L D Britt

Eastern Virginia Medical School, Norfolk, Virginia, United States

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Publications (125)272.8 Total impact

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    ABSTRACT: Procalcitonin is used as a marker for sepsis but there is little known about the correlation of the procalcitonin elevation with the causative organism in sepsis. All patients aged 18 to 80 years who were admitted to the surgery service from June 2010 to May 2012 and who had a procalcitonin drawn were evaluated. Culture data were reviewed to determine the causative organism. Infections analyzed included pneumonia, urinary tract infection (UTI), bloodstream infection, and Clostridium difficile. Other parameters assessed included reason for admission, body mass index, pressor use, antibiotic duration, and disposition. Two hundred thirty-two patient records were reviewed. Patients without a known infection/source of sepsis had a mean procalcitonin of 3.95. Those with pneumonia had a procalcitonin of 20.59 (P = 0.03). Those with a UTI had a mean procalcitonin of 66.84 (P = 0.0005). Patients with a bloodstream infection had a mean procalcitonin of 33.30 (P = 0.003). Those with C. difficile had a procalcitonin of 47.20 (P = 0.004). When broken down by causative organisms, those with Gram-positive sepsis had a procalcitonin of 23.10 (P = 0.02) compared with those with Gram-negative sepsis at 32.75 (P = 0.02). Those with fungal infections had a procalcitonin of 42.90 (P = 0.001). These data suggest that procalcitonin elevation can help guide treatment by indicating likely causative organism and infection type. These data may provide a good marker for initiation of antifungal therapy.
    The American surgeon 09/2014; 80(9). · 0.92 Impact Factor
  • L D Britt
    JAMA surgery. 08/2014;
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    ABSTRACT: Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (± 18.5) years old and neurologic injury was responsible in 63 per cent (± 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (± 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.
    The American surgeon 08/2014; 80(8). · 0.92 Impact Factor
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    ABSTRACT: Chest x-rays (CXRs) have been the mainstay for the management of thoracostomy tubes (TTs), but reports that ultrasound (US) may be more sensitive for detection of pneumothorax (PTX) continue to increase. The objective of this study was to determine if US is safe and effective for the detection of PTX following TT removal.
    The Journal of Trauma and Acute Care Surgery 08/2014; 77(2):256-261. · 2.35 Impact Factor
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    ABSTRACT: An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray (CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX) associated with TT removal after basic US training. Patients included had TT managed by the surgical team between October 2012 and May 2013. Bedside US was performed by a variety of members of the trauma team before and after removal. All residents received, at minimum, a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes occurred secondary to having incomplete imaging, charting, or death before having TT removed. Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40 years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%), hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were correctly identified by residents using US. This was confirmed on CXR with appropriate changes made. US was able to successfully predict the safe TT removal and patient discharge at all residency levels after receiving a basic US training program.
    The American surgeon 08/2014; 80(8). · 0.92 Impact Factor
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    ABSTRACT: Outer membrane vesicles (OMVs) were previously shown to be capable of initiating the inflammatory response seen in the transition of an infection to sepsis. However, another tenet of sepsis is the development of a hypercoagulable state and the role of OMVs in the development of this hypercoagulability has not been evaluated. The objective of this study was to evaluate the ability of OMVs to elicit endothelial mediators of coagulation and inflammation and induce platelet activation.
    Journal of Surgical Research 05/2014; · 2.02 Impact Factor
  • Journal of the American College of Surgeons 05/2014; 218(5):1049-55. · 4.50 Impact Factor
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    ABSTRACT: Atomic force microscopy (AFM) is a probe-based technique that permits high resolution imaging of live bacterial cells. However, stably immobilizing cells to withstand the probe-based lateral forces remains an obstacle in AFM mediated studies, especially those of live, rod shaped bacteria in nutrient media. Consequently, AFM has been under-utilized in the research of bacterial surface dynamics. The aim of the current study was to immobilize a less adherent Escherichia coli strain in a method that both facilitates AFM imaging in nutrient broth and preserves overall cell viability. Immobilization reagents and buffers were systematically evaluated and the cell membrane integrity was monitored in all sample preparations. As expected, the biocompatible gelatin coated surfaces facilitated stable cell attachment in lower ionic strength buffers, yet poorly immobilized cells in higher ionic strength buffers. In comparison, poly-l-lysine surfaces bound cells in both low and high ionic strength buffers. The benefit of the poly-l-lysine binding capacity was offset by the compromised membrane integrity exhibited by cells on poly-l-lysine surfaces. However, the addition of divalent cations and glucose to the immobilization buffer was found to mitigate this unfavorable effect. Ultimately, immobilization of E. coli cells on poly-l-lysine surfaces in a lower ionic strength buffer supplemented with Mg2+ and Ca2+ was determined to provide optimal cell attachment without compromising the overall cell viability. Cells immobilized in this method were stably imaged in media through multiple division cycles. Furthermore, permeability assays indicated that E. coli cells recover from the hypoosmotic stress caused by immobilization in low ionic strength buffers. Taken together, this data suggests that stable immobilization of viable cells on poly-l-lysine surfaces can be accomplished in lower ionic strength buffers that are supplemented with divalent cations for membrane stabilization while minimizing binding interference. The data also indicates that monitoring cell viability as a function of sample preparation is important and should be an integral part of the work flow for determining immobilization parameters. A method for immobilizing a less adherent E. coli mutant for AFM imaging in nutrient broth is presented here in addition to a proposed work flow for developing and optimizing immobilization strategies.
    Ultramicroscopy 01/2014; 137:30–39. · 2.47 Impact Factor
  • The American surgeon 01/2014; 80(4). · 0.92 Impact Factor
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    ABSTRACT: Over the past 15 years, there has been a rapid transformation in the way blunt aortic injuries (BAIs) are managed shifting from open thoracotomies to thoracic endovascular repairs (TEVAR). As a result of this change, we sought to describe our experience with open and endovascular repairs through a retrospective analysis of all trauma patients admitted with BAI to our Level I trauma center from 2002 to 2011. Demographic data, type of repair, complications, length of stay (LOS) data, and mortality were identified. No difference was noted in age, sex, Injury Severity Score, or Glasgow Coma Scale score between the two groups. There were also no differences in the number of acute complications or mortality. Intensive care unit (ICU) LOS was significantly shorter in the TEVAR group (20 vs 9 days, P < 0.05). Additionally, there was a trend toward shorter hospital LOS (28 vs 18 days, P = 0.07) and ventilator length of stay (12 vs 5 days, P = 0.171). In summary, endovascular repair of BAI is safe and has no increased rate of acute complications or mortality. ICU LOS is much shorter with TEVAR, and there was a trend toward shorter ventilator and hospital LOS, all of which may result in decreased cost. Still, more needs to be learned about potential long-term complications.
    The American surgeon 08/2013; 79(8):806-9. · 0.92 Impact Factor
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    ABSTRACT: Gram-negative bacteria release outer membrane vesicles (OMVs) during growth that contain various membrane components involved in eliciting an inflammatory response, including lipopolysaccharide and virulence factors. However, little is known about the role of OMVs in sepsis. The objective of this study was to determine how OMVs, derived from Escherichia (E.) coli, elicit the cellular responses involved in activating the inflammatory cascade, and to determine whether additional virulence factors in pathogenic OMVs augment the inflammatory response. Human umbilical endothelial cells were inoculated with OMVs from non-pathogenic E. coli (npOMV) or pathogenic E. coli (pOMV) and analyzed for adhesion protein synthesis, cytokine production, and necrosis factor (NF)-κB translocation. Flow cytometry demonstrated that human umbilical vein endothelial cells exposed to npOMV or pOMV significantly increased expression of E-selectin and intercellular adhesion molecule, with a large population of cells demonstrating increased expression of both proteins. Interleukin-6 levels were significantly elevated by 4 h after exposure to npOMV and pOMVs. NF-κB translocation to the nucleus was shown to be induced by npOMV and pOMVs. However, the role of additional virulence factors associated with pOMVs remains undefined. Both npOMVs and pOMVs are capable of initiating the inflammatory cascade in endothelial cells. OMVs trigger NF-κB translocation to the nucleus, resulting in up-regulation of adhesion molecules and cytokines, presumably for the recruitment of leukocytes. By eliciting an inflammatory response, OMVs could facilitate the transition from a localized infection to a systemic response, and ultimately sepsis.
    Journal of Surgical Research 06/2013; · 2.02 Impact Factor
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    ABSTRACT: IMPORTANCE With duty hour debates, specialization, and sex distribution changes in the applicant pool, the relative competitiveness for general surgery residency (GSR) is undefined. OBJECTIVE To determine the modern attributes of top-ranked applicants to GSR. DESIGN Validation cohort, survey. SETTING National sample of university and community-based GSR programs. PARTICIPANTS Data were abstracted from Electronic Residency Application Service files of the top 20-ranked applicants to 22 GSR programs. We ranked program competitiveness and blinded review of personal statements. MAIN OUTCOMES AND MEASURES Characteristics associated with applicant ranking by the GSR program (top 5 vs 6-20) and ranking by highly competitive programs were identified using t and χ2 tests and modified Poisson regression. RESULTS There were 333 unique applicants among the 440 Electronic Residency Application Service files. Most applicants had research experience (93.0%) and publications (76.8%), and 28.4% had Alpha Omega Alpha membership. Nearly half were women (45.2%), with wide variation by program (20.0%-75.0%) and a trend toward fewer women at programs in the South and West (38.0% and 37.5%, respectively). Men had higher United States Medical Licensing Examination Step 1 scores (238.0 vs 230.1; P < .001) but similar Step 2 scores (245.3 vs 244.5; P = .54). Using bivariate analysis, highly competitive programs were more likely to rank applicants with publications, research experience, Alpha Omega Alpha membership, higher Step 1 scores, and excellent personal statements and those who were male or Asian. However, the only significant predictors were Step 1 scores (relative risk [RR], 1.36 for every 10-U increase), publications (RR, 2.20), personal statements (RR, 1.62), and Asian race (RR, 1.70 vs white). Alpha Omega Alpha membership (RR, 1.62) and Step 1 scores (RR, 1.01) were the only variables predictive of ranking in the top 5. CONCLUSIONS AND RELEVANCE This national sample shows GSR is a highly competitive, sex-neutral discipline in which academic performance is the most important factor for ranking, especially in the most competitive programs. This study will inform applicants and program directors about applicants to the GSR program.
    JAMA surgery. 05/2013; 148(5):413-7.
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    ABSTRACT: Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for diagnosing choledocholithiasis. It is said to be as accurate as the gold standard endoscopic retrograde cholangiopancreatography (ERCP) for detecting common bile duct (CBD) stones. A study was needed to look at the accuracy of MRCP compared with intraoperative cholangiography (IOC) for detecting stones in the CBD. The aim of this study was to evaluate the diagnostic accuracy of MRCP in patients with choledocholithiasis diagnosed with IOC. This was a retrospective study looking at patients who underwent IOC. Results were compared with respective preoperative MRCP results if available. Four hundred twenty patients who underwent IOC were reviewed and met criteria for the study. Seventy patients had preoperative MRCP. Accuracy of MRCP when compared with IOC was 70%. MRCP has a high rate of false normal results compared with IOC and is not as accurate as more invasive techniques. There is no need for preoperative MRCP in patients with suspected choledocholithiasis caused by stones.
    American journal of surgery 04/2013; 205(4):371-3. · 2.36 Impact Factor
  • Article: In brief.
    Current problems in surgery 10/2012; 49(10):560-2. · 1.42 Impact Factor
  • Current problems in surgery 10/2012; 49(10):565-623. · 1.42 Impact Factor
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    ABSTRACT: Squamous cell carcinoma of the anus is rare, but more common in men with human immunodeficiency virus (HIV). We describe our findings in 50 biopsies done on 37 HIV-positive men over 5 years. The men were referred from our HIV clinic for abnormal cytology on anal pap or anal condyloma. Thirty-seven patients were referred from the HIV clinic for abnormal cytology on anal pap or the presence of anal condyloma. Biopsies were done in the operating room using acetic acid to visually localize areas of dysplasia. If no abnormalities were seen, biopsies were taken from each quadrant of the anus. A retrospective review was done for biopsy indication, pathology, recurrence, and correlation with anal pap results. On initial biopsy, anal condyloma conferred the presence of anal intraepithelial neoplasia (AIN) in 64.7 per cent (11 of 17), abnormal paps in 83.3 per cent (10 of 12), and both in 50 per cent (3 of 6). Patients with anal condyloma had AIN in an average of 2.5 quadrants whereas those with abnormal cytology had AIN in 2.3 quadrants. Thirty-four of 50 biopsies showed abnormalities (68%), with AIN present in 32 cases, one case of carcinoma in situ, and one case of invasive carcinoma. Aldara was used nine times with improvement in four cases. In HIV-positive men, the presence of condyloma warrants surgical biopsy. Performing anal cytology on patients with anal condyloma did not increase the rate of positive results. Patients with AIN often had disease in more than two quadrants, making surgical excision problematic.
    The American surgeon 08/2012; 78(8):901-3. · 0.92 Impact Factor
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    ABSTRACT: Performing laparoscopic cholecystectomy (LC) always carries the risk of having to convert from laparoscopic to open cholecystectomy (LOC). Being able to identify these patients preoperatively may allow better preoperative planning and lowering operative cost. All LC and LOC were performed by the Eastern Virginia Medical School Department of Surgery retrospectively identified between January 2008 and December 2009. Preoperative risk factors identified in both groups included: age, gender, body mass index greater than 30 kg/m(2), diabetes mellitus, previous upper abdominal surgery, previous abdominal surgery, presence of pericholecystic fluid, gallbladder wall thickness greater than 3 mm, preoperative diagnosis of acute cholecystitis, and pancreatitis. Reasons for conversion in the LOC group were identified from the operative note. A total of 346 LC and LOC were identified. The LOC group had 41 identified with a conversion rate of 11.9 per cent. The LOC group was compared with 100 randomly chosen LC. Risk factors that reached statistical significance for conversion included advanced age, male gender, previous upper abdominal surgery, preoperative diagnosis of acute cholecystitis, and gallbladder wall thickness greater than 3 mm (P = 0.0009). Average operative time was higher in LOC compared with open cholecystectomy (123 minutes average vs 109 minutes average). Of the reasons for conversion, the degree of inflammation was the most common (51.2%). Preoperative risk factors that were associated with need for conversion were advanced age, male gender, previous upper abdominal surgery, preoperative diagnosis of acute cholecystitis, and pericholecystitic fluid. In patients who have all of these risk factors, we recommend starting with an open cholecystectomy. This will save operative time and overall cost.
    The American surgeon 08/2012; 78(8):831-3. · 0.92 Impact Factor
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    ABSTRACT: Reduction of hospital-acquired infections is a patient safety goal and regularly monitored by Performance Improvement committees. There is discordance between the ventilator-associated pneumonia (VAP) rate reported by the Infection Control Committee (ICC) and that observed by our Trauma Service. To investigate this difference, a retrospective evaluation of cases of VAP diagnosed on a single service was undertaken. A prospectively collected database was queried for VAP in intensive care unit patients between January 2010 and June 2011. This was compared with the list of mechanically ventilated patients provided by the ICC. Comparison for criteria used to diagnose pneumonia, ventilator day of the diagnosis, was recorded. The ICC identified two VAPs from 136 potential patients compared with the Trauma Service identifying 36 VAPs. A difference in diagnostic criteria between the ICC and the Trauma Service focused on use of the National Nosocomial Infection Survey (NNIS) algorithm versus quantitative microbiology from bronchoalveolar lavage specimens. Thirty-five of 36 Trauma Service VAPs were not identified as VAPs by the NNIS algorithm as a result of the chest radiographs. Application of differing definitions of VAP results in markedly different VAP rates. The difference has significant implications as infection rates are increasingly reported as a quality metric.
    The American surgeon 08/2012; 78(8):851-4. · 0.92 Impact Factor
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    ABSTRACT: Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.
    The American surgeon 07/2012; 78(7):741-4. · 0.92 Impact Factor
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    ABSTRACT: Ultrasound is increasingly used by surgeons for evaluation of breast lesions. While surgical residents have sufficient exposure to breast surgery, many lack exposure to office-based procedures, such as ultrasound-guided breast biopsy. A phantom model was created to teach surgical residents basic breast ultrasound and biopsy skills and to evaluate the resident's response when incorporated into the curriculum. The model was created using a pork roast and 10 variably-sized pimento olives. Twenty-four surgical residents were given a brief introduction to breast ultrasound followed by up to 5 minutes to ultrasound the model and note the embedded lesions. The number and location of lesions found and the time spent per resident were recorded. Residents were then introduced to the vacuum-assisted core biopsy system and observed performing ultrasound-guided biopsies. Pre- and postsession evaluations were completed by all residents. Scatterplot regression models were used for data analysis. Most residents had previous ultrasound instruction. The intermediate level residents (postgraduate year [PGY]2 and 3) found the most lesions in the shortest time, missing on average 1.125 lesions in 3:09 minutes. Time spent did not correlate with number missed or previous ultrasound experience. Over 50% of residents sampled the center of the lesion on their first biopsy attempt, with no correlation to PGY or ultrasound experience. All residents rated this experience good to excellent, and 67% believed their ultrasound skills were improved. Ninety-five percent of residents felt the model was fairly realistic and 95% would like to have more experiences like this in the curriculum. The residents surveyed thought the curriculum would be best suited to a PGY2 experience. The phantom breast is a realistic and valuable teaching model for breast ultrasound. Further evaluation regarding skill retention is needed.
    Journal of Surgical Education 05/2012; 69(3):411-5. · 1.07 Impact Factor

Publication Stats

1k Citations
272.80 Total Impact Points


  • 1994–2013
    • Eastern Virginia Medical School
      • • Department of Surgery
      • • School of Medicine
      • • Division of General Surgery
      Norfolk, Virginia, United States
  • 2011
    • University of Virginia
      • Department of Surgery
      Charlottesville, VA, United States
  • 2009
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2007–2009
    • American College of Surgeons
      Chicago, Illinois, United States
  • 2008
    • Stanford University
      • Department of Surgery
      Stanford, CA, United States
  • 2006
    • Hampton University
      • Department of Communicative Sciences & Disorders
      Hampton, VA, United States
  • 2002
    • University of Maryland Medical Center
      Baltimore, Maryland, United States