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Lehrman B, Byerly S, Mitchell EL, Kerwin AJ, Howley IW. Trust but Verify? Utility of Intraoperative Angiography After Revascularization for Vascular Trauma. Am Surg 2024; 90:1059-1065. [PMID: 38126322 DOI: 10.1177/00031348231220593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Trauma surgical dogma teaches that patients should have intraoperative angiography (IA) if the surgeon cannot identify a pulse in the injured extremity following a vascular repair. This study was undertaken to assess the utility of IA in trauma patients who underwent open brachial or femoral artery revascularization. METHODS Retrospective analysis of the Prospective Observational Vascular Injury Trial (PROOVIT) database from 2013 to 2021 evaluated patients >15 years with penetrating or blunt injuries requiring operative intervention of the brachial, superficial femoral, or common femoral arteries. Prospective Observational Vascular Injury Trial data evaluated included documented pulse in the injured extremity at revascularization completion, adjunctive IA, immediate revision, and vascular reintervention during the hospitalization. RESULTS Of the 5057 patients with vascular injury, 185 patients met our inclusion criteria. The majority were male (86.5%) with a median age, injury severity score, and systolic blood pressure of 29, 12, and 117, respectively. Of the study patients, 39% underwent IA, 14% had immediate revision, and 8% required vascular reoperation during their admission. Patients who underwent IA and with no documented palpable pulse after repair were significantly more likely to require immediate revision before leaving the operating room (22% vs 9%, P = .013) and were not more likely to require reoperation, than those who did not undergo IA (7% vs 9%, P = .613). CONCLUSIONS Intraoperative angiography is a valuable tool for surgeons for vascular extremity trauma and is associated with a greater rate of immediate revision. Familiarity with angiographic technique is essential for vascular trauma and should be a focal point of training.
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Affiliation(s)
- Benjamin Lehrman
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- Department of Surgery - Division of Trauma/Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erica L Mitchell
- Department of Surgery - Division of Vascular and Endovascular Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew J Kerwin
- Department of Surgery - Division of Trauma/Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac W Howley
- Department of Surgery - Division of Trauma/Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA
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Lenart EK, Byerly SE, Gross MG, Ali YM, Evans CR, Easterday TS, Howley IW, Kerwin AJ, Fischer PE, Filiberto DM. Clinical Implications of Over- and Under-Triage Using Need for Trauma Intervention and Cribari Indices. Am Surg 2024:31348241246181. [PMID: 38613475 DOI: 10.1177/00031348241246181] [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: 04/15/2024]
Abstract
BACKGROUND Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor. METHODS The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation. RESULTS 1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT. CONCLUSIONS Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.
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Affiliation(s)
- Emily K Lenart
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya E Byerly
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Megan G Gross
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yasmin M Ali
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cory R Evans
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Thomas S Easterday
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac W Howley
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andy J Kerwin
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter E Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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3
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Noorbakhsh S, Keirsey M, Hess A, Bellu K, Laxton S, Byerly S, Filiberto DM, Kerwin AJ, Stein DM, Howley IW. Key Findings on Computed Tomography of the Head that Predict Death or the Need for Neurosurgical Intervention From Traumatic Brain Injury. Am Surg 2024; 90:616-623. [PMID: 37791615 DOI: 10.1177/00031348231204914] [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: 10/05/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) requires rapid management to avoid secondary injury or death. This study evaluated if a simple schema for quickly interpreting CT head (CTH) imaging by trauma surgeons and trainees could be validated to predict need for neurosurgical intervention (NSI) or death from TBI within 24 hours. METHODS We retrospectively reviewed TBI patients presenting to our trauma center in 2020 with blunt mechanism and GCS ≤ 12. Primary independent variables were presence of 7 normal findings on CTH (CSF at foramen magnum, open fourth ventricle, CSF around quadrigeminal plate, CSF around cerebral peduncles, absence of midline shift, visible sulci/gyri, and gray-white differentiation). Trauma surgeons and trainees separately evaluated each patient's CTH, scoring findings as normal or abnormal. Primary outcome was NSI/death in 24 hours. RESULTS Our population consisted of 444 patients; 21.4% received NSI or died within 24 hours. By trainees' interpretation, 5.8% of patients without abnormal findings had NSI/death vs 52.0% of patients with ≥1 abnormality; attending interpretation was 8.7% and 54.9%, respectively (P < .001). Sulci/gyri effacement, midline shift, and cerebral peduncle effacement maximized sensitivity and specificity for predicting NSI/death. Considering pooled results, when ≥1 of those 3 findings was abnormal, sensitivity was 77.89%, specificity was 80.80%, positive predictive value was 52.48%, and negative predictive value was 93.07%. DISCUSSION Any single abnormality in this schema significantly predicted a large increase in NSI/death in 24 hours in TBI patients, and three particular findings were most predictive. This schema may help predict need for intervention and expedite management of moderate/severe TBI.
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Affiliation(s)
| | - Michael Keirsey
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alexis Hess
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kyle Bellu
- William Carey University College of Osteopathic Medicine, Hattiesburg, MS, USA
| | - Steven Laxton
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Andrew J Kerwin
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Deborah M Stein
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Isaac W Howley
- University of Tennessee Health Science Center, Memphis, TN, USA
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Hochu G, Soule S, Lenart E, Howley IW, Filiberto D, Byerly S. Synchronous tracheostomy and gastrostomy placement results in shorter length of stay in traumatic brain injury patients. Am J Surg 2024; 227:153-156. [PMID: 37852846 DOI: 10.1016/j.amjsurg.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/31/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4-6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy. METHODS Retrospective review of TBI patients requiring tracheostomy in 2017-2022 at a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS. RESULTS 394 patients were included [mean age: 42 (SD:18); mortality: 9 %]. The DELAY group had longer LOS (39 vs 32 days, p < 0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p = 0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 % CI:1.20-1.98, p < 0.001). CONCLUSIONS Synchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients.
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Affiliation(s)
- Gabrielle Hochu
- College of Medicine, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA.
| | - Sara Soule
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Emily Lenart
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Isaac W Howley
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Dina Filiberto
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Memphis, TN, 38103, USA
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Kelly EM, Fleming AM, Lenart EK, Howley IW, Fischer PE, Kerwin AJ, Filiberto DM, Byerly S. Delayed Tracheostomy After Cervical Fixation is Not Associated With Improved Outcomes: A Trauma Quality Improvement Program Analysis. Am Surg 2023:31348231157855. [PMID: 36795590 DOI: 10.1177/00031348231157855] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Patients with unstable cervical spine (C-spine) fractures are at a significant risk of respiratory failure. There is no consensus on the optimal timing of tracheostomy in the setting of recent operative cervical fixation (OCF). This study evaluated the impact of tracheostomy timing on surgical site infections (SSIs) in patients undergoing OCF and tracheostomy. METHODS Trauma Quality Improvement Program (TQIP) was used to identify patients with isolated cervical spine injuries who underwent OCF and tracheostomy between 2017 and 2019. Early tracheostomy (<7 days from OCF) was compared with delayed tracheostomy (≥7 days from OCF). Logistic regressions identified variables associated with SSI, morbidity, and mortality. Pearson correlations evaluated time to tracheostomy and length of stay (LOS). RESULTS Of 1438 patients included, 20 had SSI (1.4%). There was no difference in SSI between early vs delayed tracheostomy (1.6% vs 1.2%, P = .5077). Delayed tracheostomy was associated with increased ICU LOS (23.0 vs 17.0 days, P < .0001), ventilator days (19.0 vs 15.0, P < .0001), and hospital LOS (29.0 vs 22.0 days, P < .0001). Increased ICU LOS was associated with SSI (OR 1.017; CI 0.999-1.032; P = .0273). Increased time to tracheostomy was associated with increased morbidity (OR 1.003; CI 1.002-1.004; P < .0001) on multivariable analysis. Time from OCF to tracheostomy correlated with ICU LOS (r (1354) = .35, P < .0001), ventilator days (r (1312) = .25, P < .0001), and hospital LOS (r (1355) = .25, P < .0001). CONCLUSION In this TQIP study, delayed tracheostomy after OCF was associated with longer ICU LOS and increased morbidity without increased SSI. This supports the TQIP best practice guidelines recommending that tracheostomy should not be delayed for concern of increased SSI risk.
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Affiliation(s)
- Emma M Kelly
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew M Fleming
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Emily K Lenart
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac W Howley
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter E Fischer
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew J Kerwin
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dina M Filiberto
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya Byerly
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
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Fleming AM, Shah K, Byerly S, Magnotti LJ, Fischer PE, Seger CP, Kerwin AJ, Croce MA, Howley IW. Cryoprecipitate Use During Massive Transfusion Does Not Reduce Mortality in Propensity Score Analysis. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.580] [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: 11/30/2022]
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Howley IW, Bennett JD, Stein DM. Rapid Detection of Significant Traumatic Brain Injury Requiring Emergency Intervention. Am Surg 2020; 87:1504-1510. [PMID: 33345574 DOI: 10.1177/0003134820973355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.
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Affiliation(s)
- Isaac W Howley
- Department of Surgery, 12325University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jonathan D Bennett
- Department of Surgery, 6886Virginia Commonwealth University, Richmond, VA, USA
| | - Deborah M Stein
- Department of Surgery, 12224University of California San Francisco School of Medicine, San Francisco, CA, USA
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Howley IW, Bruns BR, Tesoriero RB, Vesselinov R, Kufera JA, Feliciano DV, Diaz JJ. Statewide Analysis of Peptic Ulcer Disease: As Hospitalizations Decrease, Procedural Volume Remains Steady. Am Surg 2020. [DOI: 10.1177/000313481908500948] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors’ clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.
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Affiliation(s)
- Isaac W. Howley
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland and
| | - Brandon R. Bruns
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland and
| | - Ronald B. Tesoriero
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland and
| | - Roumen Vesselinov
- the National Study Center for Trauma and Emergency Medical Systems, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph A. Kufera
- the National Study Center for Trauma and Emergency Medical Systems, University of Maryland School of Medicine, Baltimore, Maryland
| | - David V. Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland and
| | - Jose J. Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland and
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9
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Howley IW, Stein DM, Scalea TM. Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation. Injury 2019; 50:2228-2233. [PMID: 31635905 DOI: 10.1016/j.injury.2019.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 09/18/2019] [Accepted: 10/06/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Portal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care. METHODS We reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes. RESULTS Twenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting. CONCLUSION Despite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality.
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Affiliation(s)
- Isaac W Howley
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA.
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Howley IW, Bruns BR, Tesoriero RB, Vesselinov R, Kufera JA, Feliciano DV, Diaz JJ. Statewide Analysis of Peptic Ulcer Disease: As Hospitalizations Decrease, Procedural Volume Remains Steady. Am Surg 2019; 85:1028-1032. [PMID: 31638519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors' clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.
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11
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Howley IW, Haut ER, Jacobs L, Morrison JJ, Scalea TM. Is thromboelastography (TEG)-based resuscitation better than empirical 1:1 transfusion? Trauma Surg Acute Care Open 2018; 3:e000140. [PMID: 29766129 PMCID: PMC5887764 DOI: 10.1136/tsaco-2017-000140] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 11/01/2017] [Accepted: 11/08/2017] [Indexed: 01/10/2023] Open
Abstract
Thomboelastography (TEG) is a whole blood measure of coagulation which was originally described in the 1950s. However, it has only been in the last few decades that assays have become accessible and viable as a point-of-care test. Following the observation that hemorrhagic shock is associated with an intrinsic coagulopathy, TEG has been used as a method of diagnosing specific coagulation defects in order to direct individualized blood products resuscitation. An alternative transfusion strategy is the administration of fixed ratio products, a paradigm borne out of military experience. It is unknown which strategy is superior and this topic was debated at the 36th Annual Point/Counterpoint Acute Care Surgery Conference. The following article summarizes the discussants points of view along with a summary of the evidence.
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Affiliation(s)
- Isaac W Howley
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Lenwoth Jacobs
- Department of Traumatology and Emergency Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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12
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Howley IW, Gupta S, Tetali S, Josyula LK, Wadhwaniya S, Gururaj G, Rao M, Hyder AA. Epidemiology of road traffic injury patients presenting to a tertiary hospital in Hyderabad, India. Surgery 2017; 162:S77-S84. [PMID: 28487043 DOI: 10.1016/j.surg.2017.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Road traffic injuries kill more people in India than in any other country in the world, and these numbers are rising with increasing population density and motorization. Official statistics regarding road traffic injuries are likely subject to underreporting. This study presents results of a surveillance program based at a public tertiary hospital in Hyderabad, India. METHODS All consenting patients who presented to the casualty ward after a road traffic injury over a 9-month period were enrolled. Interviews were performed and data abstracted from clinical records by trained research assistants. Data included demographics, injury characteristics, risk factors, safety behaviors, and outcomes. RESULTS A total of 5,298 patients were enrolled; their mean age was 32.4 years (standard deviation 13.8) and 87.3% were men; 58.2% of patients were injured while riding a motorcycle or scooter, 22.5% were pedestrians, and 9.2% used motorized rickshaws. The most frequent collision type was skid or rollover (40.9%). Male victims were younger than female victims and were overrepresented among motorized 2-wheeler users. Patients were most frequently injured from 1600 to 2400. A total of 27.3% of patients were admitted. Hospital mortality was 5.3%, and 48.2% of deaths were among motorized 2-wheeler users. CONCLUSION This is one of the few prospective, hospital-based studies of road traffic injury epidemiology in India. The patient population in this study was similar to prior hospital-based studies. When compared to government surveillance systems, this study showed motorized 2-wheeler users to be more frequently represented among the overall population and among fatalities. Further research should be done to develop interventions to decrease mortality associated with 2-wheeled vehicles in India.
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Affiliation(s)
- Isaac W Howley
- Johns Hopkins International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shivam Gupta
- Johns Hopkins International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Shailaja Tetali
- Indian Institute of Public Health-Hyderabad, Hyderabad, India
| | | | - Shirin Wadhwaniya
- Johns Hopkins International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gopalkrishna Gururaj
- Department of Epidemiology, WHO Collaborating Centre for Injury Prevention and Safety Promotion, Centre for Public Health, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Mohan Rao
- Indian Institute of Public Health-Hyderabad, Hyderabad, India
| | - Adnan A Hyder
- Johns Hopkins International Injury Research Unit, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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