Publications by authors named "Laura J Moore"

65 Publications

Evaluation of Noninvasive Hemoglobin Measurements in Trauma Patients: A Repeat Study.

J Surg Res 2021 May 20;266:213-221. Epub 2021 May 20.

University of Texas Health Science Center at Houston, McGovern School of Medicine, 6431 Fannin St, Houston, TX 77030; University of Texas Health Science Center at Houston, Memorial Hermann Red Duke Trauma Institute, 6411 Fannin St, Houston, TX 77030; University of Texas Health Science Center at Houston, Center for Translational Injury Research, 6410 Fannin St UPB 1100, Houston, TX 77030.

Introduction: Reliable, accurate, and non-invasive hemoglobin measurements would be useful in the trauma setting. The aim of this study was to re-examine the ability of the Masimo Radical 7 in this setting after recent hardware and software improvements.

Methods: Level 1 Trauma patients were prospectively enrolled in the study over a 9-mo period with the goal of obtaining 3 paired data points from 150 patients admitted to the ICU or IMU. Hospital laboratory hemoglobin values were compared with cyanomethemoglobin (HiCN) and Masimo device hemoglobin (SpHb) values using comparison plots and Bland-Altman analysis.

Results: A total of 380 patients were enrolled in the study with 150 of those being admitted to the ICU or IMU. Comparison of hospital lab hemoglobin and HiCN (n = 494) found a correlation of R2 = 0.92. Comparison of hospital lab hemoglobin and Masimo device hemoglobin (n = 218) found a correlation of R2 = 0.27. Bland-Altman analysis of the 218 of the comparable hospital hemoglobin and Masimo device hemoglobin values had a bias of 0.505 g/dL with 95% of values within the limits of agreement of 4.06 g/dL to -3.60 g/dL.

Conclusions: The Masimo Radical 7 device has the potential to provide timely, useful clinical information, but it is not currently able to serve as an initial noninvasive diagnostic tool for trauma patients. There was poor correlation between clinical Hgb and SpHb, and because of that, SpHb should not be used to evaluate hemoglobin levels in trauma patients.
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http://dx.doi.org/10.1016/j.jss.2021.04.015DOI Listing
May 2021

Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm.

Trauma Surg Acute Care Open 2021 23;6(1):e000660. Epub 2021 Feb 23.

Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.

Background: Non-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use.

Methods: A multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA.

Results: Of the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination.

Discussion: This algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1136/tsaco-2020-000660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907878PMC
February 2021

Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers.

Ann Surg 2020 Jun 23. Epub 2020 Jun 23.

*Department of Surgery, Division of Acute Care Surgery, Center for Translational Injury Research, The University of Texas McGovern Medical School, Houston, Texas †Department of Surgery, Center for Translational Injury Research, The University of Texas McGovern Medical School, Houston, Texas ‡Department of Surgery, Division of Acute Care Surgery, The University of Texas McGovern Medical School, Houston, Texas §Department of Surgery, University of Maryland, Baltimore, Maryland ¶Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, Colorado ||Department of Surgery, Emory University School of Medicine, Atlanta, Georgia **Department of Surgery, University of Southern California, Los Angeles, California ††Department of Surgery, University of Washington, Seattle, Washington ‡‡Prytime Medical Devices, Inc., Boerne, Texas.

Objective: To describe the current use of the ER-REBOA catheter and associated outcomes and complications.

Introduction: Noncompressible truncal hemorrhage is the leading cause of potentially preventable death in trauma patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel strategy to obtain earlier temporary hemorrhage control, supporting cardiac, and cerebral perfusion before definitive hemostasis.

Methods: Prospective, observational study conducted at 6 Level 1 Trauma Centers over 12-months. Inclusion criteria were age >15 years of age with evidence of truncal hemorrhage below the diaphragm and decision for emergent hemorrhage control intervention within 60 minutes of arrival. REBOA details, demographics, mechanism of injury, complications, and outcomes were collected.

Results: A total of 8166 patients were screened for enrollment. In 75, REBOA was utilized for temporary hemorrhage control. Blunt injury occurred in 80% with a median injury severity score (ISS) 34 (21, 43). Forty-seven REBOAs were placed in Zone 1 and 28 in Zone 3. REBOA inflation increased systolic blood pressure from 67 (40, 83) mm Hg to 108 (90, 128) mm Hg 5 minutes after inflation (P = 0.02). Cardiopulmonary resuscitation was ongoing during REBOA insertion in 17 patients (26.6%) and 10 patients (58.8%) had return of spontaneous circulation after REBOA inflation. The procedural complication rate was 6.6%. Overall mortality was 52%.

Conclusion: REBOA can be used in blunt and penetrating trauma patients, including those in arrest. Balloon inflation uniformly improved hemodynamics and was associated with a 59% rate of return of spontaneous circulation for patients in arrest. Use of the ER-REBOA catheter is technically safe with a low procedural complication rate.
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http://dx.doi.org/10.1097/SLA.0000000000004055DOI Listing
June 2020

Does Clamshell Thoracotomy Better Facilitate Thoracic Life-Saving Procedures Without Increased Complication Compared with an Anterolateral Approach to Resuscitative Thoracotomy? Results from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry.

J Am Coll Surg 2020 12 16;231(6):713-719.e1. Epub 2020 Sep 16.

Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.

Background: Resuscitative thoracotomy (RT) is life-saving in select patients and can be accomplished through a left anterolateral (AT) or clamshell thoracotomy (CT). CT may provide additional exposure, facilitating certain operative procedures, but the added blood and heat loss and time to perform it may increase complications. No prospective multicenter comparison of techniques has yet been reported.

Study Design: The observational AAST Aortic Occlusion for Resuscitation in Trauma and Acute care surgery (AORTA) registry was used to compare AT and CT in RT.

Results: AORTA recorded 1,218 RTs at 46 trauma centers from June 2014 to January 2020. Overall survival after RT was 6.0% (AT 6.6%; [59 of 900]; CT 4.2% [13 of 296], p = 0.132). Among all RTs, 11.1% (142 of 1,278) surviving at least 24 hours were used tocompare AT (112) and CT (30). There was no difference between the 2 groups withregard to age, sex, Injury Severity Score, or mechanism of injury (Table 1). CT was significantly more likely to be used in patients needing resection of the lung or cardiac repair. CT was not associated with increased local thoracic/systemic complications, higher transfusion requirement, or greater ventilator, ICU, or hospital days compared with AT.

Conclusions: Clamshell thoracotomy facilitates thoracic life-saving procedures withoutincreased systemic or thoracic complications compared with AT in patients undergoing RT.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.09.002DOI Listing
December 2020

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization of hemorrhage in adolescent trauma patients.

J Pediatr Surg 2020 Dec 15;55(12):2732-2735. Epub 2020 Aug 15.

University of California Riverside, Department of Surgery, 26520 Cactus Avenue Moreno Valley, CA 92555.

Background/purpose: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative technique for traumatic hemorrhage control in the adult population. The purpose of this study is to describe the details of REBOA placement in adolescent trauma patients.

Methods: Patients 18 years of age or less who received REBOA for aortic occlusion (AO) from August 2013 to February 2017 at 2 urban tertiary care centers were included.

Results: 7 adolescent trauma patients received REBOA by trauma surgeons for both blunt (n = 4) and penetrating mechanisms (n = 3); mean age was 17 + 1.5 years, mean admission lactate 13.0 + 4.85 mmol/L, and mean Hgb 10.7 + 2.7 g/dL. 3 patients received REBOA through a 12Fr sheath and 4 through a 7Fr sheath. AO occurred mostly at the distal thoracic aorta (Zone I) (85.7%) and also in the distal abdominal aorta (Zone III) (14.3%). 57% of patients were in arrest with ongoing CPR at the time of REBOA. In-hospital mortality was 57%; all of these patients were in arrest at the time of REBOA, had return of spontaneous circulation (ROSC), and survived to the operating room. No complications from REBOA were identified.

Conclusion: REBOA appears to be feasible for use in adolescents despite their smaller caliber vessels, even with use of a 12Fr sheath. REBOA results in improved physiology and can bridge adolescent trauma patients presenting in extremis to the operating room.

Type Of Study: Treatment/therapeutic study LEVEL OF EVIDENCE: Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.08.007DOI Listing
December 2020

Temporal Changes in REBOA Utilization Practices are Associated With Increased Survival: an Analysis of the AORTA Registry.

Shock 2021 01;55(1):24-32

C-STARS (Center for the Sustainment of Trauma and Readiness Skills), R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland.

Background: Aortic occlusion (AO) is utilized for patients in extremis, with resuscitative endovascular balloon occlusion of the aorta (REBOA) use increasing. Our objective was to examine changes in AO practices and outcomes over time. The primary outcome was the temporal variation in AO mortality, while secondary outcomes included changes in technique, utilization, and complications.

Study Design: This study examined the AORTA registry over a 5-year period (2014-2018). AO outcomes and utilization were analyzed using year of procedure as an independent variable. A multivariable model adjusting for year of procedure, signs of life (SOL), SBP at AO initiation, operator level, timing of AO, and hemodynamic response to AO was created to analyze AO mortality.

Results: One thousand four hundred fifty-eight AO were included. Mean age (39.1 ± 16.7) and median ISS (34[25,49]) were comparable between REBOA and open AO. Open AO patients were more likely: male (84% vs. 77%, P = 0.001), s/p penetrating trauma (61% vs. 19%, P < 0.001), and arrived without SOL (60% vs. 40%, P = 0.001). REBOA use increased significantly and adjusted mortality decreased 22%/year while open AO survival was unchanged. REBOA initiation SBP increased significantly over the study period (52.2 vs. 65, P = 0.04). Compared with patients undergoing AO with CPR, each decile increase in SBP improved survival 12% (AOR 1.12, adj P = 0.001). The use of 7F REBOA (2.9%-54.8%) and Zone III deployment increased significantly (14.7% vs 40.6%), with Zone III placement having decreased associated mortality (AOR 0.33, adj P = 0.001). Overall REBOA complication rate was 4.5% and did not increase over time (P = 0.575).

Conclusions: REBOA survival has increased significantly while open AO survival remained unchanged. This may be related to lower thresholds for REBOA insertion at higher blood pressures, increased operator experience, and improved catheter technology leading to earlier deployment.
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http://dx.doi.org/10.1097/SHK.0000000000001586DOI Listing
January 2021

Nationwide use of REBOA in adolescent trauma patients: An analysis of the AAST AORTA registry.

Injury 2020 Nov 8;51(11):2512-2516. Epub 2020 Aug 8.

University of California Davis Medical Center, Department of Surgery. Sacramento, CA, USA.

Background: Trauma is the leading cause of death for children and adolescents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method of hemorrhage control used primarily in adults. We aimed to characterize REBOA use in pediatric patients.

Methods: The American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was queried for patients <18 years old undergoing REBOA placement (2013-2020). The primary outcome was mortality. Secondary outcomes included injury severity score (ISS), additional interventions, and complications.

Results: Eleven patients with a median age of 17 years old had REBOA placed, with a survival rate of 30%. Inflation of the REBOA balloon resulted in a significant increase in systolic blood pressure (SBP) (median SBP pre-REBOA 53 mmHg vs. post-REBOA 110 mmHg, p=0.0007). Patients were severely injured with a median ISS of 29 (interquartile range 16-42). There were no access-site complications. All three surviving patients had a discharge Glasgow Coma Scale of 15.

Conclusion: REBOA is used in patients <18 years old, but all reported patients in this registry were adolescents. No REBOA-related complications were reported. Identifying pediatric patients who may benefit from REBOA and modifying currently existing technology for this group of patients is an area of ongoing research.
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http://dx.doi.org/10.1016/j.injury.2020.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609470PMC
November 2020

Accuracy of Published Indications for Predicting Use of Damage Control During Laparotomy for Trauma.

J Surg Res 2020 04 18;248:45-55. Epub 2019 Dec 18.

Department of Surgery, The University of Texas Health Science Center, Houston, Texas; Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas.

Background: Although studies have identified published indications that experts and practicing surgeons agree indicate use of damage control (DC) laparotomy, it is unknown whether these indications predict use of the procedure in practice.

Materials And Methods: We conducted a diagnostic performance study of the accuracy of a set of published appropriateness indications for predicting use of DC laparotomy. We included consecutive adults that underwent emergent laparotomy for trauma (2011-2016) at Memorial Hermann Hospital.

Results: We included 1141 injured adults. Two published preoperative appropriateness indications [a systolic blood pressure (BP) persistently <90 mmHg or core body temperature <34°C] produced moderate shifts in the pretest probability of conducting DC instead of definitive laparotomy. Five published intraoperative appropriateness indications produced large and often conclusive changes in the pretest probability of conducting DC during emergent laparotomy. These included the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex; an estimated intraoperative blood loss >4 L; administration of >10 U of packed red blood cells (PRBCs); and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation. Most indications that produced large changes in the pretest probability of conducting DC laparotomy had an incidence of 2% or less.

Conclusions: This study suggests that published appropriateness indications accurately predict use of DC laparotomy in practice. Intraoperative variables exert greater influence on the decision to conduct DC laparotomy than preoperative variables, and those indications that produce large shifts in the pretest probability of conducting DC laparotomy are uncommonly encountered.
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http://dx.doi.org/10.1016/j.jss.2019.11.010DOI Listing
April 2020

Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients.

J Diabetes Sci Technol 2021 Mar 19;15(2):279-286. Epub 2019 Nov 19.

Division of Critical Care, Stamford Hospital and Columbia Vagelos College of Physicians and Surgeons, CT, USA.

Background: The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients.

Methods: An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%.

Results: At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial.

Conclusion: Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.
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http://dx.doi.org/10.1177/1932296819886917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256060PMC
March 2021

Implementation of a multi-modal pain regimen to decrease inpatient opioid exposure after injury.

Am J Surg 2019 12 1;218(6):1122-1127. Epub 2019 Oct 1.

Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA; Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.

Introduction: In 2013, we implemented a pill-based, multi-modal pain regimen (MMPR) in order to decrease in-hospital opioid exposure after injury at our trauma center. We hypothesized that the MMPR would decrease inpatient oral morphine milligram equivalents (MME), decrease opioid prescriptions at discharge, and result in similar Numerical Rating Scale (NRS) pain scores.

Methods: Adult patients admitted to a level-1 trauma center with ≥1 rib fracture from 2010 to 2017 were included - spanning 3 years before and 4 years after MMPR implementation. MME were summarized as medians and interquartile range (IQR) by year of admission. The effect of the MMPR on daily total MME was estimated using Bayesian generalized linear model.

Results: Over the 8 year study period, 6,933 patients who met study inclusion criteria were included. No significant differences between years were observed in Abbreviated Injury Scale (AIS) Chest or Injury Severity Scores (ISS). After introduction of the MMPR, there was a significant reduction in median total MME administered per patient day from 60 MME/patient day (IQR 36-91 MME/patient day) pre-MMPR implementation to 37 MME/patient day (IQR 18-61 MME/patient day) in 2017, p < 0.01. Total MME administered per patient day decreased by 31% in 2017 as compared to 2010 (rate ratio 0.69, 95% CI 0.64-0.75). Average NRS pain scores decreased by 0.8 points (95% CI -0.87, -0.81) from 2010 to 2017.

Conclusion: The introduction of a multi-modal pain regimen resulted in significant reduction in in-patient opioid exposure after injury. The reduction in inpatient opioid use from 2010 to 2017 was equivalent to 11 mg less oxycodone or 17 mg less hydrocodone per patient per day. Additionally, use of the MMPR was associated with a reduction in NRS pain scores.
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http://dx.doi.org/10.1016/j.amjsurg.2019.09.032DOI Listing
December 2019

Overcoming Immunological Resistance Enhances the Efficacy of A Novel Anti-tMUC1-CAR T Cell Treatment against Pancreatic Ductal Adenocarcinoma.

Cells 2019 09 11;8(9). Epub 2019 Sep 11.

Department of Biological Sciences, University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223, USA.

Chimeric antigen receptor (CAR) T cells have shown remarkable success in treating hematologic cancers. However, this efficacy has yet to translate to treatment in solid tumors. Pancreatic ductal adenocarcinoma (PDA) is a fatal malignancy with poor prognosis and limited treatment options. We have developed a second generation CAR T cell using the variable fragments of a novel monoclonal antibody, TAB004, which specifically binds the tumor-associated-MUC1 (tMUC1). tMUC1 is overexpressed on ~85% of all human PDA. We present data showing that TAB004-derived CAR T cells specifically bind to tMUC1 on PDA cells and show robust killing activity; however, they do not bind or kill normal epithelial cells. We further demonstrated that the tMUC1-CAR T cells control the growth of orthotopic pancreatic tumors in vivo. We witnessed that some PDA cells (HPAFII and CFPAC) were refractory to CAR T cell treatment. qPCR analysis of several genes revealed overexpression of indoleamine 2, 3-dioxygenases-1 (IDO1), cyclooxygenase 1 and 2 (COX1/2), and galectin-9 (Gal-9) in resistant PDA cells. We showed that combination of CAR T cells and biological inhibitors of IDO1, COX1/2, and Gal-9 resulted in significant enhancement of CAR T cell cytotoxicity against PDA cells. Overcoming PDA resistance is a significant advancement in the field.
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http://dx.doi.org/10.3390/cells8091070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6770201PMC
September 2019

Catheter distances and balloon inflation volumes for the ER-REBOA™ catheter: A prospective analysis.

Am J Surg 2020 01 27;219(1):140-144. Epub 2019 Apr 27.

University of Texas Health Sciences Center and the McGovern School of Medicine, Houston, TX, USA. Electronic address:

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct used to temporize uncontrolled abdominopelvic hemorrhage. No published clinical data exist that describe average catheter lengths or balloon fill volumes necessary to occlude the aorta.

Methods: A prospective, single-institution registry was queried for patients who underwent placement of a Prytime ER-REBOA™ catheter. Demographic, catheter, hemodynamic, and morphometric data were measured. Linear regression analyses were performed to identify variables associated with insertion distances and balloon volumes.

Results: 45 patients underwent supraceliac REBOA: median catheter insertion distance 45 cm [IQR 42-46], balloon inflation volume 14 mL [IQR 8-19], systolic blood pressure (SBP) augmentation 50 mmHg [IQR 35-55]. 14 patients underwent infrarenal deployment: median catheter insertion distance 28.5 cm [IQR 26.5-32.5], balloon volume 10 mL [IQR 5-15]; SBP augmentation 55 mmHg [IQR 40-65]. Patient body metrics were not associated with catheter length or balloon volume.

Conclusion: A wide range of catheter insertion distances and balloon fill volumes were necessary for correct REBOA positioning and occlusion. No single patient metric accurately correlated with catheter distance or balloon volume.

Level Of Evidence: Level IV, Prognostic.
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http://dx.doi.org/10.1016/j.amjsurg.2019.04.019DOI Listing
January 2020

Connectivity in coastal systems: Barrier island vegetation influences upland migration in a changing climate.

Glob Chang Biol 2019 07 11;25(7):2419-2430. Epub 2019 May 11.

University of Kentucky, Lexington, Kentucky.

Due to their position at the land-sea interface, barrier islands are vulnerable to both oceanic and atmospheric climate change-related drivers. In response to relative sea-level rise, barrier islands tend to migrate landward via overwash processes which deposit sediment onto the backbarrier marsh, thus maintaining elevation above sea level. In this paper, we assess the importance of interior upland vegetation and sediment transport (from upland to marsh) on the movement of the marsh-upland boundary in a transgressive barrier system along the mid-Atlantic Coast. We hypothesize that recent woody expansion is altering the rate of marsh to upland conversion. Using Landsat imagery over a 32 year time period (1984-2016), we quantify transitions between land cover (bare, grassland, woody vegetation, and marsh) and the marsh-upland boundary. We find that the Virginia Barrier Islands have both gains and losses in backbarrier marsh and upland, with 19% net loss from the system during the timeframe of the study and increased variance in marsh to upland conversion. This is consistent with recent work indicating a shift toward increasing rates of landward barrier island migration. Despite a net loss of upland area, macroclimatic winter warming resulted in 41% increase in woody vegetation in protected, low-elevation areas, introducing new ecological scenarios that increase resistance to sediment movement from upland to marsh. Our analysis demonstrates how the interplay between elevation and interior island vegetative cover influences landward migration of the boundary between upland and marsh (a previously underappreciated indicator that an island is migrating), and thus, the importance of including ecological processes in the island interior into coastal modeling of barrier island migration and sediment movement across the barrier landscape.
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http://dx.doi.org/10.1111/gcb.14635DOI Listing
July 2019

Morphometric and Physiologic Modeling Study for Endovascular Occlusion in Pediatric Trauma Patients.

ASAIO J 2020 01;66(1):97-104

From the Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center, Houston, Texas.

The use of the resuscitative endovascular balloon occlusion of the aorta (REBOA) device is expanding in adult trauma. Reports of its use in pediatric patients have been published, but no guidelines currently exist nor has it been Food and Drug Administration approved in pediatrics. This project develops a model to determine appropriate balloon inflation volumes in pediatric patients to guide potential use. Artificial aortas were three-dimensional (3D) printed using synthetic polymers. Segments were created based on aortic diameters from 289 pediatric trauma patients' computer tomography (CT) scans. These aortic segments were inserted into a circulatory system model featuring two branches to simulate abdominal and upper body perfusion (cerebral, cardiac, and upper extremities). Sonographic flow meters and pressure transducers were placed along the circuit, and measurements were recorded as a REBOA device was inflated in the aortic segment. A negative sigmoidal relationship was observed between device inflation and aortic flow occlusion, with the initial 50% of inflation causing a 10% reduction in flow, followed by a steep decline. With increasing inflation, distal aortic flow and pressure were found to have an inverse relationship with the upper body branch metrics. In conclusion, pediatric patients present with a range of vessel diameters that occlude at various REBOA balloon inflation volumes. This study provides a basis to establish initial inflation volumes for safe REBOA deployment in appropriate pediatric trauma patients.
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http://dx.doi.org/10.1097/MAT.0000000000000961DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6856426PMC
January 2020

Guidelines for a system-wide multidisciplinary approach to institutional resuscitative endovascular balloon occlusion of the aorta implementation.

J Trauma Acute Care Surg 2019 02;86(2):337-343

From the UC Davis Medical Center (S.A.Z., B.C.B., E.S.S.), Sacramento, California; Baltimore Center for Sustainment of Trauma and Critical Care (J.J.D.), Baltimore, Maryland; Texas Trauma Institute (J.J.M.), Memorial Hermann Hospital, Houston, Texas; and Basic Endovascular Skills for Trauma (M.B.), American College of Surgeons Committee on Trauma, Chicago, Illinois.

Resuscitative endovascular occlusion of the aorta (REBOA) is a rapidly evolving technology which requires careful system-wide multidisciplinary implementation for optimal success. These guidelines developed by experienced REBOA practitioners provide a framework for a key practitioner to use in the development of a REBOA program in their institution. They detail the importance of involving doctors, nurses, and staff across departments and disciplines in the application of this technique.
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http://dx.doi.org/10.1097/TA.0000000000002138DOI Listing
February 2019

Resuscitative endovascular balloon occlusion of the aorta: current evidence.

Open Access Emerg Med 2019 14;11:29-38. Epub 2019 Jan 14.

Department of Surgery, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as a minimally invasive alternative to open aortic cross-clamping in the management of patients with non-compressible hemorrhage arising below the diaphragm. The purpose of this review is to provide a description of the technical aspects of REBOA use along with an overview of the current animal and clinical data regarding its use.
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http://dx.doi.org/10.2147/OAEM.S166087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336022PMC
January 2019

Using Machine Learning to Identify Change in Surgical Decision Making in Current Use of Damage Control Laparotomy.

J Am Coll Surg 2019 03 9;228(3):255-264. Epub 2019 Jan 9.

Department of Surgery, University of Texas McGovern Medical School, Houston, TX; Center for Clinical Research and Evidence Based Medicine, University of Texas McGovern Medical School, Houston, TX.

Background: In an earlier study, we reported the successful reduction in the use of damage control laparotomy (DCL); however, no change in the relative frequencies of specific indications was observed. In this study, we aimed to use machine learning to help identify the changes in surgical decision making that occurred.

Study Design: Adult patients undergoing emergent trauma laparotomy were included: pre-quality improvement (QI): January 1, 2011 to October 31, 2013 and post-QI: November 1, 2013 to June 30, 2016. Using 72 variables before or during emergent laparotomy, random forest algorithms predicting DCL before and after a QI intervention were created. The main end point of the algorithms was the strength of individual factor significance in predicting the use of DCL, calculated by determining the mean decrease in accuracy (MDA) in the model if that variable was removed.

Results: In the pre-QI group, 24 of 72 factors significantly predicted DCL, the strongest being bowel resection (mean MDA 16) and operating room RBC transfusions (mean MDA 15). The remaining variables were spread along the continuum of care from injury to emergent laparotomy end. In the post-QI group, 12 of 72 factors significantly predicted DCL, the strongest being last operating room lactate (mean MDA 12) and operating room RBC transfusions (mean MDA 14). In addition to having 12 fewer significant factors predictive of DCL, the predictive factors in the post-QI group were mainly intraoperative factors.

Conclusions: A machine learning analysis provided novel insights into the changes in decision making achieved by a successful QI intervention and should be considered an adjunct to understanding successful pre- and post-intervention QI studies. The analysis suggested a shift toward using mostly intraoperative factors to determine the use of DCL.
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http://dx.doi.org/10.1016/j.jamcollsurg.2018.12.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391184PMC
March 2019

Thromboelastography and rotational thromboelastometry for the surgical intensivist: A narrative review.

J Trauma Acute Care Surg 2019 04;86(4):710-721

From the Program in Trauma, Department of Surgery (B.C.D., D.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (L.J.M.), University of Texas Health Sciences Center at Houston, McGovern Medical School, Houston, Texas; Department of Surgery, Department of Critical Care Medicine (S.B.R.), St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and Department of Surgery (M.J.C.), Denver Health Medical Center, University of Colorado, Boulder, Colorado.

Background: Viscoelastic tests (VETs), specifically thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are gaining popularity in the management of critically ill surgical patients with hemorrhage or thrombosis due to their comprehensive characterization of the coagulation process and point-of-care availability in comparison to conventional coagulation tests (CCTs). We review current evidence for VET use in patients in the surgical intensive care unit (SICU).

Methods: We searched PUBMED, EMBASE and the Cochrane Library through May 30, 2018 for articles that evaluated the use of VETs in patient populations and clinical scenarios germane to the surgical intensivist. Individual articles were critically evaluated for relevance and appropriate methodology using a structured technique. Information on patient characteristics, timing and methods of CCTs/VETs, and outcomes was collected and summarized in narrative form.

Results: Of 2,589 identified articles, 36 were included. Five (14%) were interventional studies and 31 (86%) were observational. Twenty-five (69%) evaluated TEG, 11 (31%) ROTEM and 18 (50%) CCTs. Investigated outcomes included quantitative blood loss (13 (36%)), blood product transfusion (9 (25%)), thromboembolic events (9 (25%)) and mortality (6 (17%)). We identified 12 clinical scenarios with sufficient available evidence, much of which was of limited quantity and poor methodological quality. Nonetheless, research supports the use of VETs for guiding early blood product administration in severe traumatic hemorrhage and for the prediction of abstract excess bleeding following routine cardiac surgery. In contrast, evidence suggests VET-based heparin dosing strategies for venous thromboembolism prophylaxis are not superior to standard dosing in SICU patients.

Conclusion: While VETs have the potential to impact the care of critically ill surgical patients in many ways, current evidence for their use is limited, mainly because of poor methodological quality of most available studies. Further high-quality research, including several ongoing randomized controlled trials, is needed to elucidate the role of TEG/ROTEM in the SICU population.

Level Of Evidence: Systematic review, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6433488PMC
April 2019

Antibiotics versus No Antibiotics for the Treatment of Acute Uncomplicated Diverticulitis: Review of the Evidence and Future Directions.

Surg Infect (Larchmt) 2018 Oct 11;19(7):648-654. Epub 2018 Sep 11.

5 Department of Surgery, John Peter Smith Health Network , Fort Worth, Texas.

Background: Acute diverticulitis occurs in 25% of individuals with diverticular disease and is associated with significant morbidity and mortality rates. Disease severity is classified as uncomplicated or complicated, with the latter including perforation, fistula, obstruction, or distant abscess. Uncomplicated diverticulitis often improves without surgery or invasive therapies. Administration of antibiotics is a standard of care for treatment of acute uncomplicated diverticulitis. However, recent data suggest antibiotics do not influence outcomes significantly. To address these conflicting approaches, the Surgical Infection Society hosted an Update Symposium at its 37 Annual Meeting examining the role of antibiotics in the treatment of acute uncomplicated diverticulitis. Here, we provide a synopsis of the symposium's findings and a brief review of recent prospective and randomized clinical trials on the topic.

Methods: A search of Embase, MEDLINE, and the Cochrane Library was performed for prospective series and randomized clinical trials published between January 1, 2010, and January 1, 2018, comparing outcomes of antibiotic versus no antibiotic therapy for acute uncomplicated diverticulitis.

Results: We identified two single-center prospective series and two randomized clinical trials comparing outcomes for patients with acute uncomplicated diverticulitis treated with antibiotics versus no antibiotics.

Conclusion: Current evidence does not support administration of antibiotics to improve outcomes in carefully selected healthy patients with acute uncomplicated left-sided diverticulitis. Further studies should help identify specific subpopulations of patients who would derive benefit from antibiotic therapy and help define appropriate antibiotic regimens and treatment durations that minimize cost, adverse effects, and risk of anti-microbial resistance.
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http://dx.doi.org/10.1089/sur.2018.115DOI Listing
October 2018

Literature-based latitudinal distribution and possible range shifts of two US east coast dune grass species ( and ).

PeerJ 2018 8;6:e4932. Epub 2018 Jun 8.

Department of Biology, Virginia Commonwealth University, Richmond, VA, USA.

Previous work on the US Atlantic coast has generally shown that coastal foredunes are dominated by two dune grass species, (American beachgrass) and (sea oats). From Virginia northward, dominates, while is the dominant grass south of Virginia. Previous work suggests that these grasses influence the shape of coastal foredunes in species-specific ways, and that they respond differently to environmental stressors; thus, it is important to know which species dominates a given dune system. The range boundaries of these two species remains unclear given the lack of comprehensive surveys. In an attempt to determine these boundaries, we conducted a literature survey of 98 studies that either stated the range limits and/or included field-based studies/observations of the two grass species. We then produced an interactive map that summarizes the locations of the surveyed papers and books. The literature review suggests that the current southern range limit for is Cape Fear, NC, and the northern range limit for is Assateague Island, on the Maryland and Virginia border. Our data suggest a northward expansion of possibly associated with warming trends observed near the northern range limit in Painter, VA. In contrast, the data regarding a range shift for remain inconclusive. We also compare our literature-based map with geolocated records from the Global Biodiversity Information Facility and iNaturalist research grade crowd-sourced observations. We intend for our literature-based map to aid coastal researchers who are interested in the dynamics of these two species and the potential for their ranges to shift as a result of climate change.
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http://dx.doi.org/10.7717/peerj.4932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996817PMC
June 2018

Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial.

Trauma Surg Acute Care Open 2017 13;2(1):e000083. Epub 2017 Apr 13.

Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Background: Damage control laparotomy (DCL) is an abbreviated operation intended to prevent the development of hypothermia, acidosis, and coagulopathy in seriously injured patients. The indications for DCL have since been broadened with no high-quality data to guide treatment. For patients with an indication for DCL, we aim to determine the effect of definitive laparotomy on patient morbidity.

Method: This is a pragmatic, parallel-group, randomized controlled pilot trial. Emergent laparotomy is defined as admission directly to the operating room from the emergency department within 90 min of arrival. DCL indications excluded from the study include packing of the liver or retroperitoneum, abdominal compartment syndrome prophylaxis, to expedite interventional radiology for hemorrhage control, and the need for ongoing transfusions and/or continuous vasopressor support. When a surgeon determines a DCL is indicated, the patient will be screened for inclusion and exclusion criteria. Patients with any indication for DCL that is not excluded are eligible for randomization. Patients will be randomized intraoperatively to DCL (control) or definitive fascial closure of the laparotomy (intervention). The primary outcome will be major abdominal complication or death within 30 days. Major abdominal complication is a composite outcome including fascial dehiscence, organ/space surgical site infection, enteric suture line failure, and unplanned reopening of the abdomen. Outcomes will be compared using both frequentist and Bayesian statistics.

Discussion: In patients with an indication for DCL, this trial will determine the effect of definitive laparotomy on major abdominal complications and death and will inform clinicians on the risks and benefits of this procedure. Regardless of the study outcome, the results will improve the quality of care provided to injured patients.

Trial Registration Number: NCT02706041.
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http://dx.doi.org/10.1136/tsaco-2017-000083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877899PMC
April 2017

Early detection of pancreatic cancer in mouse models using a novel antibody, TAB004.

PLoS One 2018 20;13(2):e0193260. Epub 2018 Feb 20.

Department of Biological Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America.

Pancreatic ductal adenocarcinoma (PDA) is the fourth-leading cause of cancer death in the United States with a 5-year overall survival rate of 8% for all stages combined. But this decreases to 3% for the majority of patients that present with stage IV PDA at time of diagnosis. The lack of distinct early symptoms for PDA is one of the primary reasons for the late diagnosis. Common symptoms like weight loss, abdominal and back pains, and jaundice are often mistaken for symptoms of other issues and do not appear until the cancer has progressed to a late stage. Thus the development of novel imaging platforms for PDA is crucial for the early detection of the disease. MUC1 is a tumor-associated antigen (tMUC1) expressed on 80% of PDA. The goal of this study was to determine the targeting and detection capabilities of a tMUC1 specific antibody, TAB004. TAB004 antibody conjugated to a near infrared fluorescent probe was injected intraperitoneally into immune competent orthotopic and spontaneous models of PDA. Results show that fluorophore conjugated TAB004 specifically targets a) 1 week old small tumor in the pancreas in an orthotopic PDA model and b) very early pre-neoplastic lesions (PanIN lesions) that develop in the spontaneous PDA model before progression to adenocarcinoma. Thus, TAB004 is a promising antibody to deliver imaging agents directly to the pancreatic tumor microenvironment, significantly affecting early detection of PDA.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193260PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819830PMC
May 2018

Sepsis Screening: Current Evidence and Available Tools.

Surg Infect (Larchmt) 2018 Feb/Mar;19(2):126-130. Epub 2018 Jan 9.

Department of Surgical Critical Care, The University of Texas McGovern Medical School , Houston, Texas.

Background: Early recognition of sepsis is challenging, especially in the surgical patient. Because of the non-specific nature of the initial signs and symptoms, delays in recognition are all too common. To improve the early identification of sepsis, screening tools have been developed, and several papers have described their results. This article reviews the available sepsis screening tools.

Methods: A PubMed search was performed using the search terms "sepsis" and "shock," "electronic alert," "clinical decision support," and "early warning systems." The papers found were reviewed to determine their relevance to the topic of sepsis screening, and outcome data were extracted from appropriate papers.

Results: Multiple sepsis screening tools were identified with differing performance characteristics. These tools are reviewed individually along with a summary of their sensitivity, specificity, and positive and negative predictive values.

Conclusions: Clearly, sepsis screening has the potential to improve patient outcomes by aiding clinicians in the early recognition of the condition, enabling early implementation of evidence-based therapies. However, significant challenges remain, including identifying an optimal screening tool. Continued research is needed into the development and integration of automated screening tools that will be effective in a variety of clinical settings.
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http://dx.doi.org/10.1089/sur.2017.250DOI Listing
August 2018

Contemporary Utilization of Resuscitative Thoracotomy: Results From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Multicenter Registry.

Shock 2018 10;50(4):414-420

R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland.

Introduction: Several reviews of resuscitative thoracotomy (RT) use over the last five decades have been conducted, most recently the evidence-based practice management guideline (PMG) of the Eastern Association for the Surgery of Trauma (EAST). The present study was designed to examine contemporary RT utilization and outcomes compared with historical data (n = 10,238) from the EAST PMG review from published series 1974 to 2013.

Methods: The American Association for the Surgery of Trauma Aortic Occlusion for Trauma and Acute Care Surgery (AORTA) registry was utilized to identify patients undergoing RT in the emergency department (ED) from November 2013 to December 2016. Demographics, injury data, physiologic presentation, and outcomes were reviewed and compared with those of the EAST PMG review.

Results: Three-hundred ten RT patients from 16 contributing AORTA centers were identified. The majority were injured by penetrating mechanisms (197/310, 64% [gunshot (163/197, 83%)]). Signs of life (SOL) (organized electrical activity, pupillary response, spontaneous movement, or appreciable pulse/blood pressure) were present on arrival in 47% (147/310). When compared with the EAST PMG results, there was no difference in either hospital survival (5% vs. 8%) or neurologically intact survival between historical controls or AORTA registry patients in any category combination of mechanism/anatomic location/presenting signs of life. Blunt injuries W/O SOL on admission continue to constitute 14% (45/310) of RTs in the ED, without documented survivors.

Conclusion: Comparison of historical RT controls to more contemporary patients from the AORTA registry suggests that practices and outcomes following RT have not changed. Despite a wealth of accumulated data over several decades, RT continues to be performed for patients after blunt mechanisms of injury who present W/O SOL despite lack of demonstrated hope for survival benefit.
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http://dx.doi.org/10.1097/SHK.0000000000001091DOI Listing
October 2018

The pitfalls of resuscitative endovascular balloon occlusion of the aorta: Risk factors and mitigation strategies.

J Trauma Acute Care Surg 2018 01;84(1):192-202

From the University of California Davis (A.J.D., R.M.R., J.J.D.), Sacramento, California; Kirov Military Medical Academy (V.A.R.), Saint-Petersburg, Russian Federation; R Adams Cowley Shock Trauma Medical Center (M.L.B.), Baltimore, Maryland; University of Texas Health Science Center (L.J.M.), Houston, Texas; Foothills Medical Centre (C.B.), University of Calgary, Calgary, Alberta, Canada; Harborview Medical Center (E.B.), University of Washington, Seattle, Washington; Denver Health (E.E.M.), Denver, Colorado; Uniformed Services (T.E.R.), University of the Health Sciences, Bethesda, Maryland.

Despite technological advancements, REBOA is associated with significant risks due to complications of vascular access and ischemia-reperfusion. The inherent morbidity and mortality of REBOA is often compounded by coexisting injury and hemorrhagic shock. Additionally, the potential for REBOA-related injuries is exaggerated due to the growing number of interventions being performed by providers who have limited experience in endovascular techniques, inadequate resources, minimal training in the technique, and who are performing this maneuver in emergency situations. In an effort to ultimately improve outcomes with REBOA, we sought to compile a list of complications that may be encountered during REBOA usage. To address the current knowledge gap, we assembled a list of anecdotal complications from high-volume REBOA users internationally. More importantly, through a consensus model, we identify contributory factors that may lead to complications and deliberate on how to recognize, mitigate, and manage such events. An understanding of the pitfalls of REBOA and strategies to mitigate their occurrence is of vital importance to optimize patient outcomes.
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http://dx.doi.org/10.1097/TA.0000000000001711DOI Listing
January 2018

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit.

JPEN J Parenter Enteral Nutr 2018 Mar 12;42(3):529-537. Epub 2017 Dec 12.

Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.

Background: Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch-up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies.

Methods: All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014-May 2015 (intervention) and May 2012-June 2013 (baseline).

Results: The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28-ay ventilator-free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31-0.89; P = .017) after adjusting sex and Injury Severity Score.

Conclusions: Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.
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http://dx.doi.org/10.1177/0148607117699561DOI Listing
March 2018

The effect of damage control laparotomy on major abdominal complications: A matched analysis.

Am J Surg 2018 07 11;216(1):56-59. Epub 2017 Nov 11.

Department of Surgery and the Center for Translational Injury Research, The University of Texas Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA. Electronic address:

Introduction: Damage control laparotomy (DCL) for trauma is thought to be associated with increased abdominal complications. The purpose of this study is to determine the effect of DCL on abdominal complications by comparing two groups of trauma patients: DCL patients who were prospectively adjudicated to potentially being closed at the primary laparotomy (potential DEF or pDEF) and those who underwent definitive laparotomy (DEF).

Methods: The pDEF group was matched to DEF patients according to mechanism of injury, abdominal injury severity, operating room transfusions, and performance of a colon resection. The primary outcome was major abdominal complications (MAC), a composite variable.

Results: No statistically significant difference in the primary outcome, major abdominal complications, were seen (pDEF 19% versus DEF 56%, p = 0.066). The pDEF group was more likely to have a fascial dehiscence (38% versus 0%, p = 0.018), and to be re-opened after fascial closure (38% versus 0%, p = 0.018).

Conclusion: Damage control laparotomy was associated with clinically but not statistically significant increase in rates of MAC. Increased numbers of patients to analyze in this fashion is needed.
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http://dx.doi.org/10.1016/j.amjsurg.2017.10.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6272122PMC
July 2018

O availability impacts iron homeostasis in .

Proc Natl Acad Sci U S A 2017 11 30;114(46):12261-12266. Epub 2017 Oct 30.

Department of Biomolecular Chemistry, University of Wisconsin-Madison, Madison, WI 53706;

The ferric-uptake regulator (Fur) is an Fe-responsive transcription factor that coordinates iron homeostasis in many bacteria. Recently, we reported that expression of the Fur regulon is also impacted by O tension. Here, we show that for most of the Fur regulon, Fur binding and transcriptional repression increase under anaerobic conditions, suggesting that Fur is controlled by O availability. We found that the intracellular, labile Fe pool was higher under anaerobic conditions compared with aerobic conditions, suggesting that higher Fe availability drove the formation of more Fe-Fur and, accordingly, more DNA binding. O regulation of Fur activity required the anaerobically induced FeoABC Fe uptake system, linking increased Fur activity to ferrous import under iron-sufficient conditions. The increased activity of Fur under anaerobic conditions led to a decrease in expression of ferric import systems. However, the combined positive regulation of the operon by ArcA and FNR partially antagonized Fur-mediated repression of under anaerobic conditions, allowing ferrous transport to increase even though Fur is more active. This design feature promotes a switch from ferric import to the more physiological relevant ferrous iron under anaerobic conditions. Taken together, we propose that the influence of O availability on the levels of active Fur adds a previously undescribed layer of regulation in maintaining cellular iron homeostasis.
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http://dx.doi.org/10.1073/pnas.1707189114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699043PMC
November 2017

Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy.

Injury 2018 Jan 31;49(1):67-74. Epub 2017 Jul 31.

Department of Surgery, University of Texas Health Science Center at Houston, Memorial Hermann Hospital Red Duke Trauma Institute,United States. Electronic address:

Introduction: Practice management guidelines for screening and treatment of patients with blunt cerebrovascular injury (BCVI) have been associated with a decreased risk of ischemic stroke.

Treatment: of patients with BCVI and multisystem injuries that delays immediate antithrombotic therapy remains controversial. The purpose of this study was to determine the timing of BCVI treatment initiation, the incidence of stroke, and bleeding complications as a result of antithrombotic therapy in patients with isolated BCVI in comparison to those with BCVI complicated by multisystem injuries.

Materials And Methods: This study was a retrospective review of all adult blunt trauma patients admitted to a level 1 trauma center from 2009 to 2014 with a diagnosis of BCVI.

Results: A total of 28,305 blunt trauma patients were admitted during the study period. Of these, 323 (1.1%) had 481 BCEVIs and were separated into two groups. Isolated BCVI was reported in 111 (34.4%) patients and 212 (65.6%) patients had accompanying multisystem injuries (traumatic brain injury (TBI), solid organ injury, or spinal cord injury) that contraindicated immediate antithrombotic therapy.

Treatment: started in patients with isolated BCVI at a median time of 30.3 (15, 52) hours after injury in contrast to 62.4 (38, 97) hours for those with multisystem injuries (p<0.001). The incidence of stroke was identical (9.9%) between groups and no bleeding complications related to antithrombotic therapy were identified.

Conclusion: The lack of bleeding complications and equivalent stroke rates between groups suggests that the presence of TBI, solid organ injury, and spinal cord injury are not contraindications to anti-thrombotic therapy for stroke prevention in patients with BCVI.
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http://dx.doi.org/10.1016/j.injury.2017.07.036DOI Listing
January 2018

A tumor specific antibody to aid breast cancer screening in women with dense breast tissue.

Genes Cancer 2017 Mar;8(3-4):536-549

OncoTAb, Inc., Charlotte, NC, USA.

Screening for breast cancer has predominantly been done using mammography. Unfortunately, mammograms miss 50% cancers in women with dense breast tissue. Multi-modal screenings offer the best chance of enhancing breast cancer screening effectiveness. We evaluated the use of TAB004, an antibody that recognizes the tumor form of the glycoprotein MUC1 (tMUC1), to aid early detection of breast cancer. Our experimental approach was to follow tMUC1 from the tissue into circulation. We found that 95% of human breast cancer tissues across all subtypes stained positive for TAB004. In breast cancer cell lines, we showed that the amount of tMUC1 released from tumor cells is proportional to the cell's tMUC1 expression level. Finally, we showed that TAB004 can be used to assess circulating tMUC1 levels, which when monitored in the context of cancer immunoediting, can aid earlier diagnosis of breast cancer regardless of breast tissue density. In a blinded pilot study with banked serial samples, tMUC1 levels increased significantly up to 2 years before diagnosis. Inclusion of tMUC1 monitoring as part of a multi-modal screening strategy may lead to earlier stage diagnosis of women whose cancers are missed by mammography.
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http://dx.doi.org/10.18632/genesandcancer.134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489651PMC
March 2017