Publications by authors named "Daniel J Grabo"

15 Publications

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Half of geriatric trauma patients have significant ocular disease: Findings of a novel trauma provider eye examination for vision screening.

J Trauma Acute Care Surg 2021 Jul;91(1):148-153

From the Division of Trauma, Surgical Critical Care and Acute Care Surgery, Department of Surgery (J.M.B., D.J.G., K.C.C., A.W.), West Virginia University; West Virginia University School of Medicine (J.D.); West Virginia University Health Sciences Research and Graduate Education (A.A.); Division of Biostatistics (S.W.), West Virginia University School of Public Health; and Department of Ophthalmology (J.N., A.B.), West Virginia University, Morgantown, West Virginia.

Background: Geriatric ground level fall is a common admission diagnosis for trauma centers in the United States. Visual health has been linked to fall risk reduction in older adult but is rarely fully evaluated during a trauma admission. Using a commercial application and a questionnaire, we developed and tested a trauma provider eye examination (TPEE) to screen visual health. This study used the TPEE to (1) evaluate the prevalence of undiagnosed or undertreated visual disease in geriatric trauma patients and (2) determine the feasibility and reliability of the TPEE to screen for vision disease.

Methods: This prospective study included patients older than 60 years evaluated by the trauma service from June 2019 to May 2020. Patients with ocular or globe trauma were excluded. The primary outcome was significant abnormal vision (SAV) found using the TPEE. Ophthalmology performed a dilated examination as the criterion standard for comparison. We assessed the feasibility and reliability of the TPEE. Fisher's exact test and logistic model were used in the data analysis.

Results: Enrollment concluded with 96 patients. Mean age was 75 years, and fall (79%) was the most common mechanism of injury. Significant abnormal vision was common: undiagnosed disease was found in 39% and undertreated in 14%. Trauma provider examination was 94% sensitive and 92% specific for SAV cases. Congruence between TPEE and ophthalmology examination was highest in pupil examination (86%), visual fields (58%), and Amsler grid (52%). Multivariate analysis found that a combination of an abnormal Amsler test and abnormal visual field defect was significantly associated with SAV (odds ratio, 4.1; p = 0.03).

Conclusion: Trauma provider eye examination screening can identify patients with visual deficits. Given the association between visual deficits and fall risk, older adults may benefit from such a screening or a formal ophthalmology referral.

Level Of Evidence: Therapeutic/Care Management, level II.
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http://dx.doi.org/10.1097/TA.0000000000003156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243858PMC
July 2021

Pathologic Fibrinolysis is More Common in a Rural Trauma Setting.

Am Surg 2020 Dec 15:3134820973726. Epub 2020 Dec 15.

Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, 53422West Virginia University, Morgantown, WV, USA.

Introduction: Fibrinolysis (lysis) has been extensively studied in trauma patients. Many studies on the distribution of lysis phenotype have been conducted in setting with short prehospital time. This study aimed to evaluate the distribution of lysis phenotypes in a population with prolonged prehospital times in a rural environment.

Methods: A retrospective study was performed at an American College of Surgeons-verified level 1 trauma center, serving a large rural population. Full trauma team activations from January 1, 2017 to August 31, 2018 were evaluated, and all patients with an ISS>15 analyzed. Thromboelastography was routinely performed on all participants on arrival. Lysis phenotypes were classified based on LY30 results: shutdown (≤.8%), physiologic (.9-2.9%), and hyper (>2.9%).

Results: 259 patients were evaluated, 134 (52%) presented direct from the scene. For scene patients, lysis distribution was 24% physiologic, 49% shutdown, and 27% hyper. Transferred patients demonstrated a reduction in physiologic lysis to 14% ( = .03), shutdown present in 66%, and hyper in 20%. Empiric prehospital tranexamic acid was given to 18 patients, physiologic lysis was present in 6%, shutdown 72%, and hyper 22%; this increase was not statistically significant ( = .5).

Conclusion: Fibrinolysis phenotypes are not consistent across all trauma populations. This study showed rural trauma patients had a significantly increased rate of pathologic lysis. This was consistent for scene and transfer patients who received care at another facility prior to arrival for definitive care. Future studies to evaluate the factors influencing these differences are warranted.
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http://dx.doi.org/10.1177/0003134820973726DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203746PMC
December 2020

A review of general surgery resident experience in common bile duct exploration in the ERCP era.

Am J Surg 2020 10 16;220(4):899-904. Epub 2020 Feb 16.

Department of Surgery, West Virginia University, Morgantown, WV, USA. Electronic address:

Background: Use of minimally invasive techniques for management of common bile duct (CBD) stones has led to declining number of CBD explorations (CBDE) performed at teaching and non-teaching institutions. We evaluate the impact of this decline on surgery training in bile duct procedures.

Study Design: National operative data for general surgery residents (GSR) were examined from 2000 to 2018. Biliary operations including, cholecystectomy open and laparoscopic, and CBDE open and laparoscopic were evaluated for mean number of cases per graduating GSR.

Results: Despite increases in number of GSR, case numbers for laparoscopic cholecystectomy increased 39% from 84 to 117, p < .00001, per GSR. Mean number of cases for open CBDE, however, decreased 74% from 2.7 to 0.7, p < .00001, per GSR and laparoscopic CBDE declined 22% from 0.9 to 0.7 per resident.

Conclusion: GSR operative case volume in CBDE has declined significantly creating a training deficiency for this complex skill. Novel simulation, including fresh cadavers, may offer the best option with high-fidelity, dynamic training to mitigate the loss of low volume, high acuity procedures.
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http://dx.doi.org/10.1016/j.amjsurg.2020.02.032DOI Listing
October 2020

Percutaneous drainage for hinchey Ib and II acute diverticulitis with abscess improves outcomes.

Turk J Gastroenterol 2019 Nov;30(11):976-983

Division of Trauma and Acute Care Surgery, USC Department of Surgery, Los Angeles County University of Southern California Medical Center, Los Angeles, CA, USA.

Background/aims: The role of percutaneous drainage in Hinchey Ib and II diverticulitis is controversial. The aim of the present study was to clarify the indications for percutaneous drainage in such circumstances.

Materials And Methods: This was a single-center retrospective review at an academic tertiary care hospital. All Hinchey Ib and II diverticulitis cases admitted from 2012 to 2014 were considered.

Results: Overall, 104 (78%) patients underwent successful conservative treatment, whereas 30 (22%) patients underwent surgery during admission. During the index admission, abscess drainage was performed in 21 patients, of which 19 patients were successfully managed without surgery on the index admission and two patients ultimately required surgery. Elective versus same-admission surgery resulted in an increase use of laparoscopy (p=0.01), higher rate of restoration of gastrointestinal continuity with the index operation (p=0.04), and lower rate of diverting stoma formation (p<0.01).

Conclusion: Percutaneous drainage may diminish the need for emergent surgery for Hinchey Ib and II diverticulitis. Elective surgery following conservative management increases the use of laparoscopy and decreases the rates of stoma formation.
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http://dx.doi.org/10.5152/tjg.2019.18602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883990PMC
November 2019

Successful management of injuries to the portal triad: A 2019 EAST master class video presentation.

J Trauma Acute Care Surg 2019 Jul;87(1):240-246

From the Department of Surgery (K.C.C., R.L.W., J.M.B., A.W., D.B., J.W.M., D.J.G.), West Virginia University, Morgantown, West Virginia; and Department of Surgery (K.I.), Keck School of Medicine, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1097/TA.0000000000002253DOI Listing
July 2019

Unexploded Ordnance Management.

Mil Med 2018 09;183(suppl_2):24-28

Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX.

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.
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http://dx.doi.org/10.1093/milmed/usy064DOI Listing
September 2018

Catastrophic Non-Survivable Brain Injury Care-Role 2/3.

Mil Med 2018 09;183(suppl_2):73-77

Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX.

A catastrophic brain injury is defined as any brain injury that is expected to result in permanent loss of all brain function above the brain stem level. These clinical recommendations will help stabilize the patient so that they may be safely evacuated from theater. In addition to cardiovascular and hemodynamic goals, special attention must be paid to their endocrine dysfunction and its treatment-specifically steroid, insulin and thyroxin (t4) replacement while evaluating for and treating diabetes insipidus. Determining the futility of care coupled with resource management must also be made at each echelon. Logistical coordination and communication is paramount to expedite these patients to higher levels of care so that there is an increased probability of reuniting them with their family.
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http://dx.doi.org/10.1093/milmed/usy083DOI Listing
September 2018

Prevention of Deep Venous Thromboembolism.

Mil Med 2018 09;183(suppl_2):133-136

Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX.

The nature of many combat wounds puts patients at a high risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE), which fall under the broader disease category of venous thromboembolism (VTE). In addition to the hypercoagulable state induced by trauma, massive injuries to the extremities, prolonged immobility, and long fixed wing transport times to higher echelons of care are unique risk factors for venous thromboembolism in the combat-injured patient. These risk factors mandate aggressive prophylaxis for DVT and PE that can effectively be achieved by the use of lower extremity sequential compression devices and low dose unfractionated heparin or low molecular weight heparin. In addition, inferior vena cava filters are often used for PE prophylaxis when chemical DVT prophylaxis fails or is contraindicated. The following Department of Defense (DoD) Joint Trauma System (JTS) Clinical Practice Guideline (CPG) discusses the current recommendations for the prevention of DVT and PE including the use of inferior vena cava filters (IVCFs).
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http://dx.doi.org/10.1093/milmed/usy072DOI Listing
September 2018

The origin of fatal pulmonary emboli: a postmortem analysis of 500 deaths from pulmonary embolism in trauma, surgical, and medical patients.

Am J Surg 2015 Jun 18;209(6):959-68. Epub 2014 Dec 18.

Los Angeles County-University of Southern California Medical Center, Los Angeles, CA, USA. Electronic address:

Background: The traditional theory that pulmonary emboli (PE) originate from the lower extremity has been challenged.

Methods: All autopsies performed in Los Angeles County between 2002 and 2010 where PE was the cause of death were reviewed.

Results: Of the 491 PE deaths identified, 36% were surgical and 64% medical. Venous dissection for clots was performed in 380 patients; the PE source was the lower extremity (70.8%), pelvic veins (4.2 %), and upper extremity (1.1%). No source was identified in 22.6% of patients. Body mass index (adjusted odds ratio [AOR] 1.044, 95% confidence interval [CI] 1.011 to 1.078, P = .009) and age (AOR 1.018, 95% CI 1.001 to 1.036, P = .042) were independent predictors for identifying a PE source. Chronic obstructive pulmonary disease (AOR .173, 95% CI .046 to .646, P = .009) was predictive of not identifying a PE source.

Conclusions: Most medical and surgical patients with fatal PE had a lower extremity source found, but a significant number had no source identified. Age and body mass index were positively associated with PE source identification. However, a diagnosis of chronic obstructive pulmonary disease was associated with no PE source identification.
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http://dx.doi.org/10.1016/j.amjsurg.2014.09.027DOI Listing
June 2015

Strongyloidiasis hyperinfection in a patient with a history of systemic lupus erythematosus.

Am J Trop Med Hyg 2014 Oct 4;91(4):806-9. Epub 2014 Aug 4.

Department of Pathology, Department of Surgery, and Department of Gastroenterology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California.

Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis, a nematode predominately endemic to tropical and subtropical regions, such as Southeast Asia. Autoinfection enables the organism to infect the host for extended periods. Symptoms, when present, are non-specific and may initially lead to misdiagnosis, particularly if the patient has additional co-morbid conditions. Immunosuppressive states place patients at risk for the Strongyloides hyperinfection syndrome (SHS), whereby the organism rapidly proliferates and disseminates within the host. Left untreated, SHS is commonly fatal. Unfortunately, the non-specific presentation of strongyloidiasis and the hyperinfection syndrome may lead to delays in diagnosis and treatment. We describe an unusual case of SHS in a 30-year-old man with a long-standing history of systemic lupus erythematosus who underwent a partial colectomy. The diagnosis was rendered on identification of numerous organisms during histologic examination of the colectomy specimen.
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http://dx.doi.org/10.4269/ajtmh.14-0228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4183409PMC
October 2014

Surgical leadership across generations.

Bull Am Coll Surg 2012 Aug;97(8):30-5

Moffitt Cancer Center, Tampa, FL, USA.

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August 2012

Are roadside pedestrian injury patterns predictable in a densely populated, urban setting?

J Surg Res 2010 Oct 24;163(2):323-6. Epub 2010 Apr 24.

Division of Acute Care Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.

Background: Roadside pedestrian injuries represent a significant portion of trauma team activations, especially at urban trauma centers. Patient demographics and severity of injury vary greatly in this patient population. Herein, we hypothesize that injury patterns may be predictable, especially with respect to age.

Materials And Methods: All patients with roadside pedestrian injuries evaluated at our urban, level one trauma center from January 2006 through December 2008 were retrospectively reviewed. Data were collected from the institutional trauma registry. Age was used as an independent variable and compared with injury type, substance abuse, discharge setting, and mortality.

Results: There were 226 roadside pedestrian injuries during the study period. Patients were divided into groups according to age, under 20 y, 21-40 y, 41-65 y, and over 65 y. Head injuries were more prevalent in patients over age 65, 30.4% versus 14.0% (P = 0.05). There was a trend for increasing alcohol use in the younger population. The likelihood of discharge to a rehab facility increased with age, 0%, 11.8%, 38.2%, 50.0%, respectively (P < 0.001). Mortality was significantly higher in patients older than 65 y, 15.2% versus 3.3% (P = 0.049).

Conclusions: Roadside pedestrian injuries have predictable injury patterns based on age. Older patients are more likely to have a head injury, longer length of stay, need for a rehab stay, and have a higher mortality. Further studies are needed to correlate precise injuries with collision mechanism and evaluate specific risk factors in this high risk population.
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http://dx.doi.org/10.1016/j.jss.2010.03.073DOI Listing
October 2010

Changes in operative case experience for general surgery residents: has the 80-hour work week decreased residents' operative experience?

Adv Surg 2009 ;43:73-90

Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, Room 620, Philadelphia, PA 19107, USA.

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http://dx.doi.org/10.1016/j.yasu.2009.02.016DOI Listing
December 2009

Linear shear conditioning improves vascular graft retention of adipose-derived stem cells by upregulation of the alpha5beta1 integrin.

Tissue Eng Part A 2010 Jan;16(1):245-55

Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Use of adult adipose-derived stem cells (ASCs) as endothelial cell substitutes in vascular tissue engineering is attractive because of their availability. However, when seeded onto decellularized vascular scaffolding and exposed to physiological fluid shear force, ASCs are physically separated from the graft lumen. Herein we have investigated methods of increasing initial ASC attachment using luminal precoats and a novel protocol for the gradual introduction of shear stress to optimize ASC retention. Fibronectin coating of the graft lumen increased ASC attachment by nearly sixfold compared with negative controls. Gradual introduction of near physiological fluid shear stress using a novel bioreactor whereby flow rate was increased every second at a rate of 1.5 dynes/cm(2) per day resulted in complete luminal coverage compared with near complete cell loss following conventional daily abrupt increases. An upregulation of the alpha(5)beta(1) integrin was evinced following exposure to shear stress, which accounts for the observed increase in ASC retention on the graft lumen. These results indicated a novel method for seeding, conditioning, and retaining of adult stem cells on a decellularized vein scaffold within a high-shear stress microenvironment.
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http://dx.doi.org/10.1089/ten.TEA.2009.0238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810996PMC
January 2010

Have endovascular procedures negatively impacted general surgery training?

Ann Surg 2007 Sep;246(3):472-7; discussion 477-80

Departments of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.

Objective: Technological advances in vascular surgery have changed the field dramatically over the past 10 years. Herein, we evaluate the impact of endovascular procedures on general surgery training.

Methods: National operative data from the Residency Review Committee for Surgery were examined from 1997 through 2006. Total major vascular operations, traditional open vascular operations and endovascular procedures were evaluated for mean number of cases per graduating chief general surgery resident (GSR) and vascular surgery fellow (VSF).

Results: As endovascular surgical therapies became widespread, GSR vascular case volume decreased 34% over 10 years, but VSF total cases increased 78%. GSR experience in open vascular operations decreased significantly, as evidenced by a 52% decrease (P < 0.0001) in elective open AAA repair. VSFs have also seen significant decreases in open vascular procedures. Experience in endovascular procedures has increased for both general surgery and vascular residents, but the increase has been much larger in absolute number for VSFs.

Conclusions: GSR experience in open vascular procedures has significantly decreased as technology has advanced within the field. Unlike VSFs, this loss has not been replaced by direct experience with endovascular training. These data demonstrate the impact technology can have on how we currently train general surgeons. New educational paradigms may be necessary in which either vascular surgery as an essential component is abandoned or training in catheter-based interventions becomes required.
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http://dx.doi.org/10.1097/SLA.0b013e3181485652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959356PMC
September 2007