Publications by authors named "James A Vosswinkel"

27 Publications

  • Page 1 of 1

An Evolving Clinical Need: Discordant Oxygenation Measurements of Intubated COVID-19 Patients.

Ann Biomed Eng 2021 Jan 19. Epub 2021 Jan 19.

Office of the Dean, Renaissance School of Medicine, Stony Brook Medicine, Stony Brook, NY, USA.

Since the first appearance of the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) earlier this year, clinicians and researchers alike have been faced with dynamic, daily challenges of recognizing, understanding, and treating the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2. Those who are moderately to severely ill with COVID-19 are likely to develop acute hypoxemic respiratory failure and require administration of supplemental oxygen. Assessing the need to initiate or titrate oxygen therapy is largely dependent on evaluating the patient's existing blood oxygenation status, either by direct arterial blood sampling or by transcutaneous arterial oxygen saturation monitoring, also referred to as pulse oximetry. While the sampling of arterial blood for measurement of dissolved gases provides a direct measurement, it is technically challenging to obtain, is painful to the patient, and can be time and resource intensive. Pulse oximetry allows for non-invasive, real-time, continuous monitoring of the percent of hemoglobin molecules that are saturated with oxygen, and usually closely predicts the arterial oxygen content. As such, it was particularly concerning when patients with severe COVID-19 requiring endotracheal intubation and mechanical ventilation within one of our intensive care units were observed to have significant discordance between their predicted arterial oxygen content via pulse oximetry and their actual measured oxygen content. We offer these preliminary observations along with our speculative causes as a timely, urgent clinical need. In the setting of a COVID-19 intensive care unit, entering a patient room to obtain a fresh arterial blood gas sample not only takes exponentially longer to do given the time required for donning and doffing of personal protective equipment (PPE), it involves the consumption of already sparce PPE, and it increases the risk of viral exposure to the nurse, physician, or respiratory therapist entering the room to obtain the sample. As such, technology similar to pulse oximetry which can be applied to a patients finger, and then continuously monitored from outside the room is essential in preventing a particularly dangerous situation of unrealized hypoxia in this critically-ill patient population. Additionally, it would appear that conventional two-wavelength pulse oximetry may not accurately predict the arterial oxygen content of blood in these patients. This discordance of oxygenation measurements poses a critical concern in the evaluation and management of the acute hypoxemic respiratory failure seen in patients with COVID-19.
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http://dx.doi.org/10.1007/s10439-020-02722-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815279PMC
January 2021

The impact of alcohol use and withdrawal on trauma outcomes: A case control study.

Am J Surg 2020 Dec 23. Epub 2020 Dec 23.

Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA. Electronic address:

Introduction: Many patients admitted to hospitals with acute trauma have positive serum blood alcohol levels. Published associations between alcohol use, injury patterns, and outcomes are inconsistent. We sought to further delineate the impact of alcohol use and alcohol withdrawal on hospital outcomes amongst acute trauma patients.

Methods: We performed a retrospective analysis of adult trauma patients hospitalized at a suburban level 1 trauma center between January 2015 and September 2019 with a blood alcohol level measurement and/or classification as alcohol withdrawal syndrome (AWS). Patients were separated into three groups: BAL ≤10 mg/dL, BAL >10 mg/dL, and alcohol withdrawal syndrome (AWS).

Results: Overall, 3896 patients met study criteria with 75.6% BAL ≤10, 23.2% BAL >10, and 1.2% AWS. The median age was significantly different (BAL ≤ 10: 59 years, BAL > 10: 44 years, AWS: 53.5 years). Alcohol withdrawal was experienced by patients with BAL ≤10 and BAL >10. While injury severity and mortality were similar across all 3 groups, AWS patients experienced significantly longer hospital and ICU lengths of stay, unplanned ICU admission, need for mechanical ventilation, and higher rates of complications. Patients with AWS had high rates of acute neuropsychiatric symptoms, complicating their management.

Conclusions: Except for mortality, AWS patients experienced worse outcomes. The complex nature of alcohol withdrawal cases, including the possibility of developing AWS despite a negative BAL on admission, emphasizes the need for early assessment for alcohol withdrawal risk factors and input from specialists.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.026DOI Listing
December 2020

Antithrombotic Agent Use in Elderly Patients Sustaining Low-Level Falls.

J Surg Res 2021 02 5;258:216-223. Epub 2020 Oct 5.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York. Electronic address:

Background: Elderly patients who are injured from a low-level fall comprise an increasing percentage of trauma admissions. We sought to evaluate the prevalence of antithrombotic (anticoagulant or antiplatelet) agent use, injury patterns, and outcomes in this population, focusing on intracranial hemorrhage (ICH).

Methods: We retrospectively reviewed the trauma registry at an American College of Surgeons-verified Level I trauma center for all patients aged 65 y or older admitted between 2007 and 2016 following a low-level fall. Medical records of patients on antithrombotic agents were examined in detail. Patients were divided into four groups based on the presence/absence of ICH and presence/absence of preadmission antithrombotic medication use.

Results: There were 4074 elderly patients admitted after a low-level fall, of which 1153 (28.3%) had a traumatic ICH, and 1238 (30.4%) were on antithrombotic agents. Notably, 35.9% of patients on antithrombotics had an ICH, as compared to 25.0% of 2836 patients not on antithrombotics other than aspirin (P < 0.001). The overall distribution of antithrombotic agent use differed significantly between the ICH and non-ICH groups; the ICH group had more coumadin usage. The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 14.2% (P < 0.001). Excluding the 27.8% of patients who were transferred into our hospital demonstrated that significantly more admissions on antithrombotics had ICH (22.4%) versus ICH admissions not on antithrombotics (14.7%, P < 0.001). The mortality rate was significantly different across groups, with the group having ICH and a history of antithrombotics having the highest mortality at 12.0% (P < 0.001). On multivariable analysis, anticoagulants, antiplatelets, and aspirin were all significantly associated with ICH; but only anticoagulants were significantly associated with mortality.

Conclusions: Antithrombotic agent use was common in admitted elderly patients sustaining a low-level fall and is associated with an elevated rate of ICH. Anticoagulants were also associated with increased mortality.
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http://dx.doi.org/10.1016/j.jss.2020.08.047DOI Listing
February 2021

Tracheobronchial Slough, a Potential Pathology in Endotracheal Tube Obstruction in Patients With Coronavirus Disease 2019 (COVID-19) in the Intensive Care Setting.

Ann Surg 2020 08;272(2):e63-e65

Department of Surgery, Stony Brook Medicine, Stony Brook, New York.

Background: A novel coronavirus (COVID-19) erupted in the latter part of 2019. The virus, SARS-CoV-2 can cause a range of symptoms ranging from mild through fulminant respiratory failure. Approximately 25% of hospitalized patients require admission to the intensive care unit, with the majority of those requiring mechanical ventilation. High density consolidations in the bronchial tree and in the pulmonary parenchyma have been described in the advanced phase of the disease. We noted a subset of patients who had a sudden, significant increase in peak airway, plateau and peak inspiratory pressures. Partial or complete ETT occlusion was noted to be the culprit in the majority of these patients.

Methods: With institutional IRB approval, we examined a subset of our mechanically ventilated COVID-19 patients. All of the patients were admitted to one of our COVID-19 ICUs. Each was staffed by a board certified intensivist. During multidisciplinary rounds, all arterial blood gas (ABG) results, ventilator settings and ventilator measurements are discussed and addressed. ARDSNet Protocols are employed. In patients with confirmed acute occlusion of the endotracheal tube (ETT), acute elevation in peak airway and peak inspiratory pressures are noted in conjunction with desaturation. Data was collected retrospectively and demographics, ventilatory settings and ABG results were recorded.

Results: Our team has observed impeded ventilation in intubated patients who are several days into the critical course. Pathologic evaluation of the removed endotracheal tube contents from one of our patients demonstrated a specimen consistent with sloughed tracheobronchial tissues and inflammatory cells in a background of dense mucin. Of 110 patients admitted to our adult COVID-19 ICUs, 28 patients required urgent exchange of their ETT.

Conclusion: Caregivers need to be aware of this pathological finding, recognize, and to treat this aspect of the COVID-19 critical illness course, which is becoming more prevalent.
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http://dx.doi.org/10.1097/SLA.0000000000004031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268824PMC
August 2020

Diaphragm ultrasound: A novel approach to assessing pulmonary function in patients with traumatic rib fractures.

J Trauma Acute Care Surg 2020 07;89(1):96-102

From the Stony Brook University Hospital (D.N.O., S.R.), School of Medicine, Stony Brook, New York; Division of Pulmonary and Critical Care Medicine, Department of Medicine (S.A.), Stony Brook University Renaissance School of Medicine, Stony Brook, New York; Department of Biostatistics (E.T.), Stony Brook University Hospital, Stony Brook, New York; and Division of Trauma, Department of Medicine (E.H., J.A.V., R.S.J.), Stony Brook University Renaissance School of Medicine, Stony Brook, New York.

Background: Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature.

Methods: We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed.

Results: A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC.

Conclusion: To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles.

Level Of Evidence: Diagnostic tests or criteria, Level III.
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http://dx.doi.org/10.1097/TA.0000000000002723DOI Listing
July 2020

Impact of Type and Number of Complications on Mortality in Admitted Elderly Blunt Trauma Patients.

J Surg Res 2019 09 20;241:78-86. Epub 2019 Apr 20.

Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York. Electronic address:

Background: Advanced age and comorbidities are recognized risk factors for adverse outcomes in elderly trauma patients. However, the contribution of the number and type of complications to in-hospital mortality in elderly blunt trauma admissions has not been extensively studied.

Methods: A retrospective review of the trauma registry at a level 1 trauma center for blunt trauma patients age ≥65 y hospitalized for at least 2 d between 2010 and 2015.

Results: There were 2467 admissions, with a median age of 81 y and median injury severity score of 9. The most common mechanism of injury was a low-level fall. Approximately 19.6% of admissions had a complication: 11.1% major complications, 8.6% other complications. The in-hospital mortality rate was significantly different (P < 0.001) among the three groups at 16.1% of major complications group, 7.1% of other, and 2.1% of no complications (P < 0.001). On multivariate logistic regression, each major complication increased the odds for in-hospital mortality by 1.59-fold.

Conclusions: Complications are not infrequent in elderly blunt trauma admissions, despite a generally lower energy mechanism of injury. Each major complication is associated with increased odds of mortality. Multifaceted interventions for prevention and mitigation of complications are indicated.
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http://dx.doi.org/10.1016/j.jss.2019.03.031DOI Listing
September 2019

Incidence, Outcomes, and Recidivism of Elderly Patients Admitted For Isolated Hip Fracture.

J Surg Res 2018 12 14;232:257-265. Epub 2018 Jul 14.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York. Electronic address:

Introduction: Isolated hip fracture (IHF) is a common injury in the elderly after a fall. However, there is limited study on elderly IHF patients' subsequent hospitalization for a new injury, that is, trauma-related recidivism.

Methods: A retrospective review of the trauma registry at an ACS level I trauma center was performed for all elderly (age ≥ 65 y) blunt trauma patients admitted between 2007 and 2017, with a focus on IHF patients. IHF was defined as a fracture of the femoral head, neck, and/or trochanteric region without any other injuries except minor soft tissue trauma after a fall.

Results: Of the 4986 elderly blunt trauma admissions, 974 (19.5%) had an IHF. The rate of trauma-related recidivism was 8.9% (n = 87) for a second injury requiring hospitalization. The majority of recidivist (74.7%) and nonrecidivist (66.5%) patients were females. Hospital length of stay was similar at index admission (7 d for recidivists versus 8 d for nonrecidivists). The median interval between index hospitalization and admission for a second injury was 373 d (IQR 156-1002). The most common mechanism of injury at index admission (95.4%) and at second injury-related hospitalization (95.4%) was a low-level fall. Among recidivist patients at second admission, a second hip fracture was present in 34.5% and intracranial hemorrhage in 17.2%.

Conclusions: After initial admission for an IHF, 8.9% of patients were readmitted for a second injury, at a median time of approximately 1 y, overwhelmingly from a low-level fall. Emphasis on fall prevention programs and at index admission is recommended.
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http://dx.doi.org/10.1016/j.jss.2018.06.054DOI Listing
December 2018

Pulmonary contusions in the elderly after blunt trauma: incidence and outcomes.

J Surg Res 2018 10 25;230:110-116. Epub 2018 May 25.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York. Electronic address:

Background: In the general population with blunt chest trauma, pulmonary contusions (PCs) are commonly identified. However, there is limited research in the elderly. We sought to evaluate the incidence and outcomes of PCs in elderly blunt trauma admissions.

Methods: We retrospectively reviewed the trauma registry at a level I trauma center for all blunt thoracic trauma patients aged ≥65 y, who were admitted between 2007 and 2015. The medical records of PC patients were reviewed.

Results: There were 956 admissions with blunt thoracic trauma; of which 778 had no pulmonary contusion (NO) and 178 had PC. The major mechanisms of injury were falls (58.7% NO, 39.3% PC, P <0.001) and motor vehicle crash/motor cycle crash (35.6% NO, 51.7% PC, P <0.001). Rib fractures were present in 79.8% of PC and 73.8% of NO patients, P = 0.1. PC patients more often had serious (AIS ≥3) head/neck (30.3% versus 20.6%, P <0.001), abdomen (12.4% versus 6.6%, P <0.001), and extremity injuries (20.8% versus 11.4%, P <0.001). Complication (46.1% PC versus 26.6% NO, P <0.001) and mortality (14.0% PC versus 6.2% NO, P = 0.0003) rates were higher in PC patients. On multivariate logistic regression analyses, PC presence was significantly associated with mechanical ventilation (odds ratio 2.5), intensive care unit admission (odds ratio 2.3), and mortality (odds ratio 1.9).

Conclusions: Over 18.6% of elderly blunt thoracic trauma patients sustained PC, despite an often low energy mechanism of injury. The presence of a PC should prompt investigation for other serious intrathoracic and extrathoracic injuries. PC presence is associated with substantial morbidity and mortality.
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http://dx.doi.org/10.1016/j.jss.2018.04.049DOI Listing
October 2018

Vitamin D-binding protein deficiency in mice decreases systemic and select tissue levels of inflammatory cytokines in a murine model of acute muscle injury.

J Trauma Acute Care Surg 2018 06;84(6):847-854

From the Department of Pathology (R.R.K., T.T., J.E.D.), Stony Brook University School of Medicine, Stony Brook, New York; and Division of Trauma, Department of Surgery (J.A.V., R.S.J.), Stony Brook University School of Medicine, Stony Brook, New York.

Background: Severe acute muscle injury results in massive cell damage, causing the release of actin into extracellular fluids where it complexes with the vitamin D-binding protein (DBP). We hypothesized that a systemic DBP deficiency would result in a less proinflammatory phenotype.

Methods: C57BL/6 wild-type (WT) and DBP-deficient (DBP-/-) mice received intramuscular injections of either 50% glycerol or phosphate-buffered saline into thigh muscles. Muscle injury was assessed by histology. Cytokine levels were measured in plasma, muscle, kidney, and lung.

Results: All animals survived the procedure, but glycerol injection in both strains of mice showed lysis of skeletal myocytes and inflammatory cell infiltrate. The muscle inflammatory cell infiltrate in DBP-deficient mice had remarkably few neutrophils as compared with WT mice. The neutrophil chemoattractant CXCL1 was significantly reduced in muscle tissue from DBP-/- mice. However, there were no other significant differences in muscle cytokine levels. In contrast, plasma obtained 48 hours after glycerol injection revealed that DBP-deficient mice had significantly lower levels of systemic cytokines interleukin 6, CCL2, CXCL1, and granulocyte colony-stimulating factor. Lung tissue from DBP-/- mice showed significantly decreased amounts of CCL2 and CXCL1 as compared with glycerol-treated WT mice. Several chemokines in kidney homogenates following glycerol-induced injury were significantly reduced in DBP-/- mice: CCL2, CCL5, CXCL1, and CXCL2.

Conclusions: Acute muscle injury triggered a systemic proinflammatory response as noted by elevated plasma cytokine levels. However, mice with a systemic DBP deficiency demonstrated a change in their cytokine profile 48 hours after muscle injury to a less proinflammatory phenotype.
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http://dx.doi.org/10.1097/TA.0000000000001875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970036PMC
June 2018

Admission of elderly blunt thoracic trauma patients directly to the intensive care unit improves outcomes.

J Surg Res 2017 11;219:334-340

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York. Electronic address:

Introduction: Blunt thoracic trauma in the elderly has been associated with adverse outcomes. As an internal quality improvement initiative, direct intensive care unit (ICU) admission of nonmechanically ventilated elderly patients with clinically important thoracic trauma (primarily multiple rib fractures) was recommended.

Methods: A retrospective review of the trauma registry at a level 1 trauma center was performed for patients aged ≥65 y with blunt thoracic trauma, admitted between the 2 y before (2010-2012) and after (2013-2015) the recommendation.

Results: There were 258 elderly thoracic trauma admissions post-recommendation (POST) and 131 admissions pre-recommendation (PRE). Their median Injury Severity Score (13 versus 12, P = ns) was similar. The POST group had increased ICU utilization (54.3% versus 25.2%, P < 0.001). The POST group had decreased unplanned ICU admissions (8.5% versus 13.0%, P < 0.001), complications (14.3% versus 28.2%, P = 0.001), and ICU length of stay (4 versus 6 d, P = 0.05). More POST group patients were discharged to home (41.1% versus 27.5%, P = 0.008). Of these, the 140 POST and 33 PRE patients admitted to the ICU had comparable median Injury Severity Score (14 versus 17, P = ns) and chest Abbreviated Injury Score ≥3 (66.4% versus 60.6%, P = ns). The POST-ICU group redemonstrated the above benefits, as well as decreased hospital length of stay (10 versus 14 d, P = 0.03) and in-hospital mortality (2.9% versus 15.2%, P = 0.004).

Conclusions: Admission of geriatric trauma patients with clinically important blunt thoracic trauma directly to the ICU was associated with improved outcomes.
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http://dx.doi.org/10.1016/j.jss.2017.06.054DOI Listing
November 2017

Risk assessment of the blunt trauma victim: The role of the quick Sequential Organ Failure Assessment Score (qSOFA).

Am J Surg 2017 Sep 8;214(3):397-401. Epub 2017 Jun 8.

Department of Emergency Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA. Electronic address:

Background: A number or risk assessment tools are used in trauma victims. Because of its simplicity, we examined the ability of the recently described quick Sequential Organ Failure Assessment Score (qSOFA) to predict outcomes in blunt trauma patients presenting to the Emergency Department.

Methods: We queried the trauma registry at a Level 1 Trauma Center for all adult blunt trauma admissions between 1/1/10 and 9/30/15. qSOFA scores were the sum of binary scores for 3 variables (RR ≥ 22, SBP≤100 mmHg, and GCS≤13).

Results: There were 7064 admissions (5664 admissions had qSOFA = 0, 1164 had qSOFA = 1, 223 had qSOFA = 2, and 13 had qSOFA = 3). Higher qSOFA scores were associated with greater injury severity, increased ICU admission, and higher complication rates. qSOFA scores were associated with in-hospital mortality (1.7% with qSOFA = 0; 8.7% with qSOFA = 1; 22.4% with qSOFA = 2; 23.1% with qSOFA = 3; p < 0.001). On multivariate analysis, qSOFA score was an independent predictor of mortality.

Conclusions: qSOFA scores are directly associated with adverse outcomes in blunt trauma victims.
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http://dx.doi.org/10.1016/j.amjsurg.2017.05.011DOI Listing
September 2017

Extremity compartment syndrome following blunt trauma: a level I trauma center's 5-year experience.

J Surg Res 2017 09 10;217:131-136. Epub 2017 May 10.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York. Electronic address:

Background: Extremity compartment syndrome is a recognized complication of trauma. We evaluated its prevalence and outcomes at a suburban level 1 trauma center.

Methods: The trauma registry was reviewed for all blunt trauma patients aged ≥18 years, admitted between 2010 and 2014. Chart review of patients with extremity compartment syndrome was performed.

Results: Of 6180 adult blunt trauma admissions, 83 patients developed 86 extremity compartment syndromes; two patients had compartment syndromes on multiple locations. Their (n = 83) median age was 44 years (interquartile range: 31.5-55.5). The most common mechanism of injury was motor vehicle/motor cycle accident (45.8%) followed by a fall (21.7%). The median injury severity score was 9 (interquartile range: 5-17); 65.1% had extremity abbreviate injury score ≥3. Notably, 15 compartment syndromes did not have an underlying fracture. Among patients with fractures, the most commonly injured bone was the tibia, with tibial plateau followed by tibial diaphyseal fractures being the most frequent locations. Fasciotomies were performed, in order of frequency, in the leg (n = 53), forearm (n = 15), thigh (n = 9), foot (n = 5), followed by multiple or other locations.

Conclusions: Extremity compartment syndrome was a relatively uncommon finding. It occurred in all extremity locations, with or without an associated underlying fracture, and from a variety of mechanisms. Vigilance is warranted in evaluating the compartments of patients with extremity injuries following blunt trauma.
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http://dx.doi.org/10.1016/j.jss.2017.05.012DOI Listing
September 2017

Spinal Fractures in Older Adult Patients Admitted After Low-Level Falls: 10-Year Incidence and Outcomes.

J Am Geriatr Soc 2017 May 2;65(5):909-915. Epub 2016 Dec 2.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York.

Objectives: To evaluate the incidence of spinal fractures and their outcomes in the elderly who fall from low-levels in a suburban county.

Design: Retrospective county-wide trauma registry review from 2004 to 2013.

Setting: Suburban county with regionalized trauma care consisting of 11 hospitals.

Participants: Adult trauma patients aged ≥65 years who were admitted after falling from <3 feet.

Measurements: Demographic characteristics, comorbidities, and outcomes.

Results: Spinal fractures occurred in 18% of 4,202 older adult patients admitted following trauma over this 10-year time period, in the following distribution: 43% cervical spine, 5.7% thoracic, 4.9% lumbar spine, 36% sacrococcygeal, and 9.6% multiple spinal regions. As compared to non-spinal fracture patients, more spinal fracture patients went to acute/subacute rehabilitation (47% vs 34%, P < .001) and fewer were discharged home (21% vs 35%, P < .001). In-hospital mortality rate in spinal and non-spinal fracture patients was similar (8.5% vs 9.3%, P = .5).

Conclusion: Low-level falls often resulted in a spinal fracture at a variety of levels. Vigilance in evaluation of the entire spine in this population is suggested.
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http://dx.doi.org/10.1111/jgs.14669DOI Listing
May 2017

Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma.

Am J Surg 2016 Nov 4;212(5):953-960. Epub 2016 Aug 4.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, 100 Nichols Road, HSC T18-040, Stony Brook, NY, USA. Electronic address:

Background: The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown.

Methods: The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed.

Results: Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality.

Conclusions: Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction.
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http://dx.doi.org/10.1016/j.amjsurg.2016.07.013DOI Listing
November 2016

Tranexamic Acid Use in United States Trauma Centers: A National Survey.

Am Surg 2016 May;82(5):439-47

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine and Stony Brook University Medical Center, Stony Brook, New York, USA.

Tranexamic acid (TXA) is an antifibrinolytic agent that is listed as an essential medication by the World Health Organization for traumatic hemorrhage. We determined United States-based surgeons' familiarity with TXA and their use of TXA. An online survey was sent to the 1291 attending surgeon members of a national trauma organization. The survey was organized into three general parts: respondent demographics, perceptions of TXA, and experience with TXA. The survey was completed by 35 per cent of members. TXA was available at 89.1 per cent of centers. Experience with TXA was variable: 38.0 per cent use regularly, 24.9 per cent use it 1 to 2 times per year, 12.3 per cent use it rarely, and 24.7 per cent had never used it. Among surgeons who had used TXA, 77.1 per cent noted that TXA had reduced bleeding, but 22.9 per cent indicated that it had not. Reasons for not routinely using TXA included uncertain clinical benefit (47.7%) and unfamiliarity (31.5%). Finally, 90.5 per cent of respondents indicated that are looking toward national organizations to develop practice guidelines. TXA is widely available in civilian United States trauma centers. Although a majority of surveyed surgeons had used TXA, only 38 per cent use TXA regularly for significant traumatic hemorrhage; principal reasons for this are uncertainty regarding clinical benefit and unfamiliarity with the drug. National guidelines are sought.
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May 2016

Unplanned intensive care unit admission following trauma.

J Crit Care 2016 06 24;33:174-9. Epub 2016 Feb 24.

Division of Trauma, Department of Surgery, Stony Brook University Medical Center, HSC Level 18, Room 040, Stony Brook, NY, 11794-8191. Electronic address:

Background: The prevalence and outcomes of trauma patients requiring an unplanned return to the intensive care unit (ICU) and those initially admitted to a step-down unit or floor and subsequently upgraded to the ICU, collectively termed unplanned ICU (UP-ICU) admission, are largely unknown.

Methods: A retrospective review of the trauma registry of a suburban regional trauma center was conducted for adult patients who were admitted between 2007 and 2013, focusing on patients requiring ICU admission. Prehospital or emergency department intubations and patients undergoing surgery immediately after emergency room evaluation were excluded.

Results: Of 5411 admissions, there were 212 UP-ICU admissions, 541 planned ICU (PL-ICU) admissions, and 4658 that were never admitted to the ICU (NO-ICU). Of the 212 UP-ICU admits, 19.8% were unplanned readmissions to the ICU. Injury Severity Score was significantly different between PL-ICU (16), UP-ICU (13), and NO-ICU (9) admits. UP-ICU patients had significantly more often major (Abbreviated Injury Score ≥ 3) head/neck injury (46.7%) and abdominal injury (9.0%) than the NO-ICU group (22.5%, 3.4%), but significantly less often head/neck (59.5%) and abdominal injuries (17.9%) than PL-ICU patients. Major chest injury in the UP-ICU group (27.8%) occurred at a statistically comparable rate to PL-ICU group (31.6%) but more often than the NO-ICU group (14.7%). UP-ICU patients also significantly more often underwent major neurosurgical (10.4% vs 0.7%), thoracic (0.9% vs 0.1%), and abdominal surgery (8.5% vs 0.4%) than NO-ICU patients. Meanwhile, the PL-ICU group had statistically comparable rates of neurosurgical (6.8%) and thoracic surgical (0.9%) procedures but lower major abdominal surgery rate (2.0%) than the UP-ICU group. UP-ICU admission occurred at a median of 2 days following admission. UP-ICU median hospital LOS (15 days), need for mechanical ventilation (50.9%), and in-hospital mortality (18.4%) were significantly higher than those in the PL-ICU (9 days, 13.9%, 5.4%) and NO-ICU (5 days, 0%, 0.5%) groups.

Conclusions: UP-ICU admission, although infrequent, was associated with significantly greater hospital length of stay, rate of major abdominal surgery, need for mechanical ventilation, and mortality rates than PL-ICU and NO-ICU admission groups.
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http://dx.doi.org/10.1016/j.jcrc.2016.02.012DOI Listing
June 2016

Clopidogrel-Associated Thrombotic Thrombocytopenic Purpura following Endovascular Treatment of Spontaneous Carotid Artery Dissection.

J Neurol Surg Rep 2015 Nov 25;76(2):e287-90. Epub 2015 Oct 25.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York, United States.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening multisystem disease secondary to platelet aggregation. We present a patient who developed profound thrombocytopenia and anemia 8 days following initiation of therapy with clopidogrel after stent placement for carotid artery dissection. She did not have a disintegrin and metalloproteinase with thrombospondin domain 13 (ADAMTS 13) deficiency. Management included steroids and therapeutic plasma exchange. Clopidogrel has rarely been associated with TTP. Unlike other causes of acquired TTP, the diagnosis of early clopidogrel-associated TTP is largely clinical given the infrequent reduction in ADAMTS 13 activity.
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http://dx.doi.org/10.1055/s-0035-1566127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4648732PMC
November 2015

Preadmission Do Not Resuscitate advanced directive is associated with adverse outcomes following acute traumatic injury.

Am J Surg 2015 Nov 3;210(5):814-21. Epub 2015 Jun 3.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA.

Background: Do Not Resuscitate (DNR) orders have been associated with poor outcomes in surgical patients. There is limited literature on admitted trauma patients with advanced directives indicating DNR status before admission (preadmission DNR [PADNR]).

Methods: A retrospective review of the trauma registry of a suburban county was carried out for admitted trauma patients with age ≥41 years, who were admitted between 2008 and 2013.

Results: Of 7,937 admitted patients, 327 had a preadmission advanced directive indicating DNR. PADNR patients were significantly older (87 vs 69 years), with more frequent comorbidities, and were more often admitted after a fall (94.2% vs 65.8%). PADNR patients had a higher Injury Severity Score (14 vs 11). They also had significantly increased rates of pneumonia, sepsis, myocardial infarction, and death (33.6% vs 5.9%). On multivariate logistic regression, the presence of a preadmission advanced directive indicating DNR status was independently associated with a 5.2-fold increased odds of mortality.

Conclusion: An advanced directive indicating DNR is associated with adverse outcomes following trauma.
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http://dx.doi.org/10.1016/j.amjsurg.2015.04.007DOI Listing
November 2015

Outcomes following prolonged mechanical ventilation: analysis of a countywide trauma registry.

J Trauma Acute Care Surg 2015 Feb;78(2):289-94

From the Division of Trauma (J.A.R., M.F.P., D.N.R., J.A.V., J.E.M.M.J.S., and R.S.J), Department of Surgery, Stony Brook University School of Medicine; and Department of Preventive Medicine (J.Y.), Stony Brook University Medical Center, Health Sciences Center, Stony Brook, New York.

Background: The care of mechanically ventilated patients at high-volume centers in select nontrauma populations has variable effects on outcomes. We evaluated outcomes for trauma patients requiring prolonged mechanical ventilation (PMV). We further hypothesized that the higher mechanical ventilator volume trauma center would have better outcomes.

Methods: A retrospective review of a county's trauma registry was performed for trauma patients who were at least 18 years old admitted from 2006 to 2010. Eleven hospitals serve this suburban county, with a population of approximately 1.5 million people. The state has designated them as nontrauma centers (n = 6), area trauma centers (ATCs, n = 4), or regional trauma center (RTC, n = 1), where the last one provides the highest echelon of care. Patients requiring mechanical ventilation for at least 96 hours following injury were evaluated.

Results: A total of 3,382 trauma patients were admitted to the RTC, and 5,870 were admitted to the other 10 hospitals in the county. Seven hundred seventy-one received mechanical ventilation at the RTC, and 687 at the other 10 hospitals combined. Of these patients, 407 at the RTC and 308 at the remaining facilities (291 at ATCs and 17 at nontrauma centers) required PMV. Median (interquartile range [IQR]) Injury Severity Score (ISS) at the RTC was higher (29 [21-41] vs. 22 [16-29] p < 0.001) than that at ATCs. Hospital length of stay (in days) was comparable between the RTC and ATCs (28 [18-45] vs. 26 [16-44.7]). With regard to complications, rates of renal failure, sepsis, and myocardial infarction were similar. The RTC had higher pneumonia rates (59% vs. 45.4%, p < 0.001) and venous thromboembolic disease rates (20.4% vs. 10.4%, p < 0.001) than did ATCs. In-hospital mortality was 17% at the RTC and 34.4% at ATCs (p < 0.001).

Conclusion: A mortality benefit but higher VTE and pneumonia rate for PMV patients at the RTC was noted. Collaborative practice initiatives are warranted to reduce morbidity and mortality across the region.

Level Of Evidence: Epidemiologic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000000515DOI Listing
February 2015

Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center.

Am J Surg 2015 Feb 7;209(2):268-73. Epub 2014 Aug 7.

Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, HSC 18, Room 040, Stony Brook, NY 11794-8191. Electronic address:

Background: There is limited literature on early unplanned hospital readmission after acute traumatic injury, especially at suburban facilities.

Methods: A retrospective review of the trauma registry at a suburban, state-designated, level-I academic trauma center from July 2009 to June 2012 was performed for all admitted (≥24 hours) adult (age ≥18 years) trauma patients who were discharged alive, including unplanned readmissions within 30 days of discharge.

Results: Of 3,622 admitted adult trauma patients, 6.57% were readmitted at a median of 9 days. Major surgery was required in 15.9% patients on readmission. The mortality rate at readmission was 4.6%. Multiple factors were associated with readmission on univariate analysis; however, on multivariate analysis, only major comorbidities (odds ratio [OR], 1.53), hospital length of stay (OR, 1.01), abdominal Abbreviated Injury Score greater than or equal to 3 (OR, 2.10), and discharge to a skilled nursing facility or subacute facility (OR, 1.56) were significant predictors. Meanwhile, index admission to surgical services was associated with a significantly lower readmission risk (OR, .60).

Conclusions: Trauma patients are infrequently readmitted. Index admission to a surgical service reduces the risk of readmission. Earlier medical follow-up should be considered.
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http://dx.doi.org/10.1016/j.amjsurg.2014.06.026DOI Listing
February 2015

Phytobezoar as a cause of intestinal obstruction.

J Gastrointest Surg 2011 Dec 9;15(12):2293-5. Epub 2011 Aug 9.

Department of Surgery, Division of Trauma, Critical Care, General Surgery and Burns, Stony Brook University Medical Center, Stony Brook, NY, USA.

Introduction: A small bowel phytobezoar is a rare cause of intestinal obstruction, whose most common cause is adhesion.

Case Report: This is a case report in which the etiology of small bowel obstruction was identified due to intussusception via computed tomography scan, and upon exploration, was found to be due to a small bowel phytobezoar.
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http://dx.doi.org/10.1007/s11605-011-1645-0DOI Listing
December 2011

Rosiglitazone-Mediated Effects on Skeletal Muscle Gene Expression Correlate with Improvements in Insulin Sensitivity in Individuals with HIV-Insulin Resistance.

Patholog Res Int 2011 Apr 12;2011:736425. Epub 2011 Apr 12.

Division of Endocrinology, Department of Medicine, Stony Brook University Medical Center, HSC T15-060, Stony Brook, NY 11794-8154, USA.

Rosiglitazone, an agonist of peroxisome proliferator activated receptor (PPARγ), improves insulin sensitivity by increasing insulin-stimulated glucose uptake into muscle tissue. This study was undertaken to assess changes in expression of PPAR-regulated genes in muscle tissue following treatment of HIV-associated insulin resistance with rosiglitazone. Muscle gene expression was assessed in twenty-two seronegative HIV subjects (control), 21 HIV-infected individuals with normal insulin sensitivity (HIV-IS) and 19 HIV-infected individuals with insulin resistance (HIV-IR). A subset of the HIV-IR group (N = 10) were re-evaluated 12 weeks after treatment with 8 mg/d of rosiglitazone. The HIV-IR group's rosiglitazone-mediated improvement in insulin sensitivity was highly correlated with increased expression of PPARγ and carnitine palmitoyl transferase-1 (CPT-1), (r = 0.87, P < .001) and (r = 0.95, P < .001), respectively. The changes in PPARγ expression were also correlated with the changes in CPT1 expression (r = 0.75, P = .009). The results suggest that rosiglitazone; may have a direct effect on muscle tissue to improve insulin sensitivity.
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http://dx.doi.org/10.4061/2011/736425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3090220PMC
April 2011

Splenic vein turndown repair in superior mesenteric vein trauma: a reasonable alternative.

Vasc Endovascular Surg 2011 Feb 13;45(2):191-4. Epub 2010 Dec 13.

Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794-8191, USA.

Objective: To determine previous experience and results of autologous splenic vein graft repairs in traumatic superior mesenteric vein (SMV) avulsions.

Design Of Study: Systemic review was conducted for SMV trauma and methods of repair between 1897 and 2010. Articles were further analyzed for use of the splenic vein as an alternative conduit and were included in this study.

Results: Of the 56 articles identified during our search, 4 included use of the splenic vein as an autologous vein graft. A total of 5 cases using the splenic vein turndown repair were identified in addition to our case. Of the 6 patients, 4 survived. Only one other case exists regarding the successful use of the splenic vein turndown technique in blunt abdominal trauma.

Conclusion: There is little information regarding the feasibility and success of this technique in traumatic SMV disruption. Future studies are required to assess its role in abdominal vascular trauma.
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http://dx.doi.org/10.1177/1538574410390712DOI Listing
February 2011

Altered protein metabolism following coronary artery bypass graft (CABG) surgery.

Clin Sci (Lond) 2008 Feb;114(4):339-46

Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794-8191, USA.

The aim of the present study was to investigate the acute effect of CABG (coronary artery bypass graft) surgery on the rates of synthesis of muscle protein, the positive acute-phase protein fibrinogen and the negative acute-phase protein albumin. Synthesis rates of muscle protein, fibrinogen and albumin were measured simultaneously before and 4 h after the end of surgery from the incorporation of L-[(2)H(5)]phenylalanine (given at 43 mg/kg of body weight) in 12 patients undergoing CABG surgery. Surgery was performed either with the use of extracorporeal circulation with cardiopulmonary bypass (on-pump; n=5) or with the beating heart procedure without cardiopulmonary bypass (off-pump; n=7). Post-surgical muscle protein fractional synthesis rates were decreased by 36+/-6.5% compared with pre-surgical values (1.59+/-0.10 compared with 0.97+/-0.08%/day respectively; P<0.001). In contrast, the synthesis rates of both fibrinogen (36+/-4 compared with 100+/-11 mg.day(-1).kg(-1) of body weight; P<0.0001) and albumin (123+/-12 compared with 178+/-19 mg.day(-1).kg(-1) of body weight; P<0.001) were both significantly increased after surgery. No significant differences were found between surgery performed with or without cardiopulmonary bypass. In conclusion, the results demonstrate that CABG surgery has a profound effect on protein metabolism, with a differential response of protein synthesis in muscle and liver.
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http://dx.doi.org/10.1042/CS20070278DOI Listing
February 2008

Wall suction applied to needle muscle biopsy - a novel technique for increasing sample size.

J Surg Res 2007 Oct 12;142(2):301-3. Epub 2007 Jul 12.

Department of Surgery, Stony Brook University Medical Center, State University of New York at Stony Brook, Stony Brook, New York 11794-8191, USA.

Background: The needle biopsy technique described by Bergström is the most commonly used technique to obtain samples to assess muscle metabolism. Sampling of muscle, particularly the vastus lateralis, has become an essential tool in biomedical and clinical research. Optimal sample size is critical for availability of tissue for processing. To evaluate the effectiveness of a novel technique to obtain adequate sample size using wall suction applied to needle muscle biopsy, we collected samples from subjects in on-going clinical studies for gene expression.

Materials And Methods: Muscle biopsy samples of the vastus lateralis using 6 mm Bergström needles under local anesthesia were obtained from 55 subjects who had volunteered to participate in this research project. The vastus lateralis was biopsied according to the methods described by Bergström with a 6 mm biopsy needle. Wall suction was applied to the inner bore of the biopsy needle after the needle was inserted into the muscle.

Results: The mean sample of biopsy taken using the 6 mm was 233 mg (n = 55). The wall suction (200 mm Hg) applied to the needle pulled the surrounding tissue into the central bore of the needle. The quality of the samples was adequate for all biochemical assays. The biopsy technique did not result in any complications due to infection or bleeding.

Conclusions: Using a novel technique of connecting a 6 mm Bergström biopsy needle to wall suction, we have obtained 200 to 300 mg muscle biopsy specimens uniformly, with ease, and minimal discomfort. An increase in sample size allows for a wider variety of biochemical and histopathological analysis.
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http://dx.doi.org/10.1016/j.jss.2007.03.043DOI Listing
October 2007

The increase in human muscle protein synthesis induced by food intake is similar when assessed with the constant infusion and flooding techniques.

J Nutr 2006 Jun;136(6):1504-10

Department of Surgery, Stony Brook University, Stony Brook, NY 11794, USA.

Food intake is accompanied by a stimulation of muscle protein synthesis. However, the reported magnitude of the response differs with different methods of measurement. The aim of this study was to assess whether the response to feeding is dependent on the technique used for measurement when length and amount of feeding are controlled. Muscle protein fractional synthesis rates (FSRs) were measured both in the fasting and feeding states in 2 groups of healthy volunteers (n = 8). Two techniques were used to measure FSR: in one group, FSRs were assessed with a primed constant infusion of L-[2H5]phenylalanine, whereas in the other, a flooding amount of the same label was employed. The fasting FSRs assessed with the constant infusion method and estimated using the free amino acid in the tissue fluid to represent the precursor pool for protein synthesis were comparable to those obtained with the flooding method (1.94 +/- 0.15 vs. 1.86 +/- 0.13%/d). The degree of stimulation due to feeding (P < 0.02) did not differ between the constant infusion (+15%) and flooding (+22%) techniques. The stimulatory effect of feeding on muscle FSR was associated with enhanced phosphorylation of the Mr = 70,000 ribosomal protein S6 kinase, suggesting that it may involve activation of translation. This study demonstrates that human muscle FSRs obtained with the constant infusion technique are comparable to those obtained with the flooding method and that, in response to feeding, the 2 techniques give comparable estimates of stimulation.
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http://dx.doi.org/10.1093/jn/136.6.1504DOI Listing
June 2006

Direct assessment and diminished production of morphine stimulated NO by diabetic endothelium from saphenous vein.

Acta Pharmacol Sin 2002 Feb;23(2):97-102

Division of Cardiothoracic Surgery, Department of Surgery, University Hospital and Medical Center, HSC, T19-080, Stony Brook, New York 11794-8191, USA.

Aim: To directly measure in real time basal and stimulated levels of NO released from human saphenous vein endothelium and to quantify the expression of the mu opiate receptor, which has been linked with NO release.

Methods: Saphenous vein segments from patients with type 2 diabetes (n=12) and patients without diabetes (n=8) were obtained. The release of NO was measured directly from the endothelium using a NO-specific amperometric probe. N(Omega)-nitro-L-arginine methyl ester (L-NAME, 0.1 mmol/L), a NO synthase (NOS) inhibitor, or morphine (1 mumol/L), a stimulant, was administered and the measurements were repeated. Values were reported relative to the mean initial measurement of NO release from diabetic endothelium, which was defined as the relative zero level of NO release. A RT-PCR was then performed on the endothelium to measure mu opiate receptor expression.

Results: Diabetic patients (n=12) showed a relative and significantly diminished basal level of released NO, (0.049+/-0.012) nmol/L, compared with non diabetic patients (n=8), (0.42+/-0.12) nmol/L (P<0.05). Application of L-NAME to nonstimulated tissues resulted in no change in NO release from the diabetic group and a decrease in NO release of (0.21+/-0.09) nmol/L from the non diabetic group (P<0.05). Morphine stimulation of the diabetic endothelium resulted in a lower peak and shorter duration of NO release compared to the non-diabetic tissue, (21+/-6) nmol/L vs (38+/-4) nmol/L and (7.3+/-1.4) min vs (12.2+/-2.2) min, respectively (P<0.01). Lastly, evaluation of the mu opiate receptor expression was found to be diminished in the diabetics by 59.1 %.

Conclusion: Maturity-onset diabetes attenuates both the constitutive basal and morphine stimulated NO release from human saphenous vein endothelium. In this study, after NOS inhibition, the actual basal NO release in diabetes was negligible. One explanation for the impaired capacity of diabetic endothelium to release NO was the diminished mu opiate receptor that was seen in diabetic endothelium.
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February 2002