1
|
Estroff JM, Devlin J, Hoteit L, Hassoune A, Neal MD, Brown JB, Lu L, Kotch S, Hazelton JP, Christian AB, Yeates EO, Nahmias J, Jacobson LE, Williams J, Schuster KM, O'Connor R, Semon GR, Straughn AD, Cullinane D, Egodage T, Kincaid M, Rollins A, Amdur R, Sarani B. 4-factor prothrombin complex concentrate is not inferior to andexanet alfa for the reversal or oral factor Xa inhibitors: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2024:01586154-990000000-00713. [PMID: 38685190 DOI: 10.1097/ta.0000000000004345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Andexanet Alfa (AA) is the only FDA approved reversal agent for apixaban and rivaroxaban (DOAC). There are no studies comparing its efficacy with 4-Factor Prothrombin Complex Concentrate (PCC). This study aimed to compare PCC to AA for DOAC reversal, hypothesizing non-inferiority of PCC. METHODS We performed a retrospective, non-inferiority multicenter study of adult patients admitted from July 1, 2018 to December 31, 2019 who had taken a DOAC within 12 hours of injury, were transfused red blood cells (RBCs) or had traumatic brain injury, and received AA or PCC. Primary outcome was PRBC unit transfusion. Secondary outcome with ICU length of stay. MICE imputation was used to account for missing data and zero-inflated poisson regression was used to account for an excess of zero units of RBC transfused. 2 Units difference in RBC transfusion was selected as non-inferior. RESULTS Results: From 263 patients at 10 centers, 77 (29%) received PCC and 186 (71%) AA. Patients had similar transfusion rates across reversal treatment groups (23.7% AA vs 19.5% PCC) with median transfusion in both groups of 0 RBC. According to the Poisson component, PCC increases the amount of RBC transfusion by 1.02 times (95% CI: 0.79-1.33) compared to AA after adjusting for other covariates. The averaged amount of RBC transfusion (non-zero group) is 6.13. Multiplying this number by the estimated rate ratio, PCC is estimated to have an increase RBC transfusion by 0.123 (95% CI: 0.53-2.02) units compared to AA. CONCLUSION PCC appears non-inferior to AA for reversal of DOACs for RBC transfusion in traumatically injured patients. Additional prospective, randomized trials are necessary to compare PCC and AA for the treatment of hemorrhage in injured patients on DOACs. LEVEL OF EVIDENCE Therapeutic/Care Management, Level III.
Collapse
Affiliation(s)
- Jordan M Estroff
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Joseph Devlin
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Lara Hoteit
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adnan Hassoune
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joshua B Brown
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Liling Lu
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shannon Kotch
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center
| | - Joshua P Hazelton
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center
| | | | - Eric O Yeates
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA
| | | | | | | | - Rick O'Connor
- Yale University/Yale New Haven Hospital, New Haven, CT
| | - Gregory R Semon
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH
| | | | | | - Tanya Egodage
- Cooper University, Camden, NJ Grant Medical Center, Columbus, OH
| | | | | | - Richard Amdur
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| |
Collapse
|
2
|
Ratnasekera AM, Seng SS, Kim D, Ji W, Jacovides CL, Kaufman EJ, Sadek HM, Perea LL, Poloni CM, Shnaydman I, Lee AJ, Sharp V, Miciura A, Trevizo E, Rosenthal MG, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed AT, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Moncrief M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster KM, Ferrada P. Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study. Injury 2024:111523. [PMID: 38614835 DOI: 10.1016/j.injury.2024.111523] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE Level III, Therapeutic Care Management.
Collapse
Affiliation(s)
- Asanthi M Ratnasekera
- Department of Surgery, Division of Trauma and Surgical Critical Care, Associate Professor of Surgery, Drexel College of Medicine, Philadelphia, PA, United States; Crozer Health Upland PA, Currently at Christianacare Health, Newark, DE, United States.
| | - Sirivan S Seng
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Daniel Kim
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University, Roanoke, VA, United States
| | - Christina L Jacovides
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States; Currently at Temple University, Philadelphia, PA, United States
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Hannah M Sadek
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Lindsey L Perea
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, United States
| | - Christina Monaco Poloni
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Ilya Shnaydman
- Department of Surgery, Medical Director, Surgical Intensive Care Unit, New York Medical College, West Chester Medical Center, Valhalla, NY, United States
| | | | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Angela Miciura
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Eric Trevizo
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Martin G Rosenthal
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - William Zhao
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - Alicia Keininger
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - Michele Hunt
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - John Cull
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Chassidy Balentine
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Tanya Egodage
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Aleem T Mohamed
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Michelle Kincaid
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Stephanie Doris
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Robert Cotterman
- Department of Surgery, Promedica Toledo Hospital, Toledo, OH, United States
| | - Sara Seegert
- Department of Research, Promedica Toledo Hospital, Toledo, OH, United States
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Melissa Moncrief
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Brandi Palmer
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Caleb Mentzer
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Nichole Tackett
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Tjasa Hranjec
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Thomas Dougherty
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Shawna Morrissey
- Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, United States
| | - Lauren Donatelli-Seyler
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Leah C Tatebe
- Department of Surgery, Cook County Hospital, Chicago, IL, United States; Currently at Northwestern Memorial Hospital, Chicago, IL, United States
| | - Tiffany J Nevill
- Department of Surgery, Cook County Hospital, Chicago, IL, United States
| | - Michel B Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - David Hamilton
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Diane Redmond
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Daniel C Cullinane
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Mark McMellen
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Chris Duran
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Jennifer Daniels
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Shana Ballow
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Kevin M Schuster
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Paula Ferrada
- Department of Surgery, INOVA Fairfax Health System, Fairfax, VA, United States
| |
Collapse
|
3
|
Feather CB, Rehrig S, Allen R, Barth N, Kugler EM, Cullinane DC, Falank CR, Bhattacharya B, Maung AA, Seng S, Ratnasekera A, Bass GA, Butler D, Pascual JL, Srikureja D, Winicki N, Lynde J, Nowak B, Azar F, Thompson LA, Nahmias J, Manasa M, Tesoriero R, Kumar SB, Collom M, Kincaid M, Sperwer K, Santos AP, Klune JR, Turcotte J. To close or not to close? Wound management in emergent colorectal surgery, an EAST Multicenter prospective cohort study. J Trauma Acute Care Surg 2024:01586154-990000000-00677. [PMID: 38523130 DOI: 10.1097/ta.0000000000004321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND To determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS) and mortality in emergent colorectal surgery. METHODS A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, ICU admission, vasopressor use, procedure details and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS In total, 557 patients were included (SC n = 262, SLC n = 124, SO n = 171). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups (Table 1). Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group (Table 2). After risk adjustment, SO was associated with increased risk of mortality (OR = 3.003, p = 0.028 in comparison to the SC group. SLC was associated with increased risk of superficial SSI (OR = 3.439, p = 0.014), after risk adjustment. CONCLUSION When compared to the SC group, the SO group was associated with mortality, but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. STUDY TYPE Level III Therapeutic/Care Management.
Collapse
Affiliation(s)
- Cristina B Feather
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | - Scott Rehrig
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | - Rebecca Allen
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | | | | | | | | | | | | | | | | | - Gary Alan Bass
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Dale Butler
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Jose L Pascual
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Nolan Winicki
- Loma Linda University Medical Center, Loma Linda, CA
| | - Jennifer Lynde
- Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Brittany Nowak
- Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Faris Azar
- St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | - Lauren A Thompson
- St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | | | - Morgan Manasa
- University of California at Irvine Health, Orange, CA
| | - Ronald Tesoriero
- Zuckerberg San Francisco General Hospital, UCSF, San Francisco, CA
| | - Sandhya B Kumar
- Zuckerberg San Francisco General Hospital, UCSF, San Francisco, CA
| | | | | | | | - Ariel P Santos
- Texas Tech University Health Science Center, Lubbock, TX
| | - J Robert Klune
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| | - Justin Turcotte
- Anne Arundel Medical Center and Doctors Community Medical Center, Luminis Health, Annapolis, MD
| |
Collapse
|
4
|
Ratnasekera AM, Kim D, Seng SS, Jacovides C, Kaufman EJ, Sadek HM, Perea LL, Monaco C, Shnaydman I, Jeongyoon Lee A, Sharp V, Miciura A, Trevizo E, Rosenthal M, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed A, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Whitmill M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster K, Ferrada P. Early VTE Prophylaxis in Severe Traumatic Brain Injury: A Propensity Score Weighted EAST Multi-Center Study. J Trauma Acute Care Surg 2023:01586154-990000000-00329. [PMID: 37017458 DOI: 10.1097/ta.0000000000003985] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Patients with TBI are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS A retrospective review of adult patients ≥18 years of age with isolated severe TBI (AIS ≥ 3) who were admitted to 24 level 1 and level 2 trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic & clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE & ICHE with patient group as predictor of interest. RESULTS Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared to those in VTEP≤24 ( [OR] = 1.51; [95%CI] = 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared to VTEP≤24 (OR = 0.75; 95%CI = 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSIONS In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE level III, Therapeutic Care Management.
Collapse
|
5
|
Kwon E, Krause C, Luo-Owen X, McArthur K, Cochran-Yu M, Swentek L, Burruss S, Turay D, Krasnoff C, Grigorian A, Nahmias J, Butt A, Gutierrez A, LaRiccia A, Kincaid M, Fiorentino M, Glass N, Toscano S, Ley EJ, Lombardo S, Guillamondegui O, Bardes JM, DeLa'O C, Wydo S, Leneweaver K, Duletzke N, Nunez J, Moradian S, Posluszny J, Naar L, Kaafarani H, Kemmer H, Lieser M, Hanson I, Chang G, Bilaniuk JW, Nemeth Z, Mukherjee K. Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry). Eur J Trauma Emerg Surg 2021; 48:2107-2116. [PMID: 34845499 DOI: 10.1007/s00068-021-01814-w] [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: 07/15/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE 2B.
Collapse
Affiliation(s)
- Eugenia Kwon
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Cassandra Krause
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Xian Luo-Owen
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | | | - Meghan Cochran-Yu
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Lourdes Swentek
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Sigrid Burruss
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - David Turay
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Chloe Krasnoff
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Jeffrey Nahmias
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Ahsan Butt
- USC-Keck School of Medicine, Los Angeles, CA, USA
| | - Adam Gutierrez
- General Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Aimee LaRiccia
- General Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Michelle Kincaid
- General Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Michele Fiorentino
- Trauma and Surgical Critical Care, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Nina Glass
- Trauma and Surgical Critical Care, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Samantha Toscano
- General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric Jude Ley
- General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sarah Lombardo
- Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oscar Guillamondegui
- Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James Migliaccio Bardes
- Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Connie DeLa'O
- Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Salina Wydo
- Trauma, Cooper University Health System, Camden, NJ, USA
| | | | - Nicholas Duletzke
- General Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Jade Nunez
- General Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Simon Moradian
- Trauma and Critical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Joseph Posluszny
- Trauma and Critical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Leon Naar
- Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham Kaafarani
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Kemmer
- Surgery, Research Medical Center-Kansas City Hospital, Kansas City, MO, USA
| | - Mark Lieser
- Surgery, Research Medical Center-Kansas City Hospital, Kansas City, MO, USA
| | - Isaac Hanson
- Trauma and Critical Care Surgery, Mount Sinai Hospital-Chicago, Chicago, IL, USA
| | - Grace Chang
- Trauma and Critical Care Surgery, Mount Sinai Hospital-Chicago, Chicago, IL, USA
| | | | - Zoltan Nemeth
- Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA.
| |
Collapse
|
6
|
McArthur K, Krause C, Kwon E, Luo-Owen X, Cochran-Yu M, Swentek L, Burruss S, Turay D, Krasnoff C, Grigorian A, Nahmias J, Butt A, Gutierrez A, LaRiccia A, Kincaid M, Fiorentino MN, Glass N, Toscano S, Ley E, Lombardo SR, Guillamondegui OD, Bardes JM, DeLa'O C, Wydo SM, Leneweaver K, Duletzke NT, Nunez J, Moradian S, Posluszny J, Naar L, Kaafarani H, Kemmer H, Lieser MJ, Dorricott A, Chang G, Nemeth Z, Mukherjee K. Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial). J Trauma Acute Care Surg 2021; 91:100-107. [PMID: 34144559 PMCID: PMC8331055 DOI: 10.1097/ta.0000000000003210] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population. METHODS We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head. RESULTS Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001). CONCLUSION Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury. LEVEL OF EVIDENCE Therapeutic study, level IV.
Collapse
Affiliation(s)
- Kaitlin McArthur
- From the Division of Acute Care Surgery (K. McArthur), Loma Linda University School of Medicine, Loma Linda, California; Division of Acute Care Surgery (C.K., E.K., X.L.-O., M.C.-Y., S.B., D.T., K. Mukherjee), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma, Burns, Critical Care, and Acute Care Surgery (L.S., C.K., A.G., J. Nahmias), UC Irvine Medical Center, Irvine, California; Division of Trauma and Critical Care (A.B., A.G.), LAC+USC Medical Center, Los Angeles, California; Grant Medical Center Trauma Services (A.L., M.K.), Ohio Health Grant Medical Center, Columbus, Ohio; Division of Trauma/Surgical Critical Care (M.N.F., N.G.), Rutgers-New Jersey Medical School, Newark, New Jersey; Division of Trauma (S.T., E.L.), Cedars-Sinai Medical Center, Los Angeles, California; Division of Trauma and Surgical Critical Care (S.R.L., O.D.G.), Vanderbilt University Medical Center, Nashville, Tennessey; Division of Trauma/Acute Care Surgery/Critical Care (J.M.B., C.D.), West Virginia University, Morgantown, West Virginia; Division of Trauma (S.M.W., K.L.), Cooper University Health System, Camden, New Jersey; Section of Acute Care Surgery (N.T.D., J. Nunez), University of Utah Medical Center, Salt Lake City, Utah; Division of Trauma and Critical Care Surgery (S.M., J.P.), Northwestern Memorial Hospital, Chicago, Illinois; Division of Trauma, Emergency Surgery and Surgical Critical Care (L.N., H. Kaafarani), Massachusetts General Hospital, Boston, Massachusetts; Trauma Center (H. Kemmer, M.J.L.), Research Medical Center-Kansas City Hospital, Kansas City, Missouri; Mount Sinai Hospital-Chicago (A.D., G.C.), Chicago, Illinois; and Trauma and Acute Care Center (Z.N.), Morristown Medical Center, Morristown, New Jersey
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Heilbronner RN, Kincaid M, Walliser G, Pershing M, Spalding MC. Safety and efficacy of thromboelastography guidance of antifibrinolytic therapy in trauma patients: An observational cohort analysis. Int J Crit Illn Inj Sci 2021; 11:67-72. [PMID: 34395207 PMCID: PMC8318174 DOI: 10.4103/ijciis.ijciis_79_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/24/2020] [Accepted: 01/01/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Tranexamic acid (TXA) is an antifibrinolytic therapy intended to decrease blood loss and improve hemostasis in traumatic hemorrhage. Viscoelastic assays, such as thromboelastography (TEG), allow for the identification of a patient's specific hemostasis. The purpose of this research study was to explore the safety and efficacy of TEG-guided antifibrinolytic therapy in trauma patients. Methods: This study was a retrospective review of trauma patients meeting institution-specific inclusion criteria for TXA. Patients were assigned to fibrinolytic groups per TEG LY30 data. Safety outcomes (24-h mortality, overall in-hospital mortality, and thromboembolic events) were compared between patients who did or did not receive TXA and within fibrinolytic groups. Mortality outcomes were adjusted for baseline Injury Severity Score (ISS). Secondary aims included blood product utilization, length of hospital, and intensive care unit stay. Results: Hypofibrinolysis was the most common fibrinolytic phenotype. Adjusting for ISS, there were no significant differences in mortality. A 30.7% thromboembolism incidence was identified in the TXA group compared to 16.6% not receiving TXA (P = 0.26), with 72.7% of these patients experiencing fibrinolytic shutdown. Conclusions: There were no differences in 24-h mortality, all-cause mortality, or secondary outcomes. The difference in thromboembolic rates between patients receiving TXA and those who did not, while not statistically significant, poses clinical concern.
Collapse
Affiliation(s)
| | - Michelle Kincaid
- Department of Trauma, OhioHealth Grant Medical Center, Columbus, Ohio, USA
| | - Grant Walliser
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio, USA
| | - Michelle Pershing
- Department of Research, OhioHealth Research and Innovation Institute, Columbus, Ohio, USA
| | - M Chance Spalding
- Department of Trauma, OhioHealth Grant Medical Center, Columbus, Ohio, USA
| |
Collapse
|
8
|
Dybdahl D, Walliser G, Chance Spalding M, Pershing M, Kincaid M. Four-factor prothrombin complex concentrate for the reversal of factor Xa inhibitors for traumatic intracranial hemorrhage. Am J Emerg Med 2019; 37:1907-1911. [DOI: 10.1016/j.ajem.2019.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/30/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022] Open
|
9
|
Hardee A, Crossman L, Ramudit M, Kincaid M, Brohier B. Assessment of knowledge of neglected tropical diseases among future
public health professionals. Ann Glob Health 2016. [DOI: 10.1016/j.aogh.2016.04.228] [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: 11/29/2022] Open
|
10
|
Campbell J, Trgovcich J, Kincaid M, Zimmerman PD, Klenerman P, Sims S, Cook CH. Transient CD8-memory contraction: a potential contributor to latent cytomegalovirus reactivation. J Leukoc Biol 2012; 92:933-7. [PMID: 22730545 DOI: 10.1189/jlb.1211635] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
It is clear that latent CMV can reactivate in immunocompetent individuals, but the mechanism triggering such reactivations remains unclear. Recent clinical data suggest that reactivation can be subverted by CMV-specific T-memory. We therefore monitored CMV-specific T cells in immunocompetent mice with latent mCMV after a known reactivation trigger (LPS). LPS induced transient systemic contraction of mCMV-specific CD8 memory that was followed by transcriptional reactivation. Subsequent recovery of mCMV-specific T cells coincided with resumption of latency. These data suggest that bacterial antigen encounters can induce transient T-memory contraction, allowing viral recrudescence in hosts latently infected with herpes family viruses.
Collapse
Affiliation(s)
- Jonathan Campbell
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA
| | | | | | | | | | | | | |
Collapse
|
11
|
Kincaid M, Thomas A, Zimmerman P, Klenerman P, Bergdall V, Hickman-Davis J, Trgovcich J, Cook C. Development of CD8 T-memory inflation after cytomegalovirus infection determined by initial viral burden (39.28). The Journal of Immunology 2010. [DOI: 10.4049/jimmunol.184.supp.39.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Both mice and humans can develop large “inflated” populations of CD8 effector memory T-cells after cytomegalovirus (CMV) infection, and such memory inflation has been associated with immune senescence. Not all humans develop CD8 memory inflation after CMV infection, so we hypothesized that memory inflation might be predicated by the initial viral burden. Because it is impossible to know an individuals CMV inoculum during natural infection, we infected mice with murine CMV (MCMV) titers ranging from 102 to 106 PFU. After infection, peripheral blood was evaluated monthly for MCMV-specific CD8 T-cells and antibody. Using MCMV-specific MHC class I tetramers we confirm that high titer infections induce inflationary T-memory responses. In contrast, low titer infections induce significantly less inflation over time. Serum ELISA for MCMV-antibody responses showed a similar pattern. DNA from lung tissues evaluated 16 weeks after infection confirmed successful infection in all mice. Quantitative PCR showed that latent viral load in lungs correlated well with eventual lung resident T-memory responses (R2=0.96). We therefore conclude that an individual’s initial infectious burden determines their latent viral load and eventual development of memory inflation after cytomegalovirus infection, possibly explaining the wide variability in T-cell responses to CMV observed in humans.
Collapse
Affiliation(s)
| | - Alicia Thomas
- 1Dept of Surgery, The Ohio State University, Columbus, OH
| | | | - Paul Klenerman
- 2University of Oxford - Dept of Medicine, Oxford, United Kingdom
| | - Valerie Bergdall
- 4The Ohio State University - Dept of Veterinary Medicine, Columbus, OH
| | | | | | - Charles Cook
- 1Dept of Surgery, The Ohio State University, Columbus, OH
| |
Collapse
|
12
|
Miner L, Kincaid M. The hockey doc. J Okla Dent Assoc 1998; 88:34-6. [PMID: 9791236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
|
13
|
Constantino JN, Liberman M, Kincaid M. Effects of serotonin reuptake inhibitors on aggressive behavior in psychiatrically hospitalized adolescents: results of an open trial. J Child Adolesc Psychopharmacol 1997; 7:31-44. [PMID: 9192540 DOI: 10.1089/cap.1997.7.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Low concentrations of the neurotransmitter serotonin and its 5-hydroxyindoleacetic acid metabolite in the central nervous system have been associated with increased aggressive behavior in animals and humans. Controlled clinical trials of serotonin agonists in depressed adults have suggested that aggressive behavior is less likely during treatment with these medications than with placebo, but there have been no previous studies of selective serotonin reuptake inhibitors (SSRIs) and aggression in children. We prospectively followed the course of aggressive behavior in 19 psychiatrically hospitalized adolescents (not selected for aggressiveness) who received open clinical trials of fluoxetine, paroxetine, or sertraline. The patients received standard doses (equivalent to fluoxetine 10-40 mg daily) for a minimum of 5 weeks. The starting dose was 15 +/- 5 mg, and dosages were raised at a mean rate of 5 mg every 4 days up to a mean dose of 25 +/- 10 mg daily. Results from trials of the three SSRIs were clustered because the sample sizes were not sufficient for separate analyses. Overall, there were no statistically meaningful improvements in the level of aggressive behavior, as measured on a modified version of the Overt Aggression Scale, over the course of these patients' SSRI trials. Symptoms of physical aggression toward others or self were manifest in 12 of the 19 patients while on SSRIs. Of the 19 patients, 13 were assessed both on and off SSRIs: verbal aggression (p = 0.04), physical aggression toward objects (p = 0.05), and physical aggression toward self (p < 0.02) occurred significantly more frequently on SSRIs than off; no increase was observed in physical aggression toward others. Patients with the highest baseline aggressivity scores did not show greater improvement during SSRI treatment. Further research is warranted, particularly to explore whether SSRIs may have therapeutic effects on aggression at higher (or lower) doses than were administered in this open trial.
Collapse
Affiliation(s)
- J N Constantino
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | |
Collapse
|
14
|
el-Massry A, Meredith TA, Aguilar HE, Shaarawy A, Kincaid M, Dick J, Mahmoud MI. Aminoglycoside levels in the rabbit vitreous cavity after intravenous administration. Am J Ophthalmol 1996; 122:684-9. [PMID: 8909208 DOI: 10.1016/s0002-9394(14)70487-8] [Citation(s) in RCA: 28] [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: 02/03/2023]
Abstract
PURPOSE To determine the penetration of gentamicin and amikacin into the rabbit vitreous cavity after their intravenous administration. METHODS Gentamicin (1.6 mg/kg every 8 hours) and amikacin (6 mg/kg every 12 hours) were administered intravenously to 25 rabbits that had previously had the lens and vitreous removed from 43 eyes. For each drug, ocular inflammation was induced in one group of eyes by injection of heat-killed Staphylococcus epidermidis, while the other group was maintained as a control. Samples from the vitreous cavity were taken at regular intervals for 72 hours after beginning the intravenous medications and were analyzed for drug concentrations. RESULTS The maximum intravitreal concentration +/- SD achieved for gentamicin was 1.8 +/- 0.5 microgram/ml. The maximum intravitreal concentration for amikacin was 8.5 +/- 3.2 micrograms/ml. Inflamed eyes demonstrated higher concentrations than did those without inflammation. CONCLUSIONS In a rabbit model with conditions optimized to enhance penetration of antimicrobials into the vitreous cavity after intravenous administration, neither gentamicin nor amikacin penetrated sufficiently to reach potentially therapeutic concentrations consistently for either Pseudomonas or S epidermidis organisms.
Collapse
Affiliation(s)
- A el-Massry
- Department of Ophthalmology, St. Louis University School of Medicine, Missouri, USA
| | | | | | | | | | | | | |
Collapse
|
15
|
Putnam KM, Harvey PD, Parrella M, White L, Kincaid M, Powchik P, Davidson M. Symptom stability in geriatric chronic schizophrenic inpatients: a one-year follow-up study. Biol Psychiatry 1996; 39:92-9. [PMID: 8717606 DOI: 10.1016/0006-3223(95)00105-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The results of previous studies of symptom stability in schizophrenia suggest that negative symptoms manifest traitlike characteristics while positive symptoms fluctuate over time. Various prospective studies of chronic schizophrenic patients have found consistent results, regardless of the follow-up period, yet there is little research addressing symptomatology in geriatric schizophrenic patients. Since these patients have a very poor outcome and more severe negative symptoms, their symptoms might differ from younger patients. This study examined the course of symptomatology in 178 geriatric schizophrenic inpatients who were assessed twice at a 1-year interval with the Positive and Negative Syndrome Scale (PANSS). Intraclass correlations revealed that the distribution of negative symptoms was considerably more stable than that of positive symptoms over the interval, and subtypes based on negative symptoms were the only ones that manifested consistent stability over time. There was also a significant increase in negative symptom severity for the sample, with a slight decrease in positive symptom severity. Thus, even in chronic inpatients, with a very extended illness, positive symptom severity is not particularly stable within patients. These data indicate that the characteristics of negative and positive schizophrenic symptoms are similar in younger and geriatric schizophrenic patients, suggesting a continuity of the illness process. Tentative evidence for increasing severity of negative symptoms over a brief follow-up period suggests the possibility of a steady worsening of clinical state in very elderly patients who remained hospitalized.
Collapse
Affiliation(s)
- K M Putnam
- Mount Sinai School of Medicine, New York, NY 10029, USA
| | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
PURPOSE We studied the effects of inflammation, repeated antibiotic doses, and the surgical status of the eye on penetration of vancomycin hydrochloride into the rabbit vitreous cavity after intravenous administration. METHODS We studied three anatomic states (phakic, aphakic, and aphakic, vitrectomy-treated eyes) subdividing each into inflamed and noninflamed groups. Intravenous vancomycin hydrochloride (15 mg/kg of body weight) was administered every 12 hours for 48 hours. Eyes were harvested for the assay of vitreous cavity antibiotic levels at various intervals from one to 49 hours. We determined concentrations and calculated mean values and S.E.M. RESULTS Therapeutic levels were not established in the vitreous cavity at any time period in the two phakic groups. At 25 hours, the inflamed aphakic eyes had concentrations of 5.05 +/- 1.9 micrograms/ml and the control noninflamed aphakic eyes 4.5 +/- 1.23 micrograms/ml; slight increases were found by 49 hours. Concentrations tested in the aphakic, vitrectomy-treated eyes at two, 13, 25, and 49 hours demonstrated progressive increases both in the inflamed eyes (5.4 +/- 2.4 micrograms/ml, 9.64 +/- 4.25 micrograms/ml, 9.2 +/- 3.96 micrograms/ml, 10.34 +/- 4.49 micrograms/ml) and noninflamed eyes (3.52 +/- 2.1 micrograms/ml, 5.4 +/- 1.96 micrograms/ml, 6.8 +/- 2.53 micrograms/ml, 8.7 +/- 5.44 micrograms/ml). CONCLUSIONS Vitreous vancomycin concentrations in aphakic and aphakic, vitrectomy-treated eyes after intravenous administration exceed the minimal inhibitory concentrations for the usual gram-positive pathogens that create endophthalmitis, suggesting a role for intravenous vancomycin in the treatment of bacterial endophthalmitis.
Collapse
Affiliation(s)
- T A Meredith
- Department of Ophthalmology, St. Louis University School of Medicine, Missouri, USA
| | | | | | | | | | | |
Collapse
|
17
|
Abstract
PURPOSE Penetration of ceftazidime, a third generation cephalosporin, into the vitreous cavity after intravenous administration was investigated. METHODS Because antimicrobial penetration varies with surgical status of the eye and with inflammation, studies were conducted in phakic, aphakic, and aphakic, vitrectomized eyes in both normal and inflamed conditions. Ceftazidime 50 mg/kg was administered every 8 hours and vitreous cavity concentrations were tested at intervals from 2 to 72 hours after the initial dose. RESULTS No penetration was found into control phakic and aphakic eyes, but drug concentrations were detected in inflamed eyes at 24 hours. Vitreous concentrations of ceftazidime in aphakic, vitrectomized eyes reached levels well above the minimal inhibitory concentration (MIC) for Pseudomonas organisms within 2 hours of intravenous administration in control eyes (8.5 micrograms/ml) and inflamed eyes (35.4 micrograms/ml). Inflammation and removal of the lens and vitreous significantly enhanced ceftazidime penetration at all time periods tested. CONCLUSION Ceftazidime penetrates into the vitreous cavity of inflamed eyes after intravenous administration and achieves concentrations above the MIC for Pseudomonas organisms. Penetration is greatest in aphakic, vitrectomized eyes.
Collapse
Affiliation(s)
- H E Aguilar
- Department of Ophthalmology, St. Louis University School of Medicine, Missouri, USA
| | | | | | | | | |
Collapse
|
18
|
Harrison JM, O'Connor PS, Young RS, Kincaid M, Bentley R. The pattern ERG in man following surgical resection of the optic nerve. Invest Ophthalmol Vis Sci 1987; 28:492-9. [PMID: 3557862] [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: 01/06/2023] Open
Abstract
Pattern electroretinogram (PERG) results recorded in different laboratories from patients with unilateral traumatic transections of the optic nerve have led investigators to opposite conclusions about the sources of this response. There was no absolute demonstration of complete transection in any of these studies. In the present study, PERGs and flash ERGs were recorded from a patient who, 30 months earlier, had undergone surgical resection of the right optic nerve to remove a glioma. The histological section of the biopsied nerve confirmed complete optic nerve transection. Ophthalmoscopically and angiographically, the right eye was normal except for marked optic atrophy. PERGs were produced by 10 Hz reversal of high contrast checks with check widths from 13 deg 30 min to 12 min arc. Field size was 27 deg X 21 deg and space-averaged screen luminance was 110 cd/m2. Smaller checks (3 deg 23 min to 12 min) produced responses in both eyes, but the responses in the right eye were much smaller than those in the left eye. Large checks and diffuse flashes produced approximately equal responses in the two eyes. The implicit times of the PERGs produced by stimulation of the right eye with smaller checks were shorter than those of the left eye. The authors conclude that, in humans, there is a contribution to the high contrast pattern reversal ERG from cells which are not dependent upon the integrity of the ganglion cell layer. These cells and cells dependent upon ganglion cells may both contribute to the high contrast PERG in the normal human eye.
Collapse
|
19
|
Abstract
Sodium fluorescein may be safely administered orally. The resulting angiograms serve to document the presence or absence of dye leakage in the same manner as venous injection. The oral route of administration is of particular benefit for use in children, patients with inaccessible veins, and patients participating in studies of late retinal vascular leakage, such as postoperative cystoid macular edema. Serum concentrations of the dye plateau between thirty minutes and one hour, at levels approximating those obtained by intravenous injection.
Collapse
|
20
|
Kincaid M. "We kept our fingers crossed!". Am Med News 1980; 23:suppl 11-2. [PMID: 10246038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
|
21
|
Sheffer A, Green WR, Fine SL, Kincaid M. Presumed ocular histoplasmosis syndrome. A clinicopathologic correlation of a treated case. Arch Ophthalmol 1980; 98:335-40. [PMID: 6153264 DOI: 10.1001/archopht.1980.01020030331021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A patient with bilateral presumed ocular histoplasmosis had been successfully treated in his symptomatic right eye with laser photocoagulation for subretinal neovascularization in two areas of the macula. The left eye also showed neovascularization clinically and histopathologically but was not treated because there was no detectable leakage and the vision was not affected. There was no change in the left eye over a two-year period. Clinicopathologic correlation of the treated and untreated macular lesions and the peripapillary and peripheral lesions is presented.
Collapse
|
22
|
Abstract
Fluorescein sodium can be administered safely by mouth. The resulting fluorograms are useful in demonstrating many retinal conditions characterized by bright late leakage, such as cystoid macular edema. Oral administration of fluorescein may be preferred in studies of children, patients with difficult veins, and in some surveys of large patient populations.
Collapse
|
23
|
Kincaid M. Health care problems? Typical American view: no serious complaints. Am Med News 1979; 22:suppl 4. [PMID: 10278003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
|
24
|
Abstract
Laser scotometry is an accurate means of detecting dense blind spots. A small low-energy spot is guided across the fundus from nonseeing to seeing areas. Patient responses are recorded on fundus photographys, allowing direct correlation with fundus pathology. Accuracy to less than 1 degree is feasible. All typical optic nerve drusen tested with this technique had field defects. In cases of optic nerve pits, dense scotomas correlated with the shape of visible nerve fiber defects rather than with the shape of serous retinal detachments.
Collapse
|
25
|
|