Publications by authors named "Edward Chao"

35 Publications

Extended Noninvasive Glucose Monitoring in the Interstitial Fluid Using an Epidermal Biosensing Patch.

Anal Chem 2021 Sep 3. Epub 2021 Sep 3.

Department of Nanoengineering, University of California, San Diego, La Jolla, San Diego, California 92093, United States.

An effective, noninvasive glucose monitoring technology could be a pivotal factor for addressing the major unmet needs for managing diabetes mellitus (DM). Here, we describe a skin-worn, disposable, wireless electrochemical biosensor for extended noninvasive monitoring of glucose in the interstitial fluid (ISF). The wearable platform integrates three components: a screen-printed iontophoretic electrode system for ISF extraction by reverse iontophoresis (RI), a printed three-electrode amperometric glucose biosensor, and an electronic interface for control and wireless communication. Prolonged on-body glucose monitoring of up to 8 h, including clinical trials conducted in individuals with and without DM, demonstrated good correlation between glucose blood and ISF concentrations and the ability to monitor dynamically changing glucose levels upon food consumption, with no evidence of skin irritation or discomfort. Such successful extended operation addresses the challenges reported for the GlucoWatch platform by using a lower RI current density at shorter extraction times, along with a lower measurement frequency. Such a noninvasive skin-worn platform could address long-standing challenges with existing glucose monitoring platforms.
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http://dx.doi.org/10.1021/acs.analchem.1c02887DOI Listing
September 2021

Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter.

J Trauma Acute Care Surg 2021 07;91(1):241-246

From the Department of Surgery (C.T.D., A.L., E.R.L., S.M., E.C., S.H.R., S.H.T., J.M.), Jacobi Medical Center, Bronx; Kings County Hospital Center (M.E.S.J.), Brooklyn; and Albert Einstein College of Medicine (C.T.D., A.L., E.R.L., S.M., E.C., S.H.R., S.H.T., J.M., M.E.S.J.), Bronx, New York.

Background: During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase.

Methods: A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality.

Results: A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045).

Conclusion: Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population.

Level Of Evidence: Epidemiological, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8218982PMC
July 2021

Is There an Age Cutoff for Intracranial Pressure Monitoring?: A Propensity Score Matched Analysis of the National Trauma Data Bank.

Am Surg 2021 Jan 31:3134821991985. Epub 2021 Jan 31.

Department of Surgery, 24502Jacobi Medical Center, Bronx, NY, USA.

Background: Despite mostly favorable past evidence for use of intracranial pressure monitoring (ICPM), more recent data question not only the indications but also the utility of ICPM. The Fourth Edition Brain Trauma Foundation guidelines offer limited indications for ICPM. Evidence supports ICPM for reducing mortality in patients with severe traumatic brain injury (TBI) and cites decreased survival in elderly patients.

Methods: All patients ≥ 18 years of age with isolated TBI, head Abbreviated Injury Scale (AIS) ≥ 3, and a Glasgow Coma Scale (GCS) ≤ 8 between 2008 and 2014 were included from the National Trauma Data Bank. Exclusion criteria were head AIS = 6 and death within 24 hours. Patients with and without ICPM were compared using TBI-specific variables. Patients were then matched via propensity-score matching (PSM), and the odds ratio (OR) of death with ICPM was determined using logistic regression modeling for 8 different age strata.

Results: A total of 23,652 patients with a mean age of 56 years, median head AIS of 4, median GCS of 3, and overall mortality of 29.2% were analyzed. After PSM, ICPM was associated with death beginning at the age stratum of 56-65 years. Intracranial pressure monitoring was associated with survival beginning at the age-group 36-45 years.

Discussion: Based on a large propensity-matched sample of TBI patients, ICPM was not associated with improved survival for TBI patients above 55 years of age. Until level 1 evidence is available, this age threshold should be considered for further prospective study in determining indications for ICPM.
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http://dx.doi.org/10.1177/0003134821991985DOI Listing
January 2021

Ketorolac Use for Pain Management in Trauma Patients With Rib Fractures Does not Increase of Acute Kidney Injury or Incidence of Bleeding.

Am Surg 2021 May 24;87(5):790-795. Epub 2020 Nov 24.

Albert Einstein College of Medicine, Bronx, NY, USA.

Introduction: Ketorolac is useful in acute pain management to avoid opiate-related complications; however, some surgeons fear associated acute kidney injury (AKI) and bleeding despite a paucity of literature on ketorolac use in trauma patients. We hypothesized that our institution's use of intravenous ketorolac for rib fracture pain management did not increase the incidence of bleeding or AKI.

Methods: Rib fracture patients aged 15 years and above admitted between January 2016-June 2018 were identified in our trauma registry along with frequency of bleeding events. AKI was defined as ≥ 1.5x increase in serum creatinine from baseline measured on the second day of admission (after 24 hours of resuscitation) or an increase of ≥ .3 mg/dL over a 48-hour period. Patients receiving ketorolac were compared to patients with no ketorolac use.

Results: Two cohorts of 199 control and 205 ketorolac patients were found to be similar in age, gender, admission systolic blood pressure (SBP), injury severity score, intravenous radiocontrast received, and transfusion requirements. Analysis revealed no difference in frequency of AKI using both definitions (8% vs. 7.3%, = .79) and (19.6% vs. 15.1%, = .24), respectively, or bleeding events (2.5% vs. 0%, = .03). Logistic regression demonstrated that ketorolac use was not an independent predictor for AKI but age and admission SBP < 90 were.

Conclusion: Use of ketorolac in this cohort of trauma patients with rib fractures did not increase the incidence of AKI or bleeding events.
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http://dx.doi.org/10.1177/0003134820954835DOI Listing
May 2021

Use of the EVARREST patch for penetrating cardiac injury.

Trauma Case Rep 2020 Aug 27;28:100324. Epub 2020 Jun 27.

Albert Einstein College of Medicine, Division of Trauma & Critical Care Services, Jacobi Medical Center, Bronx, NY, United States of America.

Penetrating cardiac injuries have a pre-hospital mortality of 94% with a subsequent in-hospital mortality of 50% among initial survivors (Leite et al., 2017 [1]). The Western Trauma Association (WTA) guidelines recommend resuscitative thoracotomy (RT) for patients with penetrating torso trauma and less than 15 min of cardiopulmonary resuscitation (CPR) Burlew et al. (2012) [2]. Penetrating cardiac injuries are classically repaired using skin-stapling devices and/or suture repair with or without pledgets (Wall et al., 1997 [3]). In this study, we present a case of penetrating cardiac injury where all the aforementioned techniques failed, and a new approach was explored. A fibrinogen/thrombin patch was used in this clinical setting, which is an off-label use of the product, we here present our encouraging outcome.
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http://dx.doi.org/10.1016/j.tcr.2020.100324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338775PMC
August 2020

Rescue therapy for severe COVID-19-associated acute respiratory distress syndrome with tissue plasminogen activator: A case series.

J Trauma Acute Care Surg 2020 09;89(3):453-457

From the Division of Acute Care Surgery (C.D.B., R.J., M.B.Y.), Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; Departments of Biological Engineering and Biology (C.D.B., M.B.Y.), Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge; Department of Anesthesia (A.O.-G., A.M.I., M.L.K., D.S.T., S.S.), Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Division of Trauma and Surgical Critical Care (E.C., S.H.R., M.U.), Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York; Division of Pulmonary and Critical Care (A.H.M.), Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Department of Surgery (M.J.M.), Scripps Mercy Hospital, San Diego, California; Department of Emergency Medicine (A.M.I.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Surgery (H.B.M., E.E.M.), University of Colorado Denver, Aurora; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado; Division of Pulmonary, Critical Care and Sleep Medicine (E.N.B.-K.), Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented stresses on modern medical systems, overwhelming the resource infrastructure in numerous countries while presenting a unique series of pathophysiologic clinical findings. Thrombotic coagulopathy is common in critically ill patients suffering from COVID-19, with associated high rates of respiratory failure requiring prolonged periods of mechanical ventilation. Here, we report a case series of five patients suffering from profound, medically refractory COVID-19-associated respiratory failure who were treated with fibrinolytic therapy using tissue plasminogen activator (tPA; alteplase). All five patients appeared to have an improved respiratory status following tPA administration: one patient had an initial marked improvement that partially regressed after several hours, one patient had transient improvements that were not sustained, and three patients had sustained clinical improvements following tPA administration. LEVEL OF EVIDENCE: Therapeutic, Level V.
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http://dx.doi.org/10.1097/TA.0000000000002786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484332PMC
September 2020

Fast Statistical Iterative Reconstruction for Mega-voltage Computed Tomography.

J Med Invest 2020 ;67(1.2):30-39

Department of Radiology, The University of Tokyo Hospital, Japan.

Statistical iterative reconstruction is expected to improve the image quality of computed tomography (CT). However, one of the challenges of iterative reconstruction is its large computational cost. The purpose of this review is to summarize a fast iterative reconstruction algorithm by optimizing reconstruction parameters. Megavolt projection data was acquired from a TomoTherapy system and reconstructed using in-house statistical iterative reconstruction algorithm. Total variation was used as the regularization term and the weight of the regularization term was determined by evaluating signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and visual assessment of spatial resolution using Gammex and Cheese phantoms. Gradient decent with an adaptive convergence parameter, ordered subset expectation maximization (OSEM), and CPU/GPU parallelization were applied in order to accelerate the present reconstruction algorithm. The SNR and CNR of the iterative reconstruction were several times better than that of filtered back projection (FBP). The GPU parallelization code combined with the OSEM algorithm reconstructed an image several hundred times faster than a CPU calculation. With 500 iterations, which provided good convergence, our method produced a 512 × 512 pixel image within a few seconds. The image quality of the present algorithm was much better than that of FBP for patient data. J. Med. Invest. 67 : 30-39, February, 2020.
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http://dx.doi.org/10.2152/jmi.67.30DOI Listing
June 2021

A unique case of Lemierre's syndrome status post blunt cervical trauma.

Vascular 2020 Aug 30;28(4):485-488. Epub 2020 Mar 30.

Department of Cardiovascular and Thoracic Surgery, Jacobi Medical Center, Bronx, NY, USA.

Background: Lemierre's syndrome is a rare but potentially fatal condition. The course is characterized by acute tonsillopharyngitis, bacteremia, internal jugular vein thrombosis, and septic embolization. There have been some cases secondary to penetrating trauma to the neck. Literature review has yielded no cases secondary to blunt neck trauma in the absence of oropharyngeal injury. We aim to shed light on this unique cause of Lemierre's syndrome, so as to raise the index of suspicion for clinicians working up patients with blunt cervical trauma.

Methods: We present a case of a 25-year-old male restrained driver who presented with left neck and shoulder pain with a superficial abrasion to the left neck from the seatbelt who was discharged same day by the Emergency Room physicians. He returned to the Emergency Department two days later with abdominal pain. As a part of his repeat evaluation, a set of blood cultures were sent and was sent home that day. The patient was called back to the hospital one day later as preliminary blood cultures were positive for Gram positive cocci and Gram negative anaerobes. Computerized tomography scan of the neck revealed extensive occlusive left internal jugular vein thrombosis and fluid collections concerning for abscesses, concerning for septic thrombophlebitis. The patient continued to decompensate, developing severe sepsis complicated by disseminated intravascular coagulation.

Results: The patient underwent a left neck exploration with en bloc resection of the left internal jugular vein, drainage of abscesses deep to the sternocleidomastoid, and washout/debridement of necrotic tissue. Direct laryngoscopy at the time of surgery revealed no injury to the aerodigestive tract. Wound cultures were consistent with blood cultures and grew , , and . The patient underwent two subsequent operative wound explorations without any evidence of residual infection. The patient was discharged home on postoperative day 13 on a course of antibiotics and aspirin.

Conclusion: This case illustrates the importance of diagnosis of Lemierre's syndrome after an unconventional inciting event (blunt cervical trauma) and appropriate treatment.
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http://dx.doi.org/10.1177/1708538120913734DOI Listing
August 2020

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma.

J Trauma Acute Care Surg 2020 06;88(6):875-887

From the Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery (D.Y.K.), Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance; Trauma Surgery Department, Scripps Memorial Hospital La Jolla (W.B.), La Jolla, California; Department of Trauma and Burn Surgery, Stroger Hospital of Cook County (F.B.), Rush University, Chicago, Illinois; Department of Surgery (S.B.), University of Florida, Gainesville, Florida; Department of Surgery, Jacobi Medical Center (E.C.), Bronx, New York; Department of Surgery, MetroHealth Medical Center (J.A.C., J.J.C.), Cleveland, Ohio; Department of Surgery, UNLV School of Medicine (D.F.), Las Vegas, Nevada; Division of Trauma, Emergency Surgery, and Surgical Critical Care, School of Medicine (R.J.), Stony Brook University, Stony Brook, New York; Department of Surgery, University of Florida College of Medicine - Jacksonville (A.K., B.Y.), Jacksonville, Florida; Department of Surgery, Duke University (G.K.), Durham, North Carolina; Department of Surgery, Western Virginia University (U.K.), Morgantown, West Virginia; Department of Surgery (S.K.), Chippenham-Johnston Willis Medical Center, NorthStar Trauma Surgery, Richmond, Virginia; Department of Surgery, Riverside Community Hospital (D.P.), Riverside, California; Division of Trauma and Critical Care, Department of Surgery, Harborview Medical Center (B.R.H.R.), University of Washington, Seattle, Washington; Division of Acute Care and Trauma Surgery, Department of Surgery, Rochester University Medical Center (N.S.), Rochester, New York; and Department of Surgery, University of Maryland Medical Center (R.T.), Baltimore, Maryland.

Background: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents.

Methods: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI.

Results: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24-25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06-0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2-12.14; p = 0.63).

Conclusion: We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs.

Level Of Evidence: Guidelines, Level III.
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http://dx.doi.org/10.1097/TA.0000000000002668DOI Listing
June 2020

Prolonged use of spinal precautions is associated with increased morbidity in the trauma patient.

Injury 2020 Feb 17;51(2):317-321. Epub 2019 Dec 17.

Division of Trauma Surgery and Surgical Critical Care, Jacobi Medical Center, Bronx, NY, United States. Electronic address:

Background: Patients who experience traumatic spine injuries remain in spinal precautions (SP) to minimize the risk of devastating cord injury while awaiting definitive management. This study examines the incidence of pneumonia (PNA), urinary tract infection (UTI), deep vein thrombosis (DVT), or pulmonary embolism (PE) in this population.

Study Design: From 2014 to 2016, 344 patients aged 18 and older with spinal column injuries were identified in a prospectively-collected registry at an urban, level 1 trauma center. After exclusion criteria, 330 patients were reviewed and the following were analyzed: demographics, duration of SP, time to intervention, and rates of PNA, UTI, and DVT or PE. Those patients kept in SP for ≤ 72 h ("prolonged") were compared to patients maintained in SP for > 72 h ("early").

Results: Mean age was 54.6 years (SD, 21.7), median Injury Severity Score (ISS) 10 (IQR, 5-17). The median SP was 4.0 (IQR, 3.0-6.0) days. Fifty-eight (17.6%) patients underwent fixation and 170 (51.5%) received a brace. 102 (30.9%) patients initially awaiting a brace were cleared after MRI. 93 (28.2) patients suffered one of the tracked complications; 51 (15.5%) developed PNA, 35 (10.6%) UTI, 23 (7.0%) DVT, and 5 (1.5%) PE. Rate of overall complications between patients with SP ≤ 72 h versus patients with SP > 72 h was statistically significant (20.5% vs 34.6%, p = 0.005) as was the incidence of UTI (14.5 vs 6.0, p = 0.012).

Conclusion: Prolonged SP (>72 h) is associated with increased rates of immobility-associated morbidities. Focus should be on prompt, definitive care and early mobilization.

Level Of Evidence: III Retrospective review of prospectively-collected data.
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http://dx.doi.org/10.1016/j.injury.2019.12.022DOI Listing
February 2020

State of Rib Fracture Care: A NTDB Review of Analgesic Management and Surgical Stabilization.

Am Surg 2019 May;85(5):474-478

Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% 2.6%, < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% 2.8%, < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture-related pain to elucidate optimal treatment.
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May 2019

Simulation Extrapolation Method for Cox Regression Model with a Mixture of Berkson and Classical Errors in the Covariates using Calibration Data.

Int J Biostat 2019 04 6;15(2). Epub 2019 Apr 6.

Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, U.S.A.

Many biomedical or epidemiological studies often aim to assess the association between the time to an event of interest and some covariates under the Cox proportional hazards model. However, a problem is that the covariate data routinely involve measurement error, which may be of classical type, Berkson type or a combination of both types. The issue of Cox regression with error-prone covariates has been well-discussed in the statistical literature, which has focused mainly on classical error so far. This paper considers Cox regression analysis when some covariates are possibly contaminated with a mixture of Berkson and classical errors. We propose a simulation extrapolation-based method to address this problem when two replicates of the mismeasured covariates are available along with calibration data for some subjects in a subsample only. The proposed method places no assumption on the mixture percentage. Its finite-sample performance is assessed through a simulation study. It is applied to the analysis of data from an AIDS clinical trial study.
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http://dx.doi.org/10.1515/ijb-2018-0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767084PMC
April 2019

CE: The Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in Treating Hemorrhagic Shock from Severe Trauma.

Am J Nurs 2018 10;118(10):22-28

Fareed Cheema is a resident physician in the Department of Surgery, Jacobi Medical Center, Bronx, NY, where Carrie Garcia is the trauma program manager and Aksim G. Rivera and Edward Chao are attending physicians. Contact author: Edward Chao, The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

: Hemorrhage is the leading cause of preventable death in trauma patients. In recent years, technological innovations and research efforts aimed at preventing death from hemorrhagic shock have resulted in the emergence of resuscitative endovascular balloon occlusion of the aorta (REBOA). REBOA offers a less invasive option for emergent hemorrhage control in noncompressible areas of the body without the added risks and morbidities of an ED thoracotomy. This article outlines the procedure and device used, describes the procedure's evolution, and discusses various considerations, pitfalls, and nursing implications.
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http://dx.doi.org/10.1097/01.NAJ.0000546376.73926.5bDOI Listing
October 2018

Feasibility of real-time motion management with helical tomotherapy.

Med Phys 2018 Apr 23;45(4):1329-1337. Epub 2018 Feb 23.

Accuray Incorporated, 1310 Chesapeake Terrace, Sunnyvale, CA, 94089, USA.

Purpose: This study investigates the potential application of image-based motion tracking and real-time motion correction to a helical tomotherapy system.

Methods: A kV x-ray imaging system was added to a helical tomotherapy system, mounted 90 degrees offset from the MV treatment beam, and an optical camera system was mounted above the foot of the couch. This experimental system tracks target motion by acquiring an x-ray image every few seconds during gantry rotation. For respiratory (periodic) motion, software correlates internal target positions visible in the x-ray images with marker positions detected continuously by the camera, and generates an internal-external correlation model to continuously determine the target position in three-dimensions (3D). Motion correction is performed by continuously updating jaw positions and MLC leaf patterns to reshape (effectively re-pointing) the treatment beam to follow the 3D target motion. For motion due to processes other than respiration (e.g., digestion), no correlation model is used - instead, target tracking is achieved with the periodically acquired x-ray images, without correlating with a continuous camera signal.

Results: The system's ability to correct for respiratory motion was demonstrated using a helical treatment plan delivered to a small (10 mm diameter) target. The phantom was moved following a breathing trace with an amplitude of 15 mm. Film measurements of delivered dose without motion, with motion, and with motion correction were acquired. Without motion correction, dose differences within the target of up to 30% were observed. With motion correction enabled, dose differences in the moving target were less than 2%. Nonrespiratory system performance was demonstrated using a helical treatment plan for a 55 mm diameter target following a prostate motion trace with up to 14 mm of motion. Without motion correction, dose differences up to 16% and shifts of greater than 5 mm were observed. Motion correction reduced these to less than a 6% dose difference and shifts of less than 2 mm.

Conclusions: Real-time motion tracking and correction is technically feasible on a helical tomotherapy system. In one experiment, dose differences due to respiratory motion were greatly reduced. Dose differences due to nonrespiratory motion were also reduced, although not as much as in the respiratory case due to less frequent tracking updates. In both cases, beam-on time was not increased by motion correction, since the system tracks and corrects for motion simultaneously with treatment delivery.
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http://dx.doi.org/10.1002/mp.12791DOI Listing
April 2018

Evaluation of TomoTherapy dose calculations with intrafractional motion and motion compensation.

Med Phys 2018 Jan 3;45(1):18-28. Epub 2017 Dec 3.

Accuray Incorporated, 1240 Deming Way, Madison, WI, 53717, USA.

Purpose: Anatomical motion, both cyclical and aperiodic, can impact the dose delivered during external beam radiation. In this work, we evaluate the use of a research version of the clinical TomoTherapy dose calculator to calculate dose with intrafraction rigid motion. We also evaluate the feasibility of a method of motion compensation for helical tomotherapy using the jaws and MLC.

Methods: Treatment plans were created using the TomoTherapy treatment planning system. Dose was recalculated for several simple rigid motion traces including a 4 mm step motion applied either longitudinally or transversely, and a sinusoidal motion. The calculated dose volumes were compared to dose measurements that were performed by translating the phantom with the same motion traces used in the calculations. Measurements were made using film and ion chambers. Finally, the delivery plans were modified to compensate for the motion by sweeping the jaws for longitudinal motion and shifting the MLC leaves for transverse motion, and the calculations and measurements were repeated.

Results: A transverse step motion shifted the dose that was delivered after the step occurred, but otherwise did not impact the dose distribution. Film measurements agreed with dose calculations to within 2%/2 mm for 99% of dose points within the 50% isodose line. A shift in the MLC leaf delivery pattern successfully compensated for the step motion to within the 3 mm accuracy allowed by the finite leaf widths. A longitudinal step motion impacted the dose in the interior of the target volume to a degree that was dependent on the planning field width and step size. Film measurements agreed with dose calculations to within 2%/2 mm for 98% of dose points within the 50% isodose line. Shifts in the jaw position successfully compensated for the longitudinal step motion. Sinusoidal (breathing-like) motion was also studied, with similar results.

Conclusions: A research version of the clinical TomoTherapy dose calculator has been shown to accurately calculate the dose from treatment plans delivered in the presence of arbitrary rigid motion. Modifications to the delivery plan using jaw and MLC leaf shifts that follow the motion can successfully compensate for the target motion.
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http://dx.doi.org/10.1002/mp.12655DOI Listing
January 2018

End-tidal CO on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study.

Injury 2017 Jan 5;48(1):51-57. Epub 2016 Jul 5.

Department of Surgery, Jacobi Medical Center Bronx, NY, United States; Albert Einstein College of Medicine, Bronx, NY, United States. Electronic address:

Background: Critical administration threshold (≥3 units of packed red blood cells/h or CAT+) has been proposed as a new definition for massive transfusion (MT) that includes volume and rate of blood transfusion. CAT+ has been shown to eliminate survivor bias and be a better predictor of mortality than the traditional MT (>10 units/24h). End-tidal CO (ET CO) negatively correlates with lactate and is an early predictor of shock in trauma patients. We conducted a pilot study to test the hypothesis that low ET CO on admission predicts CAT+.

Methods: ET CO via capnography and serum lactate were prospectively collected on admission for 131 patients requiring trauma team activation. Demographic data were obtained from patient charts. Excluded were patients with isolated head injuries, traumatic arrests, or pre-hospital intubations. CAT± status was determined for each hour up to 6h from admission as described; likewise, MT± status was determined up to 24h from admission.

Results: After exclusion criteria, 67 patients were analyzed. Mean age was 41.2 (SD 18.5). Thirty-three patients had a blunt mechanism of injury (49%), median ISS was 9 (interquartile range 4-19), and there were 6 deaths (9%). ET CO and lactate were negatively correlated by Spearman rank-based correlation (rho=-0.41, p=0.0006). Twenty-one (31%) and 8 (12%) patients were CAT+ and traditional MT+, respectively. There were a significantly greater proportion of patients with ISS>15, ET CO <35, or who died found to be CAT+. A binomial logistic regression model adjusting for age, SBP <90, HR, and ISS >15 revealed ET CO < 35 to be independently predictive of CAT+ (OR 9.24, 95% CI 1.51-56.57, p=0.016).

Conclusions: This pilot study demonstrated that low ET CO had strong association with standard indicators for shock and was predictive of patients meeting CAT+ criteria in the first 6h after admission. Further study to verify these results and to elucidate CAT criteria's association with mortality will require a larger sample size.
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http://dx.doi.org/10.1016/j.injury.2016.07.007DOI Listing
January 2017

Factors Associated with Return to Work Postinjury: Can the Modified Rankin Scale Be Used to Predict Return to Work?

Am Surg 2016 Feb;82(2):95-101

Department of Surgery, and the †Department of Physical Medicine and Rehabilitation, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

The ability to return to work (RTW) postinjury is one of the primary goals of rehabilitation. The modified Rankin Scale (mRS) is a validated simple scale used to assess the functional status of stroke patients during rehabilitation. We sought to determine the applicability of mRS in predicting RTW postinjury in a general trauma population. The trauma registry was queried for patients, aged 18 to 65 years, discharged from 2012 to 2013. A telephone interview for each patient included questions about employment status and physical ability to determine the mRS. Patients who had RTW postinjury were compared with those who had not (nRTW). Two hundred and thirty-four patients met the inclusion criteria. Of these, 171 (72.5%) patients RTW and 63 (26.7%) did nRTW. Patients who did nRTW were significantly older, had longer length of stay and higher rates of in-hospital complications. Multivariate analysis revealed that older patients were less likely to RTW (odds ratio = 0.961, P = 0.011) and patients with a modified Rankin score ≤2 were 15 times more likely to RTW (odds ratio = 14.932, P < 0.001). In conclusion, an mRS ≤2 was independently associated with a high likelihood of returning to work postinjury. This is the first study that shows applicability of the mRS for predicting RTW postinjury in a trauma population.
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February 2016

Penetrating neck trauma in children: An uncommon entity described using the National Trauma Data Bank.

J Trauma Acute Care Surg 2016 Apr;80(4):604-9

From the Departments of Surgery (M.E.S., B.A.F., O.O., E.C., S.H.R., S.T.), and Pediatrics (J.A.M.), Jacobi Medical Center, Albert Einstein College of Medicine (S.K.), Bronx, New York.

Background: Penetrating neck trauma is uncommon in children; consequently, data describing epidemiology, injury pattern, and management are sparse. The aim of this study was to use the National Trauma Data Bank (NTDB) to describe pediatric penetrating neck trauma (PPNT).

Methods: The NTDB was queried for children (defined as <15 years old) with PPNT between years 2008 and 2012. Descriptive analysis was used to describe age groups (0-5, 6-10, and 11-14 years) and injury type categorized as aerodigestive, vascular, cervical spine, and nerve.

Results: A total of 1,238 patients with penetrating neck trauma were identified among 434,788 children in the NTDB (0.28%). Mean age was 7.9 years, and 70.6% of patients were male. The most common mechanisms of injury were stabbing (44%) and gunshot/firearm (24%). Most patients were treated at a pediatric trauma center (65.8%). Computed tomographic scan was the most frequent (42.2%) diagnostic study performed, followed by laryngoscopy (27.0%) and esophagoscopy (27.4%). Almost a quarter of patients (23.7%) went directly to the operating room from the emergency department (ED). Aerodigestive injuries were most common and occurred more frequently in the youngest age group (p < 0.001). Operative procedures for aerodigestive type injuries were most common (82.7%). There were 69 deaths, yielding a mortality rate of 5.6%. When adjusting for age, admission to a pediatric trauma center, and injury type, only vascular injury (odds ratio, 3.92; 95% confidence interval, 2.19-7.24; p < 0.0001) and ED hypotension (odds ratio, 27.12; 95% confidence interval, 15.11-48.67; p < 0.0001) were found to be independently associated with death.

Conclusion: PPNT is extremely rare--0.28% reported NTDB incidence. Age seems to influence injury type but does not affect mortality. Computed tomographic scan is the dominant diagnostic study used for selective management. Vascular injury type and hypotension on presentation to the ED were independently associated with mortality.

Level Of Evidence: Prognostic/epidemiologic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000000976DOI Listing
April 2016

Reconstruction of the treatment area by use of sinogram in helical tomotherapy.

Radiat Oncol 2014 Nov 28;9:252. Epub 2014 Nov 28.

Department of Radiology, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo, Tokyo, Japan.

Background: TomoTherapy (Accuray, USA) has an image-guided radiotherapy system with a megavoltage (MV) X-ray source and an on-board imaging device. This system allows one to acquire the delivery sinogram during the actual treatment, which partly includes information from the irradiated object. In this study, we try to develop image reconstruction during treatment with helical tomotherapy.

Findings: Sinogram data were acquired during helical tomotherapy delivery using an arc-shaped detector array that consists of 576 xenon-gas filled detector cells. In preprocessing, these were normalized with full air-scan data. A software program was developed that reconstructs 3D images during treatment with corrections as; (1) the regions outside the field were masked not to be added in the backprojection (a masking correction), and (2) each voxel of the reconstructed image was divided by the number of the beamlets passing through its voxel (a ray-passing correction). The masking correction produced a reconstructed image, however, it contained streak artifacts. The ray-passing correction reduced this artifact. Although the SNR (the ratio of mean to standard deviation in a homogeneous region) and the contrast of the reconstructed image were slightly improved with the ray-passing correction, use of only the masking correction was sufficient for the visualization purpose.

Conclusions: The visualization of the treatment area was feasible by using the sinogram in helical tomotherapy. This proposed method would be useful in the treatment verification.
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http://dx.doi.org/10.1186/s13014-014-0252-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255647PMC
November 2014

Influence of medical students' past experiences and innate dexterity on suturing performance.

Am J Surg 2014 Aug 12;208(2):302-6. Epub 2014 Apr 12.

Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Medical students often cite their ability to excel at technical tasks as justification for choosing surgery as a career path. We sought to investigate how medical students' dexterity skills and past experiences correlated with suturing performance.

Methods: Sixty-four 3rd-year medical students were surveyed about previous experiences that involved manual dexterity. Technical skills were then measured using a validated test of manual dexterity and subcuticular closure of a pig's foot incision. Spearman's rank correlation coefficients determined correlation between variables.

Results: Previous experiences, self-assessment of dexterity, prior suturing, and current interest in surgery did not significantly correlate with manual dexterity or suturing skill scores. Innate manual dexterity score was the only significant correlating factor to suture skill score (Spearman's rank correlation coefficient = .336; P = .007).

Conclusions: Innate manual dexterity skills are predictive of initial surgical suturing performance regardless of past student experiences. Interventions aimed at improving early surgical technique should be optimally focused on dexterity training.
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http://dx.doi.org/10.1016/j.amjsurg.2013.12.040DOI Listing
August 2014

SGLT-2 Inhibitors: A New Mechanism for Glycemic Control.

Authors:
Edward C Chao

Clin Diabetes 2014 Jan;32(1):4-11

Glucosuria, the presence of glucose in the urine, has long been regarded as a consequence of uncontrolled diabetes. However, glucose excretion can be induced by blocking the activity of the renal sodium-glucose cotransporter 2 (SGLT-2). This mechanism corrects hyperglycemia independently of insulin. This article provides an overview of the paradigm shift that triggered the development of the SGLT-2 inhibitor class of agents and summarizes the available evidence from clinical studies to date.
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http://dx.doi.org/10.2337/diaclin.32.1.4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521423PMC
January 2014

Quantitative characterization of tomotherapy MVCT dosimetry.

Med Dosim 2013 1;38(3):280-6. Epub 2013 Apr 1.

21st Century Oncology, Madison, WI 53719, USA.

Megavoltage computed tomography (MVCT) is used as image guidance for patient setup in almost every tomotherapy treatment. Frequent use of ionizing radiation for image guidance has raised concern of imaging dose. The purpose of this work is to quantify and characterize tomotherapy MVCT dosimetry. Our dose calculation was based on a commissioned dose engine, and the calculation result was compared with film measurement. We studied dose profiles, center dose, maximal dose, surface dose, and mean dose on homogeneous cylindrical water phantoms of various diameters for various scanning parameters, including 3 different jaw openings (of nominal value J4, J1, and J0.1) and couch speeds (fine, normal, and coarse). The comparison between calculation and film measurement showed good agreement. In particular, the thread pattern on the film of the helical delivery matched very well with calculation. For the J1 jaw and coarse imaging mode, the maximum difference between calculation and measurement was about 6% of the center dose. Calculation on various sizes of synthesized phantoms showed that the center dose decreases almost linearly as the phantom diameter increases, and that the fine mode (couch speed of 4mm/rotation) received twice the dose of the normal mode (couch speed of 8mm/rotation) and 3 times that of the coarse mode (couch speed of 12mm/rotation) as expected. The maximal dose ranged from 100% to ∼200% of the center dose, with increasing ratios for larger phantoms, smaller jaws, and faster couch speed. For all jaw settings and couch speeds, the mean dose and average surface dose vary from 95% to 125% of the center dose with increasing ratios for larger phantoms. We present a quantitative dosimetric characterization of the tomotherapy MVCT in terms of scanning parameters, phantom size, center dose, maximal dose, surface dose, and mean dose. The results can provide an overall picture of dose distribution and a reference data set that enables estimation of CT dose index for the tomotherapy MVCT.
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http://dx.doi.org/10.1016/j.meddos.2013.02.009DOI Listing
April 2014

Rare presentation of perforated diverticulitis.

Am Surg 2012 Dec;78(12):E527-8

Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

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December 2012

Estimating influenza incidence and rates of influenza-like illness in the outpatient setting.

Influenza Other Respir Viruses 2013 Sep 18;7(5):694-700. Epub 2012 Sep 18.

Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.

Background: Estimating influenza incidence in outpatient settings is challenging. We used outpatient healthcare practice populations as a proxy to estimate community incidence of influenza-like illness (ILI) and laboratory-confirmed influenza-associated ILI.

Methods: From October 2009 to July 2010, 38 outpatient practices in seven jurisdictions conducted surveillance for ILI (fever with cough or sore throat for patients ≥ 2 years; fever with ≥ 1 respiratory symptom for patients <2 years). From a sample of patients with ILI, respiratory specimens were tested for influenza.

Results: During the week of peak influenza activity (October 24, 2009), 13% of outpatient visits were for ILI and influenza was detected in 72% of specimens. For the 10-month surveillance period, ILI and influenza-associated ILI incidence were 20.0 (95% CI: 19.7, 20.4) and 8.7/1000 (95% CI: 8.2, 9.2) persons, respectively. Influenza-associated ILI incidence was highest among children aged 2-17 years. Observed trends were highly correlated with national ILI and virologic surveillance.

Conclusions: This is the first multistate surveillance system demonstrating the feasibility of using outpatient practices to estimate the incidence of medically attended influenza at the community level. Surveillance demonstrated the substantial burden of pandemic influenza in outpatient settings and especially in children aged 2-17 years. Observed trends were consistent with established syndromic and virologic systems.
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http://dx.doi.org/10.1111/irv.12014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5781202PMC
September 2013

High-dose MVCT image guidance for stereotactic body radiation therapy.

Med Phys 2012 Aug;39(8):4812-9

Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado 80045, USA.

Purpose: Stereotactic body radiation therapy (SBRT) is a potent treatment for early stage primary and limited metastatic disease. Accurate tumor localization is essential to administer SBRT safely and effectively. Tomotherapy combines helical IMRT with onboard megavoltage CT (MVCT) imaging and is well suited for SBRT; however, MVCT results in reduced soft tissue contrast and increased image noise compared with kilovoltage CT. The goal of this work was to investigate the use of increased imaging doses on a clinical tomotherapy machine to improve image quality for SBRT image guidance.

Methods: Two nonstandard, high-dose imaging modes were created on a tomotherapy machine by increasing the linear accelerator (LINAC) pulse rate from the nominal setting of 80 Hz, to 160 Hz and 300 Hz, respectively. Weighted CT dose indexes (wCTDIs) were measured for the standard, medium, and high-dose modes in a 30 cm solid water phantom using a calibrated A1SL ion chamber. Image quality was assessed from scans of a customized image quality phantom. Metrics evaluated include: contrast-to-noise ratios (CNRs), high-contrast spatial resolution, image uniformity, and percent image noise. In addition, two patients receiving SBRT were localized using high-dose MVCT scans. Raw detector data collected after each scan were used to reconstruct standard-dose images for comparison.

Results: MVCT scans acquired using a pitch of 1.0 resulted in wCTDI values of 2.2, 4.7, and 8.5 cGy for the standard, medium, and high-dose modes respectively. CNR values for both low and high-contrast materials were found to increase with the square root of dose. Axial high-contrast spatial resolution was comparable for all imaging modes at 0.5 lp∕mm. Image uniformity was improved and percent noise decreased as the imaging dose increased. Similar improvements in image quality were observed in patient images, with decreases in image noise being the most notable.

Conclusions: High-dose imaging modes are made possible on a clinical tomotherapy machine by increasing the LINAC pulse rate. Increasing the imaging dose results in increased CNRs; making it easier to distinguish the boundaries of low contrast objects. The imaging dose levels observed in this work are considered acceptable at our institution for SBRT treatments delivered in 3-5 fractions.
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http://dx.doi.org/10.1118/1.4736416DOI Listing
August 2012

Dapagliflozin: an evidence-based review of its potential in the treatment of type-2 diabetes.

Authors:
Edward C Chao

Core Evid 2012 1;7:21-8. Epub 2012 Jun 1.

University of California, San Diego and VA San Diego Healthcare System, San Diego, CA, USA.

Dapagliflozin is a sodium-glucose co-transporter-2 inhibitor that lowers plasma glucose by decreasing its renal reabsorption. The resulting excretion of glucose in the urine (glucosuria) has transformed what was once solely regarded as an adverse facet of diabetes into a potential novel therapeutic strategy. Glucosuria leads to weight loss, due to a reduction in calories, which is thought to rehabilitate insulin sensitivity, at least partially. By acting independently of insulin action or secretion, dapagliflozin appears to avert or minimize two key barriers to optimal glycemic control: hypoglycemia and weight gain. From the clinical studies conducted thus far in patients with type 2 diabetes, dapagliflozin significantly decreases HbA(1c) (by ~0.5%-1%, from a baseline of 8%-9%), as well as body weight (~2-3 kg), without increased risk of hypoglycemia. Dapagliflozin thus represents a paradigm shift in the treatment of diabetes. While long-term data on safety and efficacy are forthcoming, the results published to date suggest that this agent has the potential to be another option in the treatment of diabetes treatments. This article examines the evidence currently available on the efficacy and safety of dapagliflozin.
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http://dx.doi.org/10.2147/CE.S16359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373192PMC
October 2012

Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure?

Surg Endosc 2012 Mar 17;26(3):831-7. Epub 2011 Dec 17.

Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY 10461, USA.

Background: Providing bariatric surgery services to an inner-city population is a challenge. Laparoscopic sleeve gastrectomy (LSG) is an effective operation for morbid obesity with a relatively low complication rate. LSG appears to be a suitable alternative procedure for this group of patients.

Methods: This is a retrospective review and analysis of the experience with 185 consecutive LSGs that had completed at least 6 months follow-up. Eleven conversions from LSG to laparoscopic Roux-en-Y gastric bypass were excluded, leaving 174 patients for outcome analysis. Data collected were patient demographics, body mass index (BMI), comorbid conditions, operating time, length of hospital stay, and perioperative complications. Weight loss and resolution/improvement of comorbidities were analyzed.

Results: Mean patient age was 39.58 years and mean BMI was 48.97 kg/m(2). The percentage of patients with BMI > 50 kg/m(2) was 37.94%. Mean excess weight loss (EWL) was 44.76, 55.52, 59.22, and 58.92% at 6, 12, 24, and 36 months, respectively. Six patients (3.24%) lost less than 25% EWL. Thirteen patients (7.02%) regained an average of 13 lb after reaching a plateau. Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for gastroesophageal reflux disease symptoms (GERD). The mortality rate was zero in this series. Perioperative complications occurred in 26 patients (14.05%): four staple-line leaks (2.16%), four bleeds (2.16%), four obstructions (2.16%), five vomiting/dehydration (2.70%), six new onset of GERD symptoms (3.24%), two with pneumonia (1.08%), and one with pulmonary embolism (0.54%).

Conclusion: LSG results in stable and adequate weight loss with resolution/improvement in comorbidities in a high percentage of patients. It can be considered a definitive operation for morbid obesity.
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http://dx.doi.org/10.1007/s00464-011-1960-2DOI Listing
March 2012

Dapagliflozin--redefining treatment of T2DM?

Authors:
Edward C Chao

Nat Rev Endocrinol 2011 Oct 11;7(12):696-7. Epub 2011 Oct 11.

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http://dx.doi.org/10.1038/nrendo.2011.177DOI Listing
October 2011

A slit method to determine the focal spot size and shape of TomoTherapy system.

Med Phys 2011 Jun;38(6):2841-9

TomoTherapy, Inc., 1240 Deming Way, Madison, Wisconsin 53717, USA.

Purpose: To obtain accurate x-ray source profile measurements using a slit-collimator, the slit-collimator should have a narrow width, large height, and be positioned near the source. However, these conditions may not always be met. In this paper, the authors provide a detailed analysis of the slit measurement geometry and the relationship between the slit parameters and the measured x-ray source profile. The slit model allows the use of a shorter and more easily available slit-collimator, while accurate source profile measurements can still be obtained.

Methods: Measurements were performed with a variety of slit widths and/or slit to source distances. The relationship derived between the slit parameters and the measured profile was used to determine the true focal spot profile through a least square fit of the profile data. The model was verified by comparing the predicted profiles at a variety of slit-collimator parameters with the measured results on the TomoTherapy Hi-Art system.

Results: Both the treatment beam and the imaging beam were measured. For treatment mode, it was found that a source consisting of one Gaussian with a 0.75 mm full-width-half-maximum (FWHM) and 72% peak amplitude and a second Gaussian with a 2.27 mm FWHM and 18% peak amplitude matched measurement profiles. The overall source profile has a FWHM of 0.93 mm, but with a higher amplitude in the tail region than a single Gaussian. For imaging mode, the source consists of one Gaussian with a 0.68 mm FWHM and 82% peak amplitude and a second Gaussian with a 1.83 mm FWHM and 18% peak amplitude. The overall source profile has a FWHM of 0.77 mm.

Conclusions: Our study of the focal spot measurement using slit-collimators showed that accurate source profile measurements can be achieved through fitting of measurement results at different slit widths and source-to-slit distances (SSD). Quantitative measurements of the TomoTherapy linac focal spot showed that the source distribution could be better described with a model consisting of two Gaussian components rather than a single Gaussian model as assumed in previous studies.
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http://dx.doi.org/10.1118/1.3589133DOI Listing
June 2011

A paradigm shift in diabetes therapy--dapagliflozin and other SGLT2 inhibitors.

Authors:
Edward C Chao

Discov Med 2011 Mar;11(58):255-63

Division of Endocrinology and Metabolism, University of California, San Diego and VA San Diego, 3350 La Jolla Village Drive, San Diego, California 92161, USA.

Blocking sodium-glucose cotransporters (SGLTs) to decrease the reabsorption of glucose--and thus increase renal glucose excretion--represents a novel therapeutic approach to diabetes that is independent of insulin secretion or action. Preclinical and clinical studies of SGLT2 inhibitors in subjects with type 2 diabetes (T2DM), as well as genetic mutations in kidney-specific SGLT2 that result in no adverse sequelae, appear to support this strategy. These investigations reveal that increasing renal glucose excretion by inhibiting SGLT2 can lower plasma glucose levels, as well as reduce body weight. Further data from larger trials are forthcoming regarding efficacy and safety, but the results reported thus far suggest that the positive impact of SGLT2 inhibitors may be attained without producing significant adverse effects. This class of agents, including dapagliflozin, may thus hold an advantage over many currently used medications for diabetes. This review outlines the role of SGLT2 in glucose homeostasis and the evidence currently available on the potential for clinical application of these agents in diabetes.
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March 2011
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