Publications by authors named "Bellal A Joseph"

19 Publications

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Turning value into action: Healthcare workers using digital media advocacy to drive change.

PLoS One 2021 29;16(4):e0250875. Epub 2021 Apr 29.

Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States of America.

Background: The standard method of sharing information in academia is the scientific journal. Yet health advocacy requires alternative methods to reach key stakeholders to drive change. The purpose of this study was to analyze the impact of social media and public narrative for advocacy in matters of firearm-related injury and death.

Study Design: The movement This Is Our Lane was evaluated through the #ThisIsOurLane and #ThisIsMyLane hashtags. Sources were assessed from November 2018 through March 2019. Analyses specifically examined message volume, time course, global engagement, and content across Twitter, scientific literature, and mass media. Twitter data were analyzed via Symplur Signals. Scientific literature reviews were performed using PubMed, EMBASE, Web of Science, and Google Scholar. Mass media was compiled using Access World News/Newsbank, Newspaper Source, and Google.

Results: A total of 507,813 tweets were shared using #ThisIsOurLane, #ThisIsMyLane, or both (co-occurrence 21-39%). Fifteen scientific items and n = 358 mass media publications were published during the study period; the latter included articles, blogs, television interviews, petitions, press releases, and audio interviews/podcasts. Peak messaging appeared first on Twitter on November 10th, followed by mass media on November 12th and 20th, and scientific publications during December.

Conclusions: Social media enables clinicians to quickly disseminate information about a complex public health issue like firearms to the mainstream media, scientific community, and general public alike. Humanized data resonates with people and has the ability to transcend the barriers of language, culture, and geography. Showing society the reality of caring for firearm-related injuries through healthcare worker stories via digital media appears to be effective in shaping the public agenda and influencing real-world events.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250875PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084157PMC
April 2021

Modifiable factors to improve work-life balance for trauma surgeons.

J Trauma Acute Care Surg 2021 01;90(1):122-128

From the Department of Surgery, Division of Acute Care Surgery, Dell Medical School (C.V.R.B.), University of Texas at Austin, Austin, Texas; University of Arizona College of Medicine (B.A.J.), Tucson, Arizona; Yale School of Medicine (K.D.), New Haven, Connecticut; and University of California Davis (G.J.J.), Sacramento, California.

Introduction: A balance between work and life outside of work can be difficult for practicing physicians to achieve, especially for trauma surgeons. Work-life balance (WLB) has been associated with burnout and career changes. The specific aim of this study was to investigate factors associated with WLB for trauma surgeons. We hypothesized that trauma surgeons are dissatisfied with their WLB, and there are modifiable factors that can be adjusted to improve and maintain WLB.

Methods: Survey study of AAST members including detailed questions regarding demographics, clinical practice, family, lifestyle, and emotional support. Primary outcome was WLB, while the secondary outcome was surgeon burnout.

Results: A total of 1,383 American Association for the Surgery of Trauma members received an email with the survey, and 291 (21%) completed the survey. There was a total of 125 members (43%) satisfied with their WLB, and 166 (57%) were not. Factors independently associated with satisfying WLB included hobbies (2.3 [1.1-4.7], p = 0.03), healthy diet (2.6 [1.2-4.4], p = 0.02), exercise (2.6 [1.3-5.1], p = 0.006), vacation weeks off (1.3 [1.0-1.6], p = 0.02), and fair compensation (2.6 [1.3-5.3], p = 0.008). Conversely, factors independently associated with a poor WLB included being midcareer (0.3 [0.2-0.7], p = 0.002), more work hours (0.4 [0.2-0.7], p = 0.006), fewer awake hours at home (0.2 [0.1-0.6], p = 0.002), and feeling that there is a better job (0.4 [0.2-0.9], p = 0.02]. Risk factors for burnout were the same as those for poor WLB.

Conclusion: Only 43% of trauma surgeons surveyed were satisfied with their WLB, and 61% reported burnout. Modifiable factors independently associated with a satisfying WLB were related to lifestyle and fair compensation. Factors independently associated with poor WLB and suffering burnout were being midcareer, increased hours at work, decreased awake hours at home, and feeling that there was a better job for yourself. Many factors associated with trauma surgeon WLB are modifiable. Trauma surgeons, as well as trauma leaders, should focus on these modifiable factors to optimize WLB and minimize burnout.

Level Of Evidence: Care management, Level III.
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http://dx.doi.org/10.1097/TA.0000000000002910DOI Listing
January 2021

A statistically rigorous deep neural network approach to predict mortality in trauma patients admitted to the intensive care unit.

J Trauma Acute Care Surg 2020 10;89(4):736-742

From the Department of Pathology (F.S.A.), Yale School of Medicine, Yale University, New Haven, Connecticut; School of Information and Communication Engineering (L.A.), University of Electronic Science and Technology of China (UESTC), Chengdu, China; Department of Electrical Engineering (L.A.), University of Science and Technology, Bannu, Pakistan; Division of Trauma, Acute Care, Burn, and Emergency Surgery (B.A.J.), University of Arizona, Tucson, Arizona; Department of Neurology (A.I.), University of New Mexico, Albuquerque, New Mexico; Department of Computer Science (R.-u.-M.), COMSATS University Islamabad, Islamabad, Pakistan; and Division of Computer Science, Mathematics, and Science (Healthcare Informatics) (S.A.C.B.), St. John's University, New York, New York.

Background: Trauma patients admitted to critical care are at high risk of mortality because of their injuries. Our aim was to develop a machine learning-based model to predict mortality using Fahad-Liaqat-Ahmad Intensive Machine (FLAIM) framework. We hypothesized machine learning could be applied to critically ill patients and would outperform currently used mortality scores.

Methods: The current Deep-FLAIM model evaluates the statistically significant risk factors and then supply these risk factors to deep neural network to predict mortality in trauma patients admitted to the intensive care unit (ICU). We analyzed adult patients (≥18 years) admitted to the trauma ICU in the publicly available database Medical Information Mart for Intensive Care III version 1.4. The first phase selection of risk factor was done using Cox-regression univariate and multivariate analyses. In the second phase, we applied deep neural network and other traditional machine learning models like Linear Discriminant Analysis, Gaussian Naïve Bayes, Decision Tree Model, and k-nearest neighbor models.

Results: We identified a total of 3,041 trauma patients admitted to the trauma surgery ICU. We observed that several clinical and laboratory-based variables were statistically significant for both univariate and multivariate analyses while others were not. With most significant being serum anion gap (hazard ratio [HR], 2.46; 95% confidence interval [CI], 1.94-3.11), sodium (HR, 2.11; 95% CI, 1.61-2.77), and chloride (HR, 2.11; 95% CI, 1.69-2.64) abnormalities on laboratories, while clinical variables included the diagnosis of sepsis (HR, 2.03; 95% CI, 1.23-3.37), Quick Sequential Organ Failure Assessment score (HR, 1.52; 95% CI, 1.32-3.76). And Systemic Inflammatory Response Syndrome criteria (HR. 1.41; 95% CI, 1.24-1.26). After we used these clinically significant variables and applied various machine learning models to the data, we found out that our proposed DNN outperformed all the other methods with test set accuracy of 92.25%, sensitivity of 79.13%, and specificity of 94.16%; positive predictive value, 66.42%; negative predictive value, 96.87%; and area under the curve of the receiver-operator curve of 0.91 (1.45-1.29).

Conclusion: Our novel Deep-FLAIM model outperformed all other machine learning models. The model is easy to implement, user friendly and with high accuracy.

Level Of Evidence: Prognostic study, level II.
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http://dx.doi.org/10.1097/TA.0000000000002888DOI Listing
October 2020

Perioperative complications of complex abdominal wall reconstruction with biologic mesh: A pooled retrospective cohort analysis of 220 patients from two academic centers.

Int J Surg 2020 Feb 8;74:94-99. Epub 2020 Jan 8.

University of Arizona College of Medicine, Banner Medical Center, Tucson, AZ, USA.

Background: Perioperative outcomes in patients who undergo complex abdominal wall reconstruction (CAWR) may be associated with severe complications, mainly when these procedures are done urgently or emergently. This study aims to identify perioperative predictors of outcomes after CAWR with biologic mesh (BM).

Materials And Methods: In a retrospective study, perioperative complications (length of hospital stay, ventilator support, surgical site infection, need for wound VAC, reoperation, total complications, and mortality), were analyzed in all patients who underwent open CAWR with BM over six years in two academic centers. Furthermore, we examined the effect of cardiac disease, BMI, diabetes, COPD, case mixed index, hernia size, wound classification, mesh technique, the setting of surgery, on perioperative complications. Multivariable linear and logistic regression analyses were performed.

Results: There were 220 patients: 134 patients from center A and 86 patients from center W Mean age was 54.9 ± 14.8 years, 47.7% were females, 33.8% of the patients had BMI ≥30 kg/m2 and median hospital length of stay was 7 days. Center W patients had increased need for mechanical ventilation (10.5% vs. 3%, p = 0.02) and higher need for wound VAC (19.8% vs. 6.7%, p = 0.003). On multivariable linear regression, independent patient predictors of increased hospital length of stay (HLO) were: urgent/emergent surgery (β 6.93, 95% CI 1.65-12.22, p = 0.01), cardiac disease (β 7.84, 95% CI 1.23-14.46, p = 0.02) and epigastric defect (β 13.68, 95% CI 0.29-27.06, p = 0.045). Addition-ally, urgent/emergent setting (OR 3.06, 95% CI 1.69-5.55, p < 0.001) and cardiac disease (OR 2.15, 95% CI 1.03-4.50, p = 0.042) were independently associated with increased odds for perioperative complications.

Conclusions: Perioperative complications of patients undergoing CAWR are considerable and depend on defect complexities, the setting of surgery, comorbidities, wound classification, procedural factors, and case-mix index. Prospective studies on perioperative complications are needed.
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http://dx.doi.org/10.1016/j.ijsu.2019.12.035DOI Listing
February 2020

Prolonged operating room time in emergency general surgery is associated with venous thromboembolic complications.

Am J Surg 2019 11 6;218(5):836-841. Epub 2019 May 6.

Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.

Background: We evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS).

Methods: We reviewed six common EGS procedures in the 2013-2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions.

Results: Of 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5-16] for DVTs and 8 days [5-16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12-2.21]) and PE (OR:1.25 [1.11-2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis.

Conclusion: Prolonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation.
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http://dx.doi.org/10.1016/j.amjsurg.2019.04.022DOI Listing
November 2019

Unplanned readmission after traumatic injury: A long-term nationwide analysis.

J Trauma Acute Care Surg 2019 Jul;87(1):188-194

From the School of Medicine, Johns Hopkins University (N.L., S.V.), Baltimore, Maryland; Department of Surgery (A.M.), New York-Presbyterian Columbia University Medical Center, New York, New York; Department of Surgery (H.E., A.K., J.K.C., D.T.E., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (R.D.W.), Kentucky University Medical Center, Lexington, Kentucky; Department of Surgery (A.B.N.), University of Toronto, Toronto, ON, Canada; and Department of Surgery, University of Arizona College of Medicine (B.A.J.), Tucson, Arizona.

Background: Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury.

Methods: Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors.

Results: Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI], 1.09-1.10), comorbidities (aOR, 1.21; 95% CI, 1.21-1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07-1.10 and aOR, 1.04; 95% CI, 1.03-1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62-1.69), Medicaid (aOR, 1.51; 95% CI, 1.48-1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12-1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01-1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49-1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42-1.45), home health care (aOR, 1.27; 95% CI, 1.25-1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78-1.92).

Conclusion: Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking.

Level Of Evidence: Epidemiological study, level III.
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http://dx.doi.org/10.1097/TA.0000000000002339DOI Listing
July 2019

Trauma Surgeon and Palliative Care Physician Attitudes Regarding Goals-of-Care Delineation for Injured Geriatric Patients.

Am J Hosp Palliat Care 2019 Aug 6;36(8):669-674. Epub 2019 Jan 6.

13 Department of Surgery, University of Texas Southwestern, Dallas, TX, USA.

Background: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties' attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty's ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so.

Methods: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine.

Results: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions.

Conclusions: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.
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http://dx.doi.org/10.1177/1049909118823182DOI Listing
August 2019

Characterizing the underlying diagnoses for exploratory laparotomies to improve risk-adjustment models of postoperative mortality.

J Trauma Acute Care Surg 2019 04;86(4):664-669

From the School of Medicine (A.M., N.L.), Johns Hopkins University, Baltimore, Maryland; Department of Surgery (A.M.), New York-Presbyterian, Columbia University Medical Center, New York, New York; Department of Surgery (D.T.E., K.A.S., M.M., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (B.A.J.), University of Arizona College of Medicine, Tucson, Arizona; and Department of Surgery (S.M.F.), Reston Hospital Center, Reston, Virginia.

Background: Surgeons perform emergent exploratory laparotomies (ex-laps) for a myriad of surgical diagnoses. We characterized common diagnoses for which emergent ex-laps were performed and leveraged these groups to improve risk-adjustment models for postoperative mortality.

Methods: Using American Association for the Surgery of Trauma criteria, we identified hospitalizations where the primary procedure was an emergent ex-lap in the 2012 to 2014 (derivation cohort) and 2015 (validation cohort) Nationwide Inpatient Sample. After tabulating all International Classification of Diseases-9th Rev.-Clinical Modification diagnosis codes within these hospitalizations, we divided them into clinically relevant groups. Using two stepwise regression paradigms-forward selection and backward elimination-we identified diagnostic groups significantly associated with postoperative mortality in multivariable logistic regressions. We evaluated the addition of these groups as individual covariates in risk-adjustment models for postoperative mortality using the area under the receiver operator characteristic curve. All regressions additionally adjusted for clinical factors and hospital clustering.

Results: We identified 4127 patients in the derivation cohort (median age, 50 years; 46.0% female; 62.1% white), with an overall mortality rate of 13.4%. Among all patients, we tabulated a total of 164 diagnosis codes, of which 27 (16.5%) may have led to an emergent ex-lap. These 27 codes clinically represented seven diagnostic categories, which captured a majority of the patients (70.4%). Backward elimination and forward selection led to four common diagnosis categories associated with mortality: bleeding, obstruction, shock, and ischemia. Adjusting for these four diagnostic groups in a multivariable logistic regression assessing postoperative mortality increased the area under the receiver operator characteristic curve from 74.5% to 88.2% in the derivation cohort and from 73.8% to 88.2% in the validation cohort.

Conclusion: Seven diagnostic groups account for the majority of the emergent ex-laps. Adjusting for four groups may improve the accuracy of risk-adjustment models for mortality and validating such analytic standardization may optimize best research practices for EGS procedures.

Level Of Evidence: Prognostic and epidemiologic, Level III.
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http://dx.doi.org/10.1097/TA.0000000000002090DOI Listing
April 2019

Recurring emergency general surgery: Characterizing a vulnerable population.

J Trauma Acute Care Surg 2019 03;86(3):464-470

From the School of Medicine (N.L.), Johns Hopkins University, Baltimore, Maryland; Department of Surgery (A.M.), NewYork-Presbyterian Columbia University Medical Center, New York, New York; Department of Surgery (H.E., J.K.C., D.T.E., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (M.H., F.J., B.A.J.), University of Arizona College of Medicine, Tucson, Arizona; Department of Surgery (A.B.N.), University of Toronto, Toronto, Ontario, Canada; and Department of Surgery (J.D.J.), R Adams Cowley Shock Trauma, School of Medicine, University of Maryland, Maryland.

Background: Limited data exist for long-term outcomes after emergency general surgeries (EGSs) in the United States. This study aimed to characterize the incidence of inpatient readmissions and additional operations within 6 months of an EGS procedure.

Methods: In this retrospective observational study, we identified adults (≥18 years old) undergoing one of seven common EGS procedures (appendectomies, cholecystectomies, small bowel resections, large bowel resections, control of gastrointestinal [GI] ulcers and bleeding, peritoneal adhesiolysis, and exploratory laparotomies) who were discharged alive in the 2010-2015 National Readmissions Database. Outcomes included the rates of all-cause inpatient readmissions and of undergoing a second EGS procedure, both within 6 months. Multivariable logistic regression models identified risk factors of reoperation, adjusting for patient, clinical, and hospital factors.

Results: Of 706,678 patients undergoing an EGS procedure 131,291 (18.6%) had an inpatient readmission within 6 months. Among those readmitted, 15,178 (11.6%) underwent a second EGS procedure, occurring at a median of 45 days (interquartile range, 15-95). After adjustment, notable predictors of reoperation included male sex (adjusted odds ratio [aOR], 1.06 [95% confidence interval, 1.01-1.10]); private, nonprofit hospitals (aOR, 1.09 [1.02-1.17]); private, investor-owned hospitals (aOR, 1.09 [1.00-1.85]); discharge to short-term hospital (aOR, 1.35 [1.04-1.74]); discharge with home health care (aOR, 1.19 [1.13-1.25]); and index procedure of control of GI ulcer and bleeding (aOR, 9.38 [8.75-10.05]), laparotomy (aOR, 7.62 [6.92-8.40]), or large bowel resection (aOR, 6.94 [6.44-7.47]).

Conclusion: One fifth of patients undergoing an EGS procedure had an inpatient readmission within 6 months, where one in nine of those underwent a second EGS procedure. As half of all second EGS procedures occurred within 6 weeks of the index procedure, identifying patients with the highest health care needs (index procedure type and discharge needs) may identify patients at risk for subsequent reoperation in nonemergency settings.

Level Of Evidence: Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002151DOI Listing
March 2019

Comparing Outcomes Between "Pull" Versus "Push" Percutaneous Endoscopic Gastrostomy in Acute Care Surgery: Under-Reported Pull Percutaneous Endoscopic Gastrostomy Incidence of Tube Dislodgement.

J Surg Res 2018 12 3;232:56-62. Epub 2018 Jul 3.

Division of Acute Care Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.

Background: Percutaneous endoscopic gastrostomy (PEG) complications are often under-reported in the literature, especially regarding the incidence of tube dislodgement (TD). TD can cause significant morbidity depending on its timing. We compared outcomes between "push" and "pull" PEGs. We hypothesized that push PEGs, because of its T-fasteners and balloon tip, would have a lower incidence of TD and complications compared with pull PEGs.

Methods: We performed a chart review of our prospectively maintained acute care surgery database for patients who underwent PEG tube placement from July 1, 2009 through June 30, 2013. Data regarding age, gender, body mass index, indications (trauma versus nontrauma), and complications (including TD) were extracted. Procedure-related complications were classified as either major if patients required an operative intervention or minor if they did not. We compared outcomes between pull PEG and push PEG. Multiple regression analysis was performed to identify risk factors associated with major complications.

Results: During the 4-y study period, 264 patients underwent pull PEGs and 59 underwent push PEGs. Age, gender, body mass index, and indications were similar between the two groups. The overall complications (major and minor) were similar (20% pull versus 22% push, P = 0.61). The incidence of TD was also similar (12% pull versus 9% push, P = 0.49). However, TD associated with major complications was higher in pull PEGs but was not statistically significant (6% pull versus 2% push, P = 0.21). Multiple regression analysis showed that dislodged pull PEG was associated with major complications (odds ratio 29.5; 95% confidence interval, 11.3-76.9; P < 0.001).

Conclusions: The incidence of pull PEG TD associated with major complications is under-recognized. Specific measures should be undertaken to help prevent pull PEG TD.

Level Of Evidence: IV, therapeutic.
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http://dx.doi.org/10.1016/j.jss.2018.06.011DOI Listing
December 2018

Emergency general surgery in geriatric patients: How should we evaluate hospital experience?

J Trauma Acute Care Surg 2019 02;86(2):189-195

From the School of Medicine (A.M., S.V., N.L.), Johns Hopkins University, Baltimore, Maryland; Department of Surgery (A.M.), NewYork-Presbyterian, Columbia University Medical Center, New York, New York; Department of Surgery (D.E., E.R.H., J.V.S.), Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (B.J.), University of Arizona College of Medicine, Tucson, Arizona; and Department of Surgery (Z.C.), Brigham and Women's Hospital, Boston, Massachusetts.

Introduction: As the aging American population poses unique challenges to acute care services, we determined if either hospital proportion or annual volume of geriatric patients undergoing emergency general surgery (EGS) procedures is associated with outcomes.

Methods: Using criteria from the American Association of the Surgery of Trauma, we identified five EGS procedures in the 2012-2015 Nationwide Inpatient Sample common in geriatric patients (65+ years). We defined hospital proportion as the fraction of geriatric EGS patients divided by all EGS patients, where volume was the raw number of geriatric EGS patients. We then divided hospitals into quartiles both by proportion and then by volume of geriatric patients. Multivariable logistic regressions compared four outcomes between these quartiles: mortality, complications, failure to rescue (FTR; death after a complication), and extended length of stay (LOS; procedure-specific top decile of patients).

Results: We identified 25,084 complex EGS procedures in geriatric patients at 3,528 hospitals (mortality, 10.6%; complications, 30.5%; FTR, 27.7%; extended LOS, 9.1%). The median hospital proportion of geriatric patients among EGS procedures was 42.8% (interquartile range, 33.3-52.2%), whereas the median hospital geriatric EGS volume after nationwide weighting was 40 per year (interquartile range, 20-70/year). After adjustment, the lowest hospital proportion quartile relative to the highest was associated with adverse outcomes: mortality (odds ratio, 1.21 [95% confidence interval, 1.03-1.44]), complications (1.16 [1.05-1.29]), FTR (1.32 [1.08-1.63]), and extended LOS (1.30 [1.12-1.50]). The lowest volume quartile relative to the highest was not associated with adverse outcomes. As the hospital proportion of geriatric patients increased by 10%, the odds of all adverse outcomes decreased: mortality by 7%, complications by 4%, FTR by 9%, and extended LOS by 8%.

Conclusion: When accounting for both, hospital proportion of geriatric EGS patients but not hospital volume is associated with postoperative outcomes, having important implications for quality improvement initiatives, benchmarking endeavors, and health services research.

Level Of Evidence: Care management, level IV; prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000002142DOI Listing
February 2019

Geriatric traumatic brain injury-What we know and what we don't.

J Trauma Acute Care Surg 2018 Oct;85(4):788-798

From the Program in Trauma (D.M.S., R.A.K.), University of Maryland School of Medicine, Baltimore, Maryland; Division of Trauma and Surgical Critical Care, Department of Surgery (D.H.L., F.H., A.C.M.), Rutgers-New Jersey Medical School, Newark, New Jersey; Division Acute Care Surgery, Department of Surgery (F.L.), Department of Surgery Loyola University Medical Center, Hines, Illinois; Division Acute Care Surgery, Department of Surgery McGovern Medical School at UTHealth (S.D.A.), Houston; Department of Surgery (V.A., C.H., M.S.T.), Methodist Dallas Medical Center, Dallas, Texas; Department of Surgery (S.A.), University of Washington, Seattle, Washington; Department of Surgery (J.B., K.J.B.), Oregon Health & Science University, Portland, Oregon; Department of Surgery (R.D.B.), Lehigh Valley Health Network, Allentown, Pennsylvania; Department of Surgery (A.C.B.), University of Kentucky College of Medicine, Lexington, Kentucky; Department of Surgery (W.L.B.), Scripps Memorial Hospital La Jolla, La Jolla, California; Department of Surgery (P.L.B.), University of Alabama School of Medicine, Birmingham, Alabama; Department of Surgery (Z.C.), Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts; Division of Acute Care Surgery, Department of Surgery (P.A.E., F.A.M.), University of Florida College of Medicine, Gainesville, Florida; Department of Surgery (S.M.F.), Reston Hospital Center, Reston, Virginia; Department of Surgery (B.A.J.), University of Arizona, College of Medicine, Tucson, Division Trauma, Critical Care and Acute Care Surgery, Department of Surgery (S.J.K.), Arizona; Baylor Scott & White Health, Dallas, Texas; Department of Surgery (A.S.P.), Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; and Department of Surgery (J.A.Y.), Hofstra-Northwell School of Medicine, East Garden, New York.

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http://dx.doi.org/10.1097/TA.0000000000001910DOI Listing
October 2018

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients.

J Burn Care Res 2018 10;39(6):1000-1005

Department of Surgery, University of Texas Southwestern, Dallas, TX, USA.

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.
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http://dx.doi.org/10.1093/jbcr/iry027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454520PMC
October 2018

Safety and efficacy of brain injury guidelines at a Level III trauma center.

J Trauma Acute Care Surg 2018 03;84(3):483-489

From the Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio (G.E.M., D.A.M., T.A.P., A.T.M., M.D.G.), Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio (C.P.C., Z.J.P., L.B.N.); and Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona (B.A.J.).

Background: Patients with mild to moderate traumatic brain injury (TBI) are often primarily managed by emergency medicine and trauma/acute care physicians. The Brain Injury Guidelines (BIG) were developed at an American College of Surgeons-accredited Level 1 trauma center to triage mild to moderate TBI patients and help identify patients who warrant neurosurgical consultation. The BIG have not been validated at a Level III trauma center. We hypothesized that BIG criteria can be safely adapted to an American College of Surgeons-accredited Level III trauma center to guide transfers to a higher echelon of care.

Methods: We reviewed the trauma registry at a Level III trauma center to identify TBI patients who presented with an Abbreviated Injury Severity-Head score greater than zero. Demographic data, injury details, and clinical outcomes were abstracted with primary outcome measures of worsening on second computed tomography of the head, neurosurgical intervention, transfer to a Level I trauma center, and in-hospital mortality. Patients were classified using the BIG criteria. After validating the BIG in our cohort, we reclassified patients using updated BIG criteria. Updated criteria included mechanism of injury, reclassification of anticoagulation or antiplatelet use, and replacement of the neurologic examination component with stratification by admission Glasgow Coma Scale (GCS) score.

Results: From July 2013 to June 2016, 332 TBI patients were identified: 115 BIG-1, 25 BIG-2, and 192 BIG-3. Patients requiring neurosurgical intervention (n = 30) or who died (n = 29) were BIG-3 with one exception. Patients with GCS score of less than 12 had worse outcomes than those with a GCS score of 12 or greater, regardless of BIG classification. Anticoagulant or antiplatelet use was not associated with worsened outcomes in patients not meeting other BIG-3 criteria. The updated BIG resulted in more patients in BIG-1 (n = 109) and BIG-2 (n = 100) without negatively affecting outcomes.

Conclusion: The BIG can be applied in the Level III trauma center setting. Updated BIG criteria can aid triage of mild to moderate TBI patients to a Level I trauma center and may reduce secondary overtriage.

Level Of Evidence: Care management, level IV.
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March 2018

Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society.

J Trauma Acute Care Surg 2016 11;81(5):936-951

From the Department of Anesthesiology, University of Maryland School of Medicine and Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland (S.M.G.); Case Western Reserve University School of Medicine, and Cardiothoracic and Trauma Anesthesia, Department of Anesthesiology, MetroHealth Medical Center, Cleveland, Ohio (C.E.S.); Department of Anesthesiology, University of Miami Miller School of Medicine, and Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida (A.J.V.); Department of Orthopedic Surgery, Adult and Trauma Service, Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, Baltimore, Maryland (E.A.H.); Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, and Center for Chronic Diseases Outcomes Research, Minneapolis Veterans Affairs Health System, Minnesota (S.S.); Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, West Virginia University, Morgantown, West Virginia (G.S.); Division of Acute Care Surgery (Trauma, Burn, Critical Care, Emergency Surgery), Department of Surgery, University of Michigan, Ann Arbor, Michigan (K.B.T.); Division of Trauma Surgery and Critical Care, Department of Surgery, Rutgers University-New Jersey School of Medicine, Newark, New Jersey (A.F.); East Texas Medical Center, Tyler, Texas (D.E.R.A.); Allegheny General Hospital, Pittsburg, Pennsylvania (M.D.); Division of Trauma, Critical Care, & Emergency Surgery, The University of Arizona College of Medicine, Arizona (B.A.J.); Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington (B.R.H.R.); and Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland (E.R.H.).

Introduction: Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented.

Methods: Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay.

Results: Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel.

Conclusion: We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.
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November 2016

Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers.

Am J Med 2014 Mar 29;127(3):183-7. Epub 2013 Oct 29.

Arizona Telemedicine Program, College of Medicine-Tucson, Tucson, Ariz; Department of Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Ariz.

There has been a spike in interest and use of telehealth, catalyzed recently by the anticipated implementation of the Affordable Care Act, which rewards efficiency in healthcare delivery. Advances in telehealth services are in many areas, including gap service coverage (eg, night-time radiology coverage), urgent services (eg, telestroke services and teleburn services), mandated services (eg, the delivery of health care services to prison inmates), and the proliferation of video-enabled multisite group chart rounds (eg, Extension for Community Healthcare Outcomes programs). Progress has been made in confronting traditional barriers to the proliferation of telehealth. Reimbursement by third-party payers has been addressed in 19 states that passed parity legislation to guarantee payment for telehealth services. Medicare lags behind Medicaid, in some states, in reimbursement. Interstate medical licensure rules remain problematic. Mobile health is currently undergoing explosive growth and could be a disruptive innovation that will change the face of healthcare in the future.
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March 2014

Modified Veress needle decompression of tension pneumothorax: a randomized crossover animal study.

J Trauma Acute Care Surg 2013 Dec;75(6):1071-5

From the Division of Trauma, Critical Care and Emergency Surgery, College of Medicine, University of Arizona, Tucson, Arizona.

Background: The current prehospital standard of care using a large bore intravenous catheter for tension pneumothorax (tPTX) decompression is associated with a high failure rate. We developed a modified Veress needle (mVN) for this condition. The purpose of this study was to evaluate the effectiveness and safety of the mVN as compared with a 14-gauge needle thoracostomy (NT) in a swine tPTX model.

Methods: tPTX was created in 16 adult swine via thoracic CO2 insufflation to 15 mm Hg. After tension physiology was achieved, defined as a 50% reduction of cardiac output, the swine were randomized to undergo either mVN or NT decompression. Failure to restore 80% baseline systolic blood pressure within 5 minutes resulted in crossover to the alternate device. The success rate of each device, death, and need for crossover were analyzed using χ.

Results: Forty-three tension events were created in 16 swine (24 mVN, 19 NT) at 15 mm Hg of intrathoracic pressure with a mean CO2 volume of 3.8 L. tPTX resulted in a 48% decline of systolic blood pressure from baseline and 73% decline of cardiac output, and 42% had equalization of central venous pressure with pulmonary capillary wedge pressure. All tension events randomized to mVN were successfully rescued within a mean (SD) of 70 (86) seconds. NT resulted in four successful decompressions (21%) within a mean (SD) of 157 (96) seconds. Four swine (21%) died within 5 minutes of NT decompression. The persistent tension events where the swine survived past 5 minutes (11 of 19 NTs) underwent crossover mVN decompression, yielding 100% rescue. Neither the mVN nor the NT was associated with inadvertent injuries to the viscera.

Conclusion: Thoracic insufflation produced a reliable and highly reproducible model of tPTX. The mVN is vastly superior to NT for effective and safe tPTX decompression and physiologic recovery. Further research should be invested in the mVN for device refinement and replacement of NT in the field.
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December 2013

Organ donation after traumatic cardiopulmonary arrest.

Am J Surg 2011 Dec 13;202(6):701-5; discussion 705-6. Epub 2011 Oct 13.

Department of Trauma Surgery, University of Arizona, Tucson, AZ 85724, USA.

Background: The gap between demand of transplantable organs and their supply continues to widen. Trauma patients constitute a significant proportion of organ donors. The incidence of organ donation after traumatic cardiopulmonary arrest (TCPA), however, is not clear. The goals of this study were to determine the success rate of organ donation in patients undergoing cardiopulmonary resuscitation (CPR) after trauma and to determine if there are variables that may predict successful organ donation.

Methods: All trauma patients who sustained TCPA from April 2007 to March 2010 were reviewed. We identified all patients who required CPR in the field or the trauma center. Patients were classified as donors if the heart, lung, kidney, small bowel, pancreas, or liver was harvested. Primary outcome was organ donation after CPR.

Results: A total of 252 patients required CPR for TCPA in the field or in the trauma center. There were 39 (15.5%) survivors and 213 (84.5%) fatalities. Only 19 of 213 (8.9%) patients who died after TCPA became organ donors. A total of 26 organs were harvested including 15 kidneys, 6 livers, 4 hearts, and 1 pancreas. Of those who failed to donate organs, 64.7% had a cardiac arrest after the donor network had been contacted but before their arrival.

Conclusions: Survival rate after TCPA is low but organ donation is an important secondary outcome. Patients with predominant head injuries, without thoracic and minimal extremity injuries, should be identified as having a higher chance of going on to organ donation. The greatest barrier to organ donation in TCPA patients is cardiac arrest before donor network arrival.
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http://dx.doi.org/10.1016/j.amjsurg.2011.06.028DOI Listing
December 2011
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