Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online... more Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.
Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endo... more Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endoscopic ultrasound (EUS) is an additional staging modality to assess locoregional extent of this disease. We hypothesized that EUS may improve survival through more effective staging and better optimization of treatment. Methods: We performed a retrospective review of all patients presenting with esophageal cancer at our institution from 1993 to 2003 (n 97) and compared outcomes between patients who underwent staging EUS and computed tomography (CT) versus CT alone. Survival was calculated using Kaplan-Meier methods and compared between groups using the log-rank test. Mean survival was compared using analysis of variance (ANOVA) methods. Results: Overall 3-, 6-, and 12-month survival did not differ between the 2 groups (EUS: 92%, 84%, and 80% and CT: 83%, 67%, and 43%, log-rank P .1), which held true despite stratification by treatment modality (all P .1). The mean survival for the EUS gr...
Learning Objectives: Changes to aminoglycoside (AG) pharmacokinetics during critical illness may ... more Learning Objectives: Changes to aminoglycoside (AG) pharmacokinetics during critical illness may affect attainment of pharmacokinetic targets. Use of continuous renal replacement therapies (CRRT) complicates attainment due to variable and poorly understood extracorporeal drug clearance compared with patients with normal renal function. We hypothesize that critically ill patients undergoing CRRT will have an expanded volume of distribution (Vd) and reduced clearance, with variation in clearance observed between CRRT modalities. Methods: Adult patients who received a first dose of amikacin or tobramycin during CRRT between 2/1/2012 and 2/28/2017 were retrospectively evaluated. Patients were allocated to different study arms per their receipt of SLED, CVVHD, or CVVH. Two post-distributional serum levels were required for pharmacokinetic calculations. Patients were excluded if fewer than 2 serum AG levels were collected, if previous AG dose given within 7 days, if already enrolled or if...
Intraoperative parathyroid hormone (PTH) monitoring has become an integral adjunct to minimally i... more Intraoperative parathyroid hormone (PTH) monitoring has become an integral adjunct to minimally invasive parathyroidectomy. Guidelines for predicting therapeutic excision of all hyperactive parathyroid tissue have been routinely based on peripheral blood samples drawn at various time intervals. Whether these same guidelines can be used to predict success based on central blood draws has not been established. The authors wanted to evaluate whether peripheral criteria were applicable when PTH levels were drawn from a central location. Simultaneous peripheral venous (PV) and central venous (CV) PTH samples were drawn from 64 patients undergoing cervical exploration for primary hyperparathyroidism. Median preexcision PTH was significantly higher centrally at 165 pg/mL (interquartile range [IQR], 101–391 pg/mL) versus peripherally 102 pg/mL (interquartile range, 73–156 pg/mL, P < 0.0001). Postexcision PTH was slightly greater in CV (38 pg/mL; IQR, 24–62) than in PV (29 pg/mL; IQR, 22–...
Background Amyotrophic lateral sclerosis is a progressive neurodegenerative disease that affects ... more Background Amyotrophic lateral sclerosis is a progressive neurodegenerative disease that affects motor neurons. When bulbar symptoms impair oral nutritional uptake, guidelines recommend percutaneous endoscopic gastrostomy tube placement. Studies evaluating the appropriate timing and procedural method of placement of gastrostomy tubes have been published; however, no study has been published that evaluated outcomes from a team-based approach to percutaneous endoscopic gastrostomy placement. Methods A retrospective cohort study was performed to evaluate 26 amyotrophic lateral sclerosis patients with various respiratory statuses, who had percutaneous endoscopic gastrostomy tubes placed using a multidisciplinary approach that included neurology, anesthesia, general surgery, and gastroenterology. Preprocedural risks and postprocedural outcomes were compared with previously published studies. Results The mean age at percutaneous endoscopic gastrostomy placement was 66 years. The mean forced vital capacity was 54% and 18 patients (72%) were on noninvasive ventilation. There were 3 minor complications and no major complications prior to index discharge. The mean length of hospital stay was 3 days. There were no delayed complications or deaths. All patients alive at 6 months and 1 year were using their gastrostomy tubes without problems. Conclusions Compared to previously published studies, a multidisciplinary approach to percutaneous endoscopic gastrostomy placement had a better placement rate, fewer minor and major complications, and a comparative length of stay. These data support the effectiveness of a multidisciplinary approach to increase the success and survival rates of patients with amyotrophic lateral sclerosis.
no significant effect of the time interval on MAE. Thirty-day improvement in neurologic status ra... more no significant effect of the time interval on MAE. Thirty-day improvement in neurologic status rate was 20% and predictors for improvement in neurologic status were centralization in the stroke unit (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3-14.2; P ¼ .013) and eversion CEA (OR, 3.2; 95% CI, 1.4-7.2; P ¼ .004). Selective shunting owing to lack of Willis' circle compensation was negatively associated to the risk of impairment in neurologic status (OR, .3; 95% CI, 0.950-0.095; P ¼ .004). Conclusions: Our 10-year experience study showed a combined mortality and stroke rate of 3.5%, which did not differ significantly between the four different time interval groups analyzed. CEA was safe in our cohort, even when performed as soon as possible after the index event. Centralization in a stroke unit of a symptomatic carotid stenosis (NIHSS of <5) is advised with the significant result of a high rate of neurologic status improvement at 30-day.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jan 16, 2018
Preoperative exposure to narcotics has recently been associated with poor outcomes after elective... more Preoperative exposure to narcotics has recently been associated with poor outcomes after elective major surgery, but little is known as to how preoperative opioid use impacts outcomes after common, emergency general surgical procedures (EGS). A high-volume, single-center analysis was performed on patients who underwent EGS from 2012 to 2013. EGS was defined as the seven emergent operations that account for 80% of the national burden. Preoperative opioid use was defined as having an active opioid prescription within 7 days prior to surgery. Chronic opioid use was defined as having an opioid prescription concurrent with 90 days after discharge. A total of 377 patients underwent EGS during the study period. Preoperative opioid use was present in 84 patients (22.3%). Preoperative opioid users had longer hospital LOS (10.5 vs 6 days), higher costs of care ($25,331 vs $11,454), and higher 30-day readmission rates (22.6 vs 8.2%) compared with opioid-naïve patients (p < 0.001 each). Afte...
Background: Zygomycetes cause different patterns of infection in immunosuppressed individuals, in... more Background: Zygomycetes cause different patterns of infection in immunosuppressed individuals, including sino-orbito-cerebral, pulmonary, skin/soft tissue infection and disseminated disease. Infections with Zygomycetes have a high mortality rate, even with prompt treatment, which includes anti-fungal agents and surgical debridement. In some centers, clear margins are monitored by serial frozen sections, but there are no specific guidelines for the use of frozen sections during surgical debridement. Studies in fungal rhinosinusitis found 62.5-85 % sensitivity of frozen section analysis in margin assessment. However, the utility of frozen section analysis for margin evaluation in debridement of skin/soft tissue infection has not been published. Methods: We present a case of zygomycosis of decubitus ulcers in which we assessed statistical measures of performance of frozen section analysis for presence of fungal organisms on the margin, compared with formalin-fixed paraffin embedded (FFPE) sections as gold standard. A total of 33 specimens (94 blocks) were sectioned, stained with H&E and evaluated by both frozen and FFPE analysis. Negative interpretations were confirmed by Gomori methenamine silver stain on FFPE sections. Results: H&E staining of frozen sections had 68.4 % sensitivity and 100 % specificity for assessing margins clear of fungal organisms. The negative and positive predictive values were 70.0 % and 100 %, respectively. Using presence of acute inflammation and necrosis as markers of fungal infection improved sensitivity (100 %) at the expense of specificity (42.9 %). Conclusion: Use of intraoperative assessment of skin and soft tissue margins for fungal infection is a valuable tool in the management of skin and soft tissue fungal infection treatment.
The management of patients who have sustained blast injuries poses an important challenge for mil... more The management of patients who have sustained blast injuries poses an important challenge for military healthcare professionals. Current military operations are generating large numbers of casualties and modern military healthcare facilities are increasingly using CT scanning to facilitate their management. This small case series serves to draw attention to a rare (or possibly under-reported) phenomenon after blast injury. We report two patients exposed to blast who had pneumoperitoneum identified by CT scan but who did not have abdominal visceral injury or ballistic peritoneal violation. The use of cross-sectional imaging is leading to the recognition of otherwise occult injury. Military practitioners should be aware of this injury pattern when using CT to help select patients for conservative management after abdominal blast injury.
Introduction: Group AB plasma, the traditional universal donor plasma product, is a limited resou... more Introduction: Group AB plasma, the traditional universal donor plasma product, is a limited resource. We compared outcomes of Group A plasma transfusion in comparison to AB. Methods: Analysis of blunt-injured patients who received emergency release plasma from was performed. Multivariable logistic regression was utilized to identify associations with morbidity and mortality. Results: There were 191 patients; 115 Group A and 76 Group AB. No differences were seen in age, sex, plasma transfusions, uncrossmatched red blood cells (RBCs), and Glasgow Coma Scale (GCS). Patients who received Group A plasma had signifi cantly lower Injury Severity Score, chest Abbreviated Injury Scale (AIS), and scene transfer rate but not head AIS, or abdomen AIS. In addition, signifi cant differences were noted in terms of blood products transfused within 24 hours in those receiving Group A over AB. Development of acute respiratory distress syndrome (ARDS), but not mortality, was higher within the AB cohort. No hemolytic or transfusion associated-ARDS reactions were noted in either group. ARDS; RBC transfusion volumes and head AIS were independently associated with mortality. Conclusion: Utilization of Group A plasma for emergency blood resuscitation is a safe option which may alleviate potential shortages of AB plasma .
The conflicts in Iraq and Afghanistan have seen the advancement of combat medicine. The nature of... more The conflicts in Iraq and Afghanistan have seen the advancement of combat medicine. The nature of the conflicts, with troops located in remote areas and faced with explosive ordinance designed to focus massive injuries on dismounted personnel, have forced military medical personnel to adapt accordingly. There has been a rekindling of interest in the use of tourniquets to stop exsanguination from extremity wounds, as well as in the transfusion of fresh whole blood from walking blood banks. These previously discarded techniques, born on battlefields long ago, have been refined and perfected and have led to an unprecedented survival for our wounded warriors. New developments in the field of applied hemostatic agents, damage control surgical techniques, and the implementation of an efficient evacuation system have also contributed to these results. The field of combat medicine has taken several concepts initially designed in civilian settings, such as temporary abdominal packing and vascular shunting, and adapted them to the military setting to provide state of the art trauma management to our troops in combat. In turn, developments in the resuscitation of the trauma patient, using increased blood and plasma products and less crystalloid, have been pioneered in conflict and transitioned to the civilian sector. Advancements made during the wars in Iraq and Afghanistan, as well as those still being developed, will shape the care of the injured patient, in both civilian and military settings, for the foreseeable future.
Background. Graft-versus-host disease (GVHD) is a rare complication following liver transplantati... more Background. Graft-versus-host disease (GVHD) is a rare complication following liver transplantation and carries a poor prognosis with mortality approaching 90-95%. Diagnosis of GVHD is often delayed due to early symptoms mimicking more common, entities such as drug reactions and viral syndromes. To date, definitive diagnosis has been difficult and has relied on a constellation of clinical and histopathologic variables. We present the use of short tandem repeat DNA "fingerprinting" technology as a method of early, definitive diagnosis of GVHD in patients after liver transplantation. Methods. A patient status-postorthotopic cadaveric-liver transplant, with an uncomplicated immediate posttransplant course, presented 4 weeks after transplant with fever, diarrhea, and maculopapular rash on her palms, soles, and back. The patient's condition worsened despite empiric treatment for an infectious etiology. Skin and rectal biopsies were suspicious for GVHD. Results. DNA was isolated from the skin and rectal biopsies as well as from a donor lymph node. PCR amplification was done for nine highly polymorphic short tandem repeats for each specimen and a unique DNA "fingerprint" was obtained from each. DNA from skin and rectum demonstrated mixed chimerism with both donor and recipient alleles detected. Thorough analysis confirmed GVHD. Conclusion. Short tandem repeats for DNA fingerprinting represents an efficient and reproducible method for the definitive diagnosis of GVHD after liver transplantation. Rapid detection of GVHD using this technology, coupled with early initiation of therapy, may lead to improved survival for patients with GVHD after solid organ transplant.
Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endo... more Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endoscopic ultrasound (EUS) is an additional staging modality to assess locoregional extent of this disease. We hypothesized that EUS may improve survival through more effective staging and better optimization of treatment. Methods: We performed a retrospective review of all patients presenting with esophageal cancer at our institution from 1993 to 2003 (n ϭ 97) and compared outcomes between patients who underwent staging EUS and computed tomography (CT) versus CT alone. Survival was calculated using Kaplan-Meier methods and compared between groups using the log-rank test. Mean survival was compared using analysis of variance (ANOVA) methods. Results: Overall 3-, 6-, and 12-month survival did not differ between the 2 groups (EUS: 92%, 84%, and 80% and CT: 83%, 67%, and 43%, log-rank P ϭ .1), which held true despite stratification by treatment modality (all P Ͼ.1). The mean survival for the EUS group was 16 Ϯ 3 months and for the CT group, 12 Ϯ 1.5 months (P ϭ .2). Further analysis by stage showed no difference in survival between the 2 groups (all P Ͼ.1). However, stage 2A and 3 surgical patients had better survival than nonsurgical patients (both P ϭ .02) irrespective of staging modality. EUS patients were no more likely to receive surgical, neoadjuvant, or definitive chemoradiation than CT patients (all P Ͼ.1). Conclusions: Overall survival as well as survival by stage did not differ between patients who underwent staging via EUS and CT versus CT alone, and patients staged with EUS were not more likely to receive any one intervention. Irrespective of staging modality, stage 2A and 3 patients who underwent surgical intervention had better survival than those who did not receive an operation.
The purpose of this study was to compare physicians' perceptions about managed care restrictions ... more The purpose of this study was to compare physicians' perceptions about managed care restrictions on drug prescribing with objective measures of the restrictions' effects. When asked a general question, 17 emergency medicine physicians in one urban, university hospital answered that they had to prescribe an antibiotic that was not their first choice because of managed care restrictions 32% of the time. The actual frequency of prescribing other than first-choice antibiotics, which was determined by asking the same physicians about the prescription of specific antibiotics for specific patients seen recently in the emergency department, was 6% (p Ͻ .0001). We conclude that emercency medicine physicians treating patients in one managed care system significantly overstimated the restrictions imposed by managed care formularies on their antibiotic prescribing practices. Additional studies are warranted to measure the extent of this bias.
Results: Eleven C135FR have been modified to accommodate the medical solution. The technical plat... more Results: Eleven C135FR have been modified to accommodate the medical solution. The technical platform includes patient care modules (intensive care modules accommodating one mechanically ventilated patient; light care modifiable modules) and logistical modules (two racks, one preparation table, one centralized monitoring area). The medical team includes two anesthesiologists, three anesrhesiology nurses, two emergency physicians, two nurses, two MEDEVAC nurses, and one medical specialist or liaison officer. Conclusions: The MORPHEE system and its successful operational missions emphasize the versatility and efficiency of a solution based on mission-tailored "plug and play" modules easily and quickly installable aboard a non-dedicated aircraft.
Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online... more Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.
Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endo... more Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endoscopic ultrasound (EUS) is an additional staging modality to assess locoregional extent of this disease. We hypothesized that EUS may improve survival through more effective staging and better optimization of treatment. Methods: We performed a retrospective review of all patients presenting with esophageal cancer at our institution from 1993 to 2003 (n 97) and compared outcomes between patients who underwent staging EUS and computed tomography (CT) versus CT alone. Survival was calculated using Kaplan-Meier methods and compared between groups using the log-rank test. Mean survival was compared using analysis of variance (ANOVA) methods. Results: Overall 3-, 6-, and 12-month survival did not differ between the 2 groups (EUS: 92%, 84%, and 80% and CT: 83%, 67%, and 43%, log-rank P .1), which held true despite stratification by treatment modality (all P .1). The mean survival for the EUS gr...
Learning Objectives: Changes to aminoglycoside (AG) pharmacokinetics during critical illness may ... more Learning Objectives: Changes to aminoglycoside (AG) pharmacokinetics during critical illness may affect attainment of pharmacokinetic targets. Use of continuous renal replacement therapies (CRRT) complicates attainment due to variable and poorly understood extracorporeal drug clearance compared with patients with normal renal function. We hypothesize that critically ill patients undergoing CRRT will have an expanded volume of distribution (Vd) and reduced clearance, with variation in clearance observed between CRRT modalities. Methods: Adult patients who received a first dose of amikacin or tobramycin during CRRT between 2/1/2012 and 2/28/2017 were retrospectively evaluated. Patients were allocated to different study arms per their receipt of SLED, CVVHD, or CVVH. Two post-distributional serum levels were required for pharmacokinetic calculations. Patients were excluded if fewer than 2 serum AG levels were collected, if previous AG dose given within 7 days, if already enrolled or if...
Intraoperative parathyroid hormone (PTH) monitoring has become an integral adjunct to minimally i... more Intraoperative parathyroid hormone (PTH) monitoring has become an integral adjunct to minimally invasive parathyroidectomy. Guidelines for predicting therapeutic excision of all hyperactive parathyroid tissue have been routinely based on peripheral blood samples drawn at various time intervals. Whether these same guidelines can be used to predict success based on central blood draws has not been established. The authors wanted to evaluate whether peripheral criteria were applicable when PTH levels were drawn from a central location. Simultaneous peripheral venous (PV) and central venous (CV) PTH samples were drawn from 64 patients undergoing cervical exploration for primary hyperparathyroidism. Median preexcision PTH was significantly higher centrally at 165 pg/mL (interquartile range [IQR], 101–391 pg/mL) versus peripherally 102 pg/mL (interquartile range, 73–156 pg/mL, P < 0.0001). Postexcision PTH was slightly greater in CV (38 pg/mL; IQR, 24–62) than in PV (29 pg/mL; IQR, 22–...
Background Amyotrophic lateral sclerosis is a progressive neurodegenerative disease that affects ... more Background Amyotrophic lateral sclerosis is a progressive neurodegenerative disease that affects motor neurons. When bulbar symptoms impair oral nutritional uptake, guidelines recommend percutaneous endoscopic gastrostomy tube placement. Studies evaluating the appropriate timing and procedural method of placement of gastrostomy tubes have been published; however, no study has been published that evaluated outcomes from a team-based approach to percutaneous endoscopic gastrostomy placement. Methods A retrospective cohort study was performed to evaluate 26 amyotrophic lateral sclerosis patients with various respiratory statuses, who had percutaneous endoscopic gastrostomy tubes placed using a multidisciplinary approach that included neurology, anesthesia, general surgery, and gastroenterology. Preprocedural risks and postprocedural outcomes were compared with previously published studies. Results The mean age at percutaneous endoscopic gastrostomy placement was 66 years. The mean forced vital capacity was 54% and 18 patients (72%) were on noninvasive ventilation. There were 3 minor complications and no major complications prior to index discharge. The mean length of hospital stay was 3 days. There were no delayed complications or deaths. All patients alive at 6 months and 1 year were using their gastrostomy tubes without problems. Conclusions Compared to previously published studies, a multidisciplinary approach to percutaneous endoscopic gastrostomy placement had a better placement rate, fewer minor and major complications, and a comparative length of stay. These data support the effectiveness of a multidisciplinary approach to increase the success and survival rates of patients with amyotrophic lateral sclerosis.
no significant effect of the time interval on MAE. Thirty-day improvement in neurologic status ra... more no significant effect of the time interval on MAE. Thirty-day improvement in neurologic status rate was 20% and predictors for improvement in neurologic status were centralization in the stroke unit (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3-14.2; P ¼ .013) and eversion CEA (OR, 3.2; 95% CI, 1.4-7.2; P ¼ .004). Selective shunting owing to lack of Willis' circle compensation was negatively associated to the risk of impairment in neurologic status (OR, .3; 95% CI, 0.950-0.095; P ¼ .004). Conclusions: Our 10-year experience study showed a combined mortality and stroke rate of 3.5%, which did not differ significantly between the four different time interval groups analyzed. CEA was safe in our cohort, even when performed as soon as possible after the index event. Centralization in a stroke unit of a symptomatic carotid stenosis (NIHSS of <5) is advised with the significant result of a high rate of neurologic status improvement at 30-day.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jan 16, 2018
Preoperative exposure to narcotics has recently been associated with poor outcomes after elective... more Preoperative exposure to narcotics has recently been associated with poor outcomes after elective major surgery, but little is known as to how preoperative opioid use impacts outcomes after common, emergency general surgical procedures (EGS). A high-volume, single-center analysis was performed on patients who underwent EGS from 2012 to 2013. EGS was defined as the seven emergent operations that account for 80% of the national burden. Preoperative opioid use was defined as having an active opioid prescription within 7 days prior to surgery. Chronic opioid use was defined as having an opioid prescription concurrent with 90 days after discharge. A total of 377 patients underwent EGS during the study period. Preoperative opioid use was present in 84 patients (22.3%). Preoperative opioid users had longer hospital LOS (10.5 vs 6 days), higher costs of care ($25,331 vs $11,454), and higher 30-day readmission rates (22.6 vs 8.2%) compared with opioid-naïve patients (p < 0.001 each). Afte...
Background: Zygomycetes cause different patterns of infection in immunosuppressed individuals, in... more Background: Zygomycetes cause different patterns of infection in immunosuppressed individuals, including sino-orbito-cerebral, pulmonary, skin/soft tissue infection and disseminated disease. Infections with Zygomycetes have a high mortality rate, even with prompt treatment, which includes anti-fungal agents and surgical debridement. In some centers, clear margins are monitored by serial frozen sections, but there are no specific guidelines for the use of frozen sections during surgical debridement. Studies in fungal rhinosinusitis found 62.5-85 % sensitivity of frozen section analysis in margin assessment. However, the utility of frozen section analysis for margin evaluation in debridement of skin/soft tissue infection has not been published. Methods: We present a case of zygomycosis of decubitus ulcers in which we assessed statistical measures of performance of frozen section analysis for presence of fungal organisms on the margin, compared with formalin-fixed paraffin embedded (FFPE) sections as gold standard. A total of 33 specimens (94 blocks) were sectioned, stained with H&E and evaluated by both frozen and FFPE analysis. Negative interpretations were confirmed by Gomori methenamine silver stain on FFPE sections. Results: H&E staining of frozen sections had 68.4 % sensitivity and 100 % specificity for assessing margins clear of fungal organisms. The negative and positive predictive values were 70.0 % and 100 %, respectively. Using presence of acute inflammation and necrosis as markers of fungal infection improved sensitivity (100 %) at the expense of specificity (42.9 %). Conclusion: Use of intraoperative assessment of skin and soft tissue margins for fungal infection is a valuable tool in the management of skin and soft tissue fungal infection treatment.
The management of patients who have sustained blast injuries poses an important challenge for mil... more The management of patients who have sustained blast injuries poses an important challenge for military healthcare professionals. Current military operations are generating large numbers of casualties and modern military healthcare facilities are increasingly using CT scanning to facilitate their management. This small case series serves to draw attention to a rare (or possibly under-reported) phenomenon after blast injury. We report two patients exposed to blast who had pneumoperitoneum identified by CT scan but who did not have abdominal visceral injury or ballistic peritoneal violation. The use of cross-sectional imaging is leading to the recognition of otherwise occult injury. Military practitioners should be aware of this injury pattern when using CT to help select patients for conservative management after abdominal blast injury.
Introduction: Group AB plasma, the traditional universal donor plasma product, is a limited resou... more Introduction: Group AB plasma, the traditional universal donor plasma product, is a limited resource. We compared outcomes of Group A plasma transfusion in comparison to AB. Methods: Analysis of blunt-injured patients who received emergency release plasma from was performed. Multivariable logistic regression was utilized to identify associations with morbidity and mortality. Results: There were 191 patients; 115 Group A and 76 Group AB. No differences were seen in age, sex, plasma transfusions, uncrossmatched red blood cells (RBCs), and Glasgow Coma Scale (GCS). Patients who received Group A plasma had signifi cantly lower Injury Severity Score, chest Abbreviated Injury Scale (AIS), and scene transfer rate but not head AIS, or abdomen AIS. In addition, signifi cant differences were noted in terms of blood products transfused within 24 hours in those receiving Group A over AB. Development of acute respiratory distress syndrome (ARDS), but not mortality, was higher within the AB cohort. No hemolytic or transfusion associated-ARDS reactions were noted in either group. ARDS; RBC transfusion volumes and head AIS were independently associated with mortality. Conclusion: Utilization of Group A plasma for emergency blood resuscitation is a safe option which may alleviate potential shortages of AB plasma .
The conflicts in Iraq and Afghanistan have seen the advancement of combat medicine. The nature of... more The conflicts in Iraq and Afghanistan have seen the advancement of combat medicine. The nature of the conflicts, with troops located in remote areas and faced with explosive ordinance designed to focus massive injuries on dismounted personnel, have forced military medical personnel to adapt accordingly. There has been a rekindling of interest in the use of tourniquets to stop exsanguination from extremity wounds, as well as in the transfusion of fresh whole blood from walking blood banks. These previously discarded techniques, born on battlefields long ago, have been refined and perfected and have led to an unprecedented survival for our wounded warriors. New developments in the field of applied hemostatic agents, damage control surgical techniques, and the implementation of an efficient evacuation system have also contributed to these results. The field of combat medicine has taken several concepts initially designed in civilian settings, such as temporary abdominal packing and vascular shunting, and adapted them to the military setting to provide state of the art trauma management to our troops in combat. In turn, developments in the resuscitation of the trauma patient, using increased blood and plasma products and less crystalloid, have been pioneered in conflict and transitioned to the civilian sector. Advancements made during the wars in Iraq and Afghanistan, as well as those still being developed, will shape the care of the injured patient, in both civilian and military settings, for the foreseeable future.
Background. Graft-versus-host disease (GVHD) is a rare complication following liver transplantati... more Background. Graft-versus-host disease (GVHD) is a rare complication following liver transplantation and carries a poor prognosis with mortality approaching 90-95%. Diagnosis of GVHD is often delayed due to early symptoms mimicking more common, entities such as drug reactions and viral syndromes. To date, definitive diagnosis has been difficult and has relied on a constellation of clinical and histopathologic variables. We present the use of short tandem repeat DNA "fingerprinting" technology as a method of early, definitive diagnosis of GVHD in patients after liver transplantation. Methods. A patient status-postorthotopic cadaveric-liver transplant, with an uncomplicated immediate posttransplant course, presented 4 weeks after transplant with fever, diarrhea, and maculopapular rash on her palms, soles, and back. The patient's condition worsened despite empiric treatment for an infectious etiology. Skin and rectal biopsies were suspicious for GVHD. Results. DNA was isolated from the skin and rectal biopsies as well as from a donor lymph node. PCR amplification was done for nine highly polymorphic short tandem repeats for each specimen and a unique DNA "fingerprint" was obtained from each. DNA from skin and rectum demonstrated mixed chimerism with both donor and recipient alleles detected. Thorough analysis confirmed GVHD. Conclusion. Short tandem repeats for DNA fingerprinting represents an efficient and reproducible method for the definitive diagnosis of GVHD after liver transplantation. Rapid detection of GVHD using this technology, coupled with early initiation of therapy, may lead to improved survival for patients with GVHD after solid organ transplant.
Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endo... more Background: Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endoscopic ultrasound (EUS) is an additional staging modality to assess locoregional extent of this disease. We hypothesized that EUS may improve survival through more effective staging and better optimization of treatment. Methods: We performed a retrospective review of all patients presenting with esophageal cancer at our institution from 1993 to 2003 (n ϭ 97) and compared outcomes between patients who underwent staging EUS and computed tomography (CT) versus CT alone. Survival was calculated using Kaplan-Meier methods and compared between groups using the log-rank test. Mean survival was compared using analysis of variance (ANOVA) methods. Results: Overall 3-, 6-, and 12-month survival did not differ between the 2 groups (EUS: 92%, 84%, and 80% and CT: 83%, 67%, and 43%, log-rank P ϭ .1), which held true despite stratification by treatment modality (all P Ͼ.1). The mean survival for the EUS group was 16 Ϯ 3 months and for the CT group, 12 Ϯ 1.5 months (P ϭ .2). Further analysis by stage showed no difference in survival between the 2 groups (all P Ͼ.1). However, stage 2A and 3 surgical patients had better survival than nonsurgical patients (both P ϭ .02) irrespective of staging modality. EUS patients were no more likely to receive surgical, neoadjuvant, or definitive chemoradiation than CT patients (all P Ͼ.1). Conclusions: Overall survival as well as survival by stage did not differ between patients who underwent staging via EUS and CT versus CT alone, and patients staged with EUS were not more likely to receive any one intervention. Irrespective of staging modality, stage 2A and 3 patients who underwent surgical intervention had better survival than those who did not receive an operation.
The purpose of this study was to compare physicians' perceptions about managed care restrictions ... more The purpose of this study was to compare physicians' perceptions about managed care restrictions on drug prescribing with objective measures of the restrictions' effects. When asked a general question, 17 emergency medicine physicians in one urban, university hospital answered that they had to prescribe an antibiotic that was not their first choice because of managed care restrictions 32% of the time. The actual frequency of prescribing other than first-choice antibiotics, which was determined by asking the same physicians about the prescription of specific antibiotics for specific patients seen recently in the emergency department, was 6% (p Ͻ .0001). We conclude that emercency medicine physicians treating patients in one managed care system significantly overstimated the restrictions imposed by managed care formularies on their antibiotic prescribing practices. Additional studies are warranted to measure the extent of this bias.
Results: Eleven C135FR have been modified to accommodate the medical solution. The technical plat... more Results: Eleven C135FR have been modified to accommodate the medical solution. The technical platform includes patient care modules (intensive care modules accommodating one mechanically ventilated patient; light care modifiable modules) and logistical modules (two racks, one preparation table, one centralized monitoring area). The medical team includes two anesthesiologists, three anesrhesiology nurses, two emergency physicians, two nurses, two MEDEVAC nurses, and one medical specialist or liaison officer. Conclusions: The MORPHEE system and its successful operational missions emphasize the versatility and efficiency of a solution based on mission-tailored "plug and play" modules easily and quickly installable aboard a non-dedicated aircraft.
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Papers by Jason Schrager