PMCID: PMC7223517 DOI: 10.1007/s00383-020-04618-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Utilization of ICP monitors for pediatric patients is low and varies between centers. We hypothesized that in more severely injured patients (GCS 3-4), there would be a decreased mortality associated with invasive monitoring devices. METHODS The pediatric Trauma Quality Improvement Program (TQIP) was queried for patients aged ≤ 16 years meeting criteria for invasive monitors. Our primary outcome was mortality. Patients with ICP monitoring were compared to those without. A logistic regression was used to examine the risk of mortality. RESULTS Of 3,808 patients, 685 (18.0%) underwent ICP monitoring. ICP monitors were associated with increased risk of mortality (OR 1.82, CI 1.36-2.44, p < 0.001). A secondary analysis including type of invasive ICP monitor and dividing GCS into 3 categories revealed both intraventricular drain (OR 1.89, CI 1.3-2.7, p = 0.001) and intraparenchymal pressure monitor (OR 1.86, CI 1.32-2.6, p < 0.001) to be independently associated with an increased likelihood of mortality regardless of GCS, while intraparenchymal oxygen monitoring was not (OR 0.47, CI 0.11-2.05, p = 0.316). The strongest effect was seen in those patients with a GCS of 5-6. CONCLUSION ICP monitors are an independent risk factor for mortality, particularly with intraventricular drains and intraparenchymal monitors in patients with a GCS 5-6.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA.
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Michael Mallicote
- Department of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #100, Los Angeles, CA, 90027, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Catherine M Kuza
- Department of Anesthesiology, University of Southern California, 1450 San Pablo Street Suite 360, Los Angeles, CA, 90033, USA
| | - Matthew Dolich
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
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Schubl SD, Woods AL, de Virgilio C, Kim DY. Gunshot Wound to the Left Neck. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sheehan BM, Grigorian A, de Virgilio C, Fujitani RM, Kabutey NK, Lekawa M, Schubl SD, Nahmias J. Predictors of blunt abdominal aortic injury in trauma patients and mortality analysis. J Vasc Surg 2019; 71:1858-1866. [PMID: 31699513 DOI: 10.1016/j.jvs.2019.07.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI. RESULTS From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001). CONCLUSIONS In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.
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Affiliation(s)
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, Calif
| | | | - Roy M Fujitani
- Department of Surgery, University of California, Irvine, Orange, Calif
| | - Nii-Kabu Kabutey
- Department of Surgery, University of California, Irvine, Orange, Calif
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine, Orange, Calif
| | | | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, Calif
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Covarrubias J, Grigorian A, Schubl SD, Gambhir SM, Dolich MO, Lekawa ME, Nguyen NT, Nahmias JT. Obesity Associated with Increased Postoperative Pulmonary Complications and Mortality after Trauma Laparotomy. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abate ME, Grigorian A, Lekawa ME, Schubl SD, Dolich MO, Delaplain PT, Kuza CM, Nahmias J. Predictors of Mortality in Trauma Patients with ARDS on Extracorporeal Membrane Oxygenation. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Delaplain PT, Phillips JL, Lundeberg M, Nahmias J, Kuza CM, Sheehan BM, Murphy LS, Pejcinovska M, Grigorian A, Gabriel V, Barie PS, Schubl SD. No Reduction in Surgical Site Infection Obtained with Post-Operative Antibiotics in Facial Fractures, Regardless of Duration or Anatomic Location: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2019; 21:112-121. [PMID: 31526317 DOI: 10.1089/sur.2019.149] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: We performed a systematic review of the literature on antibiotic prophylaxis practices in open reduction, and internal fixation of, facial fracture(s) (ORIFfx). We hypothesized that prolonged antibiotic prophylaxis (PAP) would not decrease the rate of surgical site infections (SSIs). Methods: We performed a systematic review of four databases: PubMed, CENTRAL, EMBase, and Web of Science, from inception through January 15, 2017. Three independent reviewers extracted fracture location (orbital, mid-face, mandible), antibiotic use, SSI incidence, and time from injury to surgery. Mantel-Haenszel and generalized estimating equations were carried out independently for each fracture zone. Results: Of the 587 articles identified, 54 underwent full-text review, yielding 27 studies that met our inclusion criteria. Of these, 16 studies (n = 2,316 patients) provided data for mandible fractures, four studies (n = 439) for mid-face fractures, and six studies (n = 377) for orbital fractures. Pooled analysis of each fracture type's SSI rate showed no statistically significant association with the odds ratio (OR) of developing an SSI. For mandible fractures treated with ORIFfx, the OR for an SSI after 24-72 hours of prophylaxis relative to <24 hours was 0.85 (95% confidence interval [CI] 0.62-1.17), whereas for >72 hours compared with <24 hours, the OR was 1.42 (95% CI) 0.96-2.11). For mid-face fractures, there was no improvement in SSI rate from PAP (OR 1.05; 95% CI 0.20-5.63). Conclusions: We did not demonstrate a lower rate of SSI associated with PAP for any ORIFfx repair. Post-operative antibiotics for >72 hours paradoxically may increase the SSI risk after mandible fracture repairs.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Jacquelyn L Phillips
- Department of Surgery, University of California, San Francisco East Bay, San Francisco, California
| | | | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Catherine M Kuza
- Department of Anesthesiology, University of Southern California, Los Angeles, California
| | - Brian M Sheehan
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Linda S Murphy
- Reference Department, University of California-Irvine Libraries, NS, University of California, Irvine, Irvine, California
| | - Marija Pejcinovska
- Center for Statistical Consulting, University of California, Irvine, Irvine, California
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Viktor Gabriel
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Philip S Barie
- Department of Surgery, Weill Cornell Medical College at New York/Presbyterian Hospital, New York, New York
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
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Grigorian A, Lester E, Lekawa M, Figueroa C, Kuza CM, Dolich M, Schubl SD, Barrios C, Nahmias J. Marijuana use and outcomes in adult and pediatric trauma patients after legalization in California. Am J Surg 2019; 218:1189-1194. [PMID: 31521241 DOI: 10.1016/j.amjsurg.2019.08.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Marijuana has become legal in eight states since 2012. We hypothesized the incidence of marijuana-positive trauma patients and rate of mortality has increased post-legalization. METHODS A single level-I trauma center was used to identify patients screening positive for marijuana on urine-toxicology. Patients in the pre-legalization and post-legalization periods were compared. RESULTS In the pre-legalization cohort 9.4% were marijuana-positive versus 11.0% in the post-legalization cohort (p = 0.001). Marijuana-positive patients post-legalization had higher rates of critical trauma activation (20.0% vs. 15.0%, p = 0.01) and mortality (2.6% vs. 1.2%, p = 0.03). In the pediatric (age 12-17) subgroup, the incidence of marijuana-positive patients did not change after legalization (pre: 39.3%, post: 46.4%, p = 0.24). CONCLUSION The incidence of marijuana-positive trauma patients increased post-legalization. Adult marijuana-positive trauma patients post-legalization were more likely to meet criteria for critical trauma activation and have a higher mortality rate. A subgroup of pediatric patients had an alarmingly high rate of marijuana use. SUMMARY The rate of marijuana use among trauma patients increased post-legalization in California. The rate of critical trauma activation also increased as well as the mortality rate.
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Affiliation(s)
- A Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
| | - E Lester
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - M Lekawa
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - C Figueroa
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - C M Kuza
- University of Southern California, Department of Anesthesia, Los Angeles, CA, USA
| | - M Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - S D Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - C Barrios
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - J Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
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Grigorian A, Nahmias J, Dolich M, Barrios C, Schubl SD, Sheehan B, Lekawa M. Increased risk of head injury in pediatric patients with attention deficit hyperactivity disorder. J Child Adolesc Psychiatr Nurs 2019; 32:171-176. [PMID: 31328370 DOI: 10.1111/jcap.12246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/18/2019] [Accepted: 07/02/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The prevalence of attention deficit hyperactivity disorder (ADHD) in the general pediatric population is 7%, whereas the prevalence in trauma is unknown. We hypothesized pediatric patients with ADHD would have a higher risk of involvement in a mechanism of injury (MOI) requiring constant attention to surroundings, such as a bicycle collision. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients with ADHD. Patients, less than 16 years of age, with ADHD were compared to those without ADHD. RESULTS The prevalence of ADHD was 2.5% (2,866). ADHD patients had higher risk for bicycle collision (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.59-2.15; p < .001). ADHD bicyclists were less likely to wear a helmet (9.4% vs. 18.2%, p = .003) and had a higher rate of traumatic brain injury (TBI; 55.6% vs. 39.7%, p < .001), compared to non-ADHD bicyclists. CONCLUSIONS Pediatric ADHD patients have a 60% higher risk of being involved in a bicycle collision. ADHD patients that are involved in a bicycle collision are less likely to wear a helmet with a higher rate of TBI. Increased public awareness, education, and supervision may help reduce risk of bicycle collisions and TBI in this population.
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Affiliation(s)
- Areg Grigorian
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
| | - Matthew Dolich
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
| | - Cristobal Barrios
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
| | - Sebastian D Schubl
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
| | - Brian Sheehan
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California, Irvine, California
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Grigorian A, Kuza CM, Schubl SD, Nguyen NT, de Virgilio C, Kim D, Lekawa M, Nahmias J. Same-Day Discharge after Non-Perforated Laparoscopic Appendectomy Is Safe. J INVEST SURG 2019; 34:270-275. [PMID: 31218891 DOI: 10.1080/08941939.2019.1630065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose: Several single-center studies have demonstrated same-day discharge (SDD) to be safe in adults undergoing laparoscopic appendectomy (LA) for non-perforated appendicitis (NPA). The proportion of SDD appendectomy patients nationally is unknown. We sought to identify the incidence of SDD among patients undergoing LA after NPA hypothesizing a similar risk of complications including superficial surgical site infections (SSSIs), post-operative intra-abdominal abscess, and 30-day readmission rates. Materials and methods: The 2016-2017 ACS-NSQIP Procedure-Targeted Appendectomy database was queried for adults undergoing LA with no intraoperative findings of perforation or abscess. Patients with SDD were compared to those discharged within two days. A multivariable logistic regression model was used for analysis. Results: From 16,931 patients undergoing LA, 3988 (23.6%) were SDD. Compared to those with a longer hospital stay, patients with SDD were of similar age (p = 0.29) and less likely to have a contaminated wound-class (58.5% vs. 62.6%, p < 0.001). After adjusting for age and comorbidities, patients with SDD had a similar risk of 30-day readmission (p = 0.088) and post-operative abscess (p = 0.739) but lower risk of SSSI (OR: 0.48, 0.28-0.82, p = 0.008), compared to those discharged within two days. Conclusions: Nearly a quarter of patients with NPA undergoing LA are discharged the same day. The risk of 30-day readmission is similar compared to those with a longer index hospital stay. Interestingly, the risk of SSSI is lower, however this may be related to differences in wound classification and/or selection bias. Regardless, SDD for NPA patients appears safe and should be utilized whenever possible.
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Affiliation(s)
- Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Catherine M Kuza
- Department of Anesthesia, University of Southern California, Los Angeles, CA, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Ninh T Nguyen
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Christian de Virgilio
- Department of Surgery, University of California, Los Angeles - Harbor, Torrance, CA, USA
| | - Dennis Kim
- Department of Surgery, University of California, Los Angeles - Harbor, Torrance, CA, USA
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, CA, USA
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Farhat A, Grigorian A, Nguyen NT, Smith B, Williams BJ, Schubl SD, Joe V, Elfenbein D, Nahmias J. Obese trauma patients have increased need for dialysis. Eur J Trauma Emerg Surg 2019; 46:1327-1334. [PMID: 31111163 DOI: 10.1007/s00068-019-01147-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/11/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Obesity is a risk factor for the development of acute kidney injury but its effect on the need for dialysis in trauma has not been elucidated. Additionally, the contribution that obesity has towards risk of mortality in trauma is unclear. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis and mortality after trauma. METHODS This is a retrospective analysis using the National Trauma Data Bank. All patients ≥ 8 years old were grouped based on BMI: normal (18.5-24.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2) and morbidly obese (≥ 40 kg/m2). The primary outcome was hemodialysis initiation. The secondary outcome was mortality during the index hospitalization. RESULTS From 988,988 trauma patients, 571,507 (57.8%) had a normal BMI, 233,340 (23.6%) were obese, 94,708 (9.6%) were severely obese, and 89,433 (9.0%) were morbidly obese. The overall rate of hemodialysis was 0.3%. After adjusting for covariates, we found that obese (OR 1.36, CI 1.22-1.52, p < 0.001), severely obese (OR 1.89, CI 1.66-2.15, p < 0.001) and morbidly obese (OR 2.04, CI 1.82-2.29, p < 0.001) patients had a stepwise increased need for hemodialysis after trauma. Obese patients had decreased (OR 0.92, CI 0.88-0.95, p < 0.001), severely obese had similar (OR 1.02, CI 0.97-1.08, p = 0.50) and morbidly obese patients had increased (OR 1.06, CI 1.01-1.12, p = 0.011) risk of mortality after trauma. CONCLUSIONS Obesity was associated with an increased risk for dialysis after trauma. Mortality risk was reduced in obese, similar in severely obese, and increased in morbidly obese trauma patients suggesting an inflection threshold BMI for risk of mortality in trauma.
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Affiliation(s)
- Ahmed Farhat
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Ninh T Nguyen
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Brian Smith
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Barbara J Williams
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Victor Joe
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Dawn Elfenbein
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
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Grigorian A, Lekawa M, Dolich M, Schubl SD, Doben AR, Kuza CM, Barrios C, Nahmias J. Smoking is associated with an improved short-term outcome in patients with rib fractures. Eur J Trauma Emerg Surg 2019; 46:927-933. [PMID: 31115615 DOI: 10.1007/s00068-019-01152-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/13/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Smokers with cardiovascular disease have been reported to have decreased mortality compared to non-smokers. Rib fractures are associated with significant underlying injuries such as lung contusions, lacerations, and/or pneumothoraces. We hypothesized that blunt trauma patients with rib fractures who are smokers have decreased ventilator days and risk of in-hospital mortality compared to non-smokers. STUDY DESIGN The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a blunt rib fracture. Patients that died within 24 h of admission were excluded. A multivariable logistic regression model was performed. RESULTS From 282,986 patients with rib fractures, 57,619 (20.4%) were smokers. Compared to non-smokers with rib fractures, smokers had a higher median injury severity score (17 vs. 16, p < 0.001). Smokers had a higher rate of pneumonia (7.5% vs. 6.6%, p < 0.001), however, less ventilator days (5 vs. 6, p = 0.04), and lower in-hospital mortality rate (2.3% vs. 4.6%, p < 0.001), compared to non-smokers. After controlling for covariates, smokers with rib fractures were associated with a decreased risk for in-hospital mortality compared to non-smokers with rib fractures (OR 0.64, 0.56-0.73, p < 0.001). CONCLUSION Despite having more severe injuries and increased rates of pneumonia, smokers with rib fractures were associated with nearly a 40% decreased risk of in-hospital mortality and one less ventilator day compared to non-smokers. The long-term detrimental effects of smoking have been widely established. However, the biologic and pathophysiologic adaptations that smokers have may confer a survival benefit when recovering in the hospital from chest wall trauma. This study was limited by the database missing the number of pack-years smoked. Future prospective studies are needed to confirm this association and elucidate the physiologic mechanisms that may explain these findings.
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Affiliation(s)
- Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
| | - Michael Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Matthew Dolich
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Andrew R Doben
- Department of Surgery, Baystate Medical Center Affiliate of Tufts University School of Medicine, Springfield, MA, USA
| | - Catherine M Kuza
- Department of Anesthesiology, University of Southern California, Los Angeles, CA, USA
| | - Cristobal Barrios
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
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