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Bulger EM, Bixby PJ, Price MA, Villarreal CL, Moreno AN, Herrera-Escobar JP, Bailey JA, Brasel KJ, Cooper ZR, Costantini TW, Gibran NS, Groner JI, Joseph BA, Newgard CD, Stein DM. An Executive Summary of the National Trauma Research Action Plan (NTRAP). J Trauma Acute Care Surg 2024:01586154-990000000-00669. [PMID: 38523118 DOI: 10.1097/ta.0000000000004279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.
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Dillon ST, Otu HH, Ngo LH, Fong TG, Vasunilashorn SM, Xie Z, Kunze LJ, Vlassakov KV, Abdeen A, Lange JK, Earp BE, Cooper ZR, Schmitt E, Arnold SE, Hshieh T, Jones RN, Inouye SK, Marcantonio ER, Libermann TA. Patterns and Persistence of Perioperative Plasma and Cerebrospinal Fluid Neuroinflammatory Protein Biomarkers After Elective Orthopedic Surgery Using SOMAscan. Anesth Analg 2023; 136:163-175. [PMID: 35389379 PMCID: PMC9537343 DOI: 10.1213/ane.0000000000005991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The neuroinflammatory response to surgery can be characterized by peripheral acute plasma protein changes in blood, but corresponding, persisting alterations in cerebrospinal fluid (CSF) proteins remain mostly unknown. Using the SOMAscan assay, we define acute and longer-term proteome changes associated with surgery in plasma and CSF. We hypothesized that biological pathways identified by these proteins would be in the categories of neuroinflammation and neuronal function and define neuroinflammatory proteome changes associated with surgery in older patients. METHODS SOMAscan analyzed 1305 proteins in blood plasma (n = 14) and CSF (n = 15) samples from older patients enrolled in the Role of Inflammation after Surgery for Elders (RISE) study undergoing elective hip and knee replacement surgery with spinal anesthesia. Systems biology analysis identified biological pathways enriched among the surgery-associated differentially expressed proteins in plasma and CSF. RESULTS Comparison of postoperative day 1 (POD1) to preoperative (PREOP) plasma protein levels identified 343 proteins with postsurgical changes ( P < .05; absolute value of the fold change [|FC|] > 1.2). Comparing postoperative 1-month (PO1MO) plasma and CSF with PREOP identified 67 proteins in plasma and 79 proteins in CSF with altered levels ( P < .05; |FC| > 1.2). In plasma, 21 proteins, primarily linked to immune response and inflammation, were similarly changed at POD1 and PO1MO. Comparison of plasma to CSF at PO1MO identified 8 shared proteins. Comparison of plasma at POD1 to CSF at PO1MO identified a larger number, 15 proteins in common, most of which are regulated by interleukin-6 (IL-6) or transforming growth factor beta-1 (TGFB1) and linked to the inflammatory response. Of the 79 CSF PO1MO-specific proteins, many are involved in neuronal function and neuroinflammation. CONCLUSIONS SOMAscan can characterize both short- and long-term surgery-induced protein alterations in plasma and CSF. Acute plasma protein changes at POD1 parallel changes in PO1MO CSF and suggest 15 potential biomarkers for longer-term neuroinflammation that warrant further investigation.
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Affiliation(s)
- Simon T. Dillon
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Boston, MA
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Long H. Ngo
- Harvard Medical School, Boston, MA
- Divisions of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Tamara G. Fong
- Harvard Medical School, Boston, MA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Sarinnapha M. Vasunilashorn
- Harvard Medical School, Boston, MA
- Divisions of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Zhongcong Xie
- Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Lisa J. Kunze
- Harvard Medical School, Boston, MA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamen V. Vlassakov
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Ayesha Abdeen
- Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jeffrey K. Lange
- Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Brandon E. Earp
- Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women’s Faulkner Hospital, Boston, MA
| | - Zara R. Cooper
- Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Eva Schmitt
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Steven E. Arnold
- MGH Institute for Neurodegenerative Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA
| | - Tammy Hshieh
- Harvard Medical School, Boston, MA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Divisions of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard N. Jones
- Departments of Psychiatry and Human Behavior and Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, MA
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA
- Divisions of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Towia A. Libermann
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Boston, MA
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Boston, MA
- Harvard Medical School, Boston, MA
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Ouyang DJ, Lief L, Russell D, Xu J, Berlin DA, Gentzler E, Su A, Cooper ZR, Senglaub SS, Maciejewski PK, Prigerson HG. Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes. PLoS One 2020; 15:e0227971. [PMID: 32069306 PMCID: PMC7028295 DOI: 10.1371/journal.pone.0227971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 01/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death. Methods 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model. Results 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures. Conclusions Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.
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Affiliation(s)
- Daniel J. Ouyang
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Lindsay Lief
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - David Russell
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Sociology, Appalachian State University, Boone, North Carolina, United State of America
| | - Jiehui Xu
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - David A. Berlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - Eliza Gentzler
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Amanda Su
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Zara R. Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Steven S. Senglaub
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Paul K. Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- Department of Radiology, Weill Cornell Medicine, New York, New York, United State of America
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- * E-mail:
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Havens JM, Olufajo OA, Cooper ZR, Haider AH, Shah AA, Salim A. Defining Rates and Risk Factors for Readmissions Following Emergency General Surgery. JAMA Surg 2016; 151:330-6. [PMID: 26559368 DOI: 10.1001/jamasurg.2015.4056] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Hospital readmission rates following surgery are increasingly being used as a marker of quality of care and are used in pay-for-performance metrics. To our knowledge, comprehensive data on readmissions to the initial hospital or a different hospital after emergency general surgery (EGS) procedures do not exist. OBJECTIVE To define readmission rates and identify risk factors for readmission after common EGS procedures. DESIGN, SETTING, AND PARTICIPANTS Patients undergoing EGS, as defined by the American Association for the Surgery of Trauma, were identified in the California State Inpatient Database (2007-2011) on January 15, 2015. Patients were 18 years and older. We identified the 5 most commonly performed EGS procedures in each of 11 EGS diagnosis groups. Patient demographics (sex, age, race/ethnicity, and insurance type) as well as Charlson Comorbidity Index score, length of stay, complications, and discharge disposition were collected. Factors associated with readmission were determined using multivariate logistic regression models analysis. MAIN OUTCOMES AND MEASURES Thirty-day hospital readmission. RESULTS Among 177,511 patients meeting inclusion criteria, 57.1% were white, 48.8% were privately insured, and most were 45 years and older (51.3%). Laparoscopic appendectomy (35.2%) and laparoscopic cholecystectomy (19.3%) were the most common procedures. The overall 30-day readmission rate was 5.91%. Readmission rates ranged from 4.1% (upper gastrointestinal) to 16.8% (cardiothoracic). Of readmitted patients, 16.8% were readmitted at a different hospital. Predictors of readmission included Charlson Comorbidity Index score of 2 or greater (adjusted odds ratio: 2.26 [95% CI, 2.14-2.39]), leaving against medical advice (adjusted odds ratio: 2.24 [95% CI, 1.89-2.66]), and public insurance (adjusted odds ratio: 1.55 [95% CI, 1.47-1.64]). The most common reasons for readmission were surgical site infections (16.9%), gastrointestinal complications (11.3%), and pulmonary complications (3.6%). CONCLUSIONS AND RELEVANCE Readmission after EGS procedures is common and varies widely depending on patient factors and diagnosis categories. One in 5 readmitted patients will go to a different hospital, causing fragmentation of care and potentially obscuring the utility of readmission as a quality metric. Assisting socially vulnerable patients and reducing postoperative complications, including infections, are targets to reduce readmissions.
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Affiliation(s)
- Joaquim M Havens
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts2Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Olubode A Olufajo
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts2Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara R Cooper
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts2Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil A Shah
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts3Division of General Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona
| | - Ali Salim
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts2Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Olufajo OA, Reznor G, Lipsitz SR, Cooper ZR, Haider AH, Salim A, Rangel EL. Preoperative assessment of surgical risk: creation of a scoring tool to estimate 1-year mortality after emergency abdominal surgery in the elderly patient. Am J Surg 2016; 213:771-777.e1. [PMID: 27743591 DOI: 10.1016/j.amjsurg.2016.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/07/2016] [Accepted: 08/07/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The risk of mortality after emergency general surgery (EGS) in elderly patients is prolonged beyond initial hospitalization. Our objective was to develop a preoperative scoring tool to quantify risk of 1-year mortality. METHODS Three hundred ninety EGS patients aged 70 years or more were analyzed. Risk factors for 1-year mortality were identified using stepwise-forward logistic multivariate regression and weights assigned using natural logarithm of odds ratios. A geriatric emergency surgery mortality (GEM) score was derived from the aggregate of weighted scores. Leave-one-out cross-validation was performed. RESULTS One-year mortality was 32%. Risk factors and their weights were: acute kidney injury (2), American Society of Anesthesiology class greater than or equal to 4 (2), Charlson Comorbidity Index greater than or equal to 4 (1), albumin less than 3.5 mg/dL (1), and body mass index (less than 18.5 kg/m2 [1]; 18.5 to 29.9 kg/m2 [0]; ≥30 kg/m2 [-1]). One-year mortality was: GEM 0 to 1 (0% to 7%); GEM 2 to 5 (32% to 68%); GEM 6 to 8 (94% to 100%). C-statistics were .82 and .75 in training and validation data sets, respectively. CONCLUSIONS A simple score using 5 clinical variables predicts 1-year mortality after EGS with reasonable accuracy and assists in preoperative counseling.
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Affiliation(s)
- Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gally Reznor
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Zara R Cooper
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Adil H Haider
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Erika L Rangel
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery Brigham and Women's Hospital, Boston, MA, USA.
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Knudson MM, Velmahos G, Cooper ZR. Response to mass casualty events: from the battlefield to the Stop the Bleed campaign. Trauma Surg Acute Care Open 2016; 1:e000023. [PMID: 29766063 PMCID: PMC5891703 DOI: 10.1136/tsaco-2016-000023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 11/09/2022] Open
Abstract
In the aftermath of a number of episodes of mass casualty events, we must be reminded of how important it is to be prepared and to reflect on the knowledge accumulated over the past 15 years of war in Iraq and Afghanistan.
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Affiliation(s)
| | - George Velmahos
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zara R Cooper
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Olufajo OA, Rios-Diaz A, Peetz AB, Williams KJ, Havens JM, Cooper ZR, Gates JD, Haider AH, Salim A, Askari R. Comparing Readmissions and Infectious Complications of Blunt Splenic Injuries Using a Statewide Database. Surg Infect (Larchmt) 2016; 17:191-7. [PMID: 26859534 DOI: 10.1089/sur.2015.137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although non-operative management of blunt splenic injury (BSI) is increasingly common, the long-term infectious complications after adjunct splenic artery embolization (SAE) are not well described. METHODS Patients aged 18-64 y with BSI were identified in the California State Inpatient Database (2007-2011) and categorized as receiving either non-operative management (NOM) without SAE, NOM with SAE, or operative management (OM). The cumulative incidence of infections (surgical site infections [SSI], pneumonia, urinary tract infections, and sepsis) requiring readmission at different times up to one y after injury were calculated. Patient and treatment factors associated with infectious readmissions were determined using multivariable logistic regression models. RESULTS Of the 4,360 patients with BSI, 61.6% had NOM without SAE, 5.8% had NOM with SAE, and 32.6% had OM. The cumulative incidences of infectious complications after each of the management modes were 1.27%, 1.59%, and 1.76%, respectively, during admission (p = 0.446); 2.16%, 5.18%, and 4.85%, respectively, at 30 d after injury (p < 0.001); and 4.69%, 9.16%, and 8.85%, respectively, at one y after injury (p < 0.001). Risk factors for infection-associated readmissions within one y after injury were Charlson score ≥2 (adjusted odds ratio [AOR] 3.9; 95% confidence interval [CI] 2.61-6.02), length of stay >seven d (AOR 2.47; 95% CI 1.58-3.85), NOM with SAE (AOR 2.00; 95% CI 1.19-3.34), and OM (AOR 1.47; 95% CI 1.05-2.07). CONCLUSIONS The long-term risk of infectious complications in patients with BSI who have NOM with SAE is similar to that in patients who are treated with OM, indicating the need for pro-active strategies to reduce long-term infectious complications after SAE.
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Affiliation(s)
- Olubode A Olufajo
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Arturo Rios-Diaz
- 2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Allan B Peetz
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Katherine J Williams
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joaquim M Havens
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Zara R Cooper
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jonathan D Gates
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Adil H Haider
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ali Salim
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Reza Askari
- 1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,2 Center for Surgery and Public Health, Brigham and Women's Hospital , Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Pernar LI, Peyre SE, Smink DS, Block SD, Cooper ZR. Feasibility and impact of a case-based palliative care workshop for general surgery residents. J Am Coll Surg 2011. [DOI: 10.1016/j.jamcollsurg.2011.06.294] [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: 11/26/2022]
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Affiliation(s)
- Zara R Cooper
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Cooper ZR, Rose S. Fecal incontinence: a clinical approach. Mt Sinai J Med 2000; 67:96-105. [PMID: 10747364] [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] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
"Fecal incontinence" is defined as the involuntary loss of stool at any time of life after toilet training. It is a socially and psychologically devastating condition for patients and their families, and a topic which both patients and physicians are reluctant to approach. Although the true prevalence of fecal incontinence is unknown, studies have reported it to be as high as 2. 2% in the general population, with significantly higher rates among nursing home residents and hospitalized elderly. Risk factors include advancing age, female gender and multiparity. An understanding of pelvic floor anatomy and physiology is required to appreciate how diverse medical conditions can affect mechanisms involved in normal continence. The rectum serves as a storage reservoir until elimination can take place at a socially acceptable time and place. The pelvic floor muscles help to regulate the defecatory process and maintain continence. These muscles include the internal anal sphincter, the external anal sphincter and the puborectalis muscle. Each muscle contributes to normal continence, although the relative importance of each is controversial. Neurologic integrity and sensation are also key factors. Conditions associated with fecal incontinence include diarrheal states, fecal impaction, idiopathic neurologic injury, surgical and obstetric injury, pelvic trauma, collagen vascular disease, and neurologic impairment related to stroke, diabetes, or multiple sclerosis. Evaluation of the patient with fecal incontinence includes a directed history and physical examination, with particular attention paid to integrity of the perineum and rectum, and a complete neurologic evaluation. Diagnostic tools such as stool studies, anorectal manometry, defecography, electromyography, pudendal nerve conduction, and endoanal ultrasound may be employed in an outpatient setting. Fecal incontinence may be treated conservatively by employing such methods as dietary restriction, stool bulking agents, and biofeedback. Surgery may be the best option for cases refractory to medical treatment, or for those patients with rectocele or obstetrical injury. In this article, we review the presentation, epidemiology, pathophysiology, and etiology of fecal incontinence. Evaluation, including key components of directed history and physical examination, and the appropriate use of diagnostic studies and indications for treatment options are also addressed.
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Affiliation(s)
- Z R Cooper
- Mount Sinai School of Medicine, Box 1257, One East 100th Street, New York, NY 10029, USA
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