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Sharven Taghavi,
Senthil N Jayarajan,
Swapnil Khoche,
Jason M Duran,
Gonzalo E Cruz-Schiavone,
Richard E Milner,
Lewis Holt-Bright, John P Gaughan,
Joseph F Rappold,
Lars O Sjoholm,
Jay Dujon,
Abhijit Pathak,
Thomas A Santora,
Steven R Houser,
Amy J Goldberg
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ABSTRACT: Prehospital intubation does not result in a survival advantage in patients experiencing penetrating trauma, yet resistance to immediate transportation to facilitate access to definitive care remains. An animal model was developed to determine whether intubation provides a survival advantage during severe hemorrhagic shock. We hypothesized that intubation would not provide a survival advantage in potentially lethal hemorrhage.
After starting a propofol drip, Yorkshire pigs were intubated (n = 6) or given bag-valve mask ventilation (n = 7) using 100% oxygen. The carotid artery was cannulated with a 14-gauge catheter, and a Swan-Ganz catheter was placed under fluoroscopy using a central venous introducer. After obtaining baseline hemodynamic and laboratory data, the animals were exsanguinated through the carotid line until death. The primary end point was time until death, while secondary end points included volume of blood shed, temperature, cardiac index, mean arterial pressure, lactic acid, base excess, and creatinine levels measured in 10-minute intervals.
There was no difference in time until death between the two groups (51.1 [2.5] minutes vs. 48.5 [2.4] minutes, p = 0.52). Intubated animals had greater volume of blood shed at 30 minutes (33.6 [4.4] mL/kg vs. 28.5 [4.3] mL/kg, p = 0.03), 40 minutes (41.7 [4.7] mL/kg vs. 34.9 [3.8] mL/kg, p = 0.04), and 50 minutes (49.2 [8.6] mL/kg vs. 40.2 [1.0] mL/kg, p = 0.001). In addition, the intubated animals were more hypothermic at 40 minutes (35.5°C [0.4°C] vs. 36.7°C [0.2°C], p = 0.01) and had higher lactate levels (2.4 [0.1] mmol/L vs. 1.8 [0.4] mmol/L, p = 0.04) at 10 minutes. Cardiac index (p = 0.66), mean arterial pressure (p = 0.69), base excess (p = 0.14), and creatinine levels (p = 0.37) were not different throughout the shock phase.
Intubation does not convey a survival advantage in this model of severe hemorrhagic shock. Furthermore, intubation in the setting of severe hemorrhagic shock may result in a more profuse hemorrhage, worse hypothermia, and higher lactate when compared with bag-valve mask ventilation.
The journal of trauma and acute care surgery. 05/2013; 74(5):1246-51.
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ABSTRACT: BACKGROUND: Advanced Life Support (ALS) providers may perform more invasive prehospital procedures, while Basic Life Support (BLS) providers offer stabilisation care and often "scoop and run". We hypothesised that prehospital interventions by urban ALS providers prolong prehospital time and decrease survival in penetrating trauma victims. STUDY DESIGN: We prospectively analysed 236 consecutive ambulance-transported, penetrating trauma patients an our urban Level-1 trauma centre (6/2008-12/2009). Inclusion criteria included ICU admission, length of stay >/=2 days, or in-hospital death. Demographics, clinical characteristics, and outcomes were compared between ALS and BLS patients. Single and multiple variable logistic regression analysis determined predictors of hospital survival. RESULTS: Of 236 patients, 71% were transported by ALS and 29% by BLS. When ALS and BLS patients were compared, no differences in age, penetrating mechanism, scene GCS score, Injury Severity Score, or need for emergency surgery were detected (p>0.05). Patients transported by ALS units more often underwent prehospital interventions (97% vs. 17%; p<0.01), including endotracheal intubation, needle thoracostomy, cervical collar, IV placement, and crystalloid resuscitation. While ALS ambulance on-scene time was significantly longer than that of BLS (p<0.01), total prehospital time was not (p=0.98) despite these prehospital interventions (1.8±1.0 per ALS patient vs. 0.2±0.5 per BLS patient; p<0.01). Overall, 69.5% ALS patients and 88.4% of BLS patients (p<0.01) survived to hospital discharge. CONCLUSION: Prehospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time but do not significantly increase total prehospital time. Regardless, these interventions did not appear to benefit our rapidly transported, urban penetrating trauma patients.
Injury 02/2013; · 1.98 Impact Factor
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ABSTRACT: Few data exist regarding payer status as a predictor of outcomes in penetrating trauma. This study determined whether insurance status impacts in-hospital complications and mortality in gunshot and stab wound patients at our inner-city, level I trauma center.
Penetrating trauma admissions from 2005 to 2009 were reviewed for patient demographics, insurance, Injury Severity Score, complications, duration of stay, and mortality.
A total of 1,347 penetrating trauma patients were admitted with 652 (48.4%) uninsured. Although uninsured patients were more likely to be male (93.3% vs 89.8%, P = .030), there was no difference in age, ISS, or number of radiologic, operative, or interventional procedures. Uninsured patients had lesser intensive care unit (4.4 vs 3.3 days; P = .049) and total hospital length of stay (10.2 vs 8.3; P = .049). No uninsured patients were placed into a rehabilitation facility at the time of discharge (0.0% vs 1.6%, P < .001). There was no difference in frequency of pulmonary complications, thromboembolic complications, sepsis, urinary tract infection, or wound infections. On multivariate analysis, being uninsured was not an independent predictor of in-hospital complications (1.010, 95% confidence interval 0.703-1.450, P = .959) or mortality (odds ratio 0.905, 95% confidence interval 0.523-1.566, P = .722).
This is the first study to show that penetrating trauma patients who are uninsured have lesser duration of stay and decreased placement into a rehabilitation facility. Being uninsured added no additional risk of in-hospital complications or mortality.
Surgery 08/2012; 152(2):227-31. · 3.10 Impact Factor
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Sharven Taghavi,
Jason M Duran,
Senthil Jayarajan,
Gonzalo E Cruz-Schiavone,
Richard E Milner, John P Gaughan,
Lars O Sjoholm,
Abhijit Pathak,
Thomas A Santora,
Steven R Houser,
Amy J Goldberg
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ABSTRACT: Prehospital intubation does not appear to result in a survival advantage for patients experiencing penetrating trauma; yet, there is still resistance to the practice of "scoop and run" to speed access to advanced care. An animal model was used to determine whether intubation provides a survival advantage during potentially lethal hemorrhage.
The carotid arteries of Sprague-Dawley rats were cannulated, and mean arterial pressure (MAP) was measured. One group of animals (n = 10) was intubated and placed on a ventilator, whereas the other (n = 9) was administered with 100% oxygen via nose cone. Rats were exsanguinated to a MAP of 40 mm Hg and then bled periodically to maintain a MAP between 40 mm Hg and 45 mm Hg. The primary end-point was time until death. Secondary end-points included lactic acid and base excess levels measured in blood collected at 30-minute intervals after inducing shock.
There was no significant difference in time until death between the intubated and nose cone groups (85.5 vs. 93.3 minutes, p = 0.60). Intubated animals had higher lactic acid levels at 90 minutes (6.1 vs. 3.5 mmol/L; p = 0.02) and 120 minutes (7.7 vs. 2.6 mmol/L, p = 0.03) after the initiation of shock. In addition, intubated animals had worse base excess at 90 minutes (-13.5 vs. -7.9 mmol/L, p = 0.04).
Intubation does not result in a survival advantage in this rat model of hemorrhagic shock. Positive pressure ventilation may cause decreased venous return and accentuate end-organ hypoperfusion. Large animal studies are needed to further investigate these findings.
The journal of trauma and acute care surgery. 08/2012; 73(2):332-7; discussion 337.
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ABSTRACT: Various series have reported successful management of scoliosis after surgical treatment of the associated Chiari malformation, syrinx, or bracing. Multiple factors have been associated with curve progression, but interpretation of outcomes is confounded by the wide range of reported results and size of individual series. We attempted to evaluate the outcomes of Chiari I-associated scoliosis by performing a meta-analysis of currently published data.
We conducted a systematic review of published articles using Medline, PubMed (from 1950 to January 2010), and reference lists of identified articles for Chiari malformation and scoliosis.
One hundred and twenty patients were identified in 12 studies, of them, 37 % were male. The mean age at the time of surgery was 9.7 ± 4.1 years. The mean curve magnitude at presentation was 34.4 ± 13.0° and progressed to a mean value of 38.9 ± 20.2°, with an average follow-up of 48.3 ± 48.2 months. After surgical intervention, curve magnitude improved in 37 % of patients (n = 42); there was no change in 18 % (n = 20), and curves progressed in 45 % (n = 51). Age (p = 0.0097) and presence of surgical intervention (foramen magnum decompression [p = 0.0099] and syrinx shunting/drainage [p = 0.0039]) were statistically associated with improvement of the scoliotic curve. Surgical decompression of the foramen magnum had the greatest impact on the scoliotic curves.
Data accrued from our analysis suggest that curve magnitude will improve after surgical treatment of the Chiari malformation in one third of patients, and curve progression will stabilize or improve in one half.
Child s Nervous System 04/2012; 28(8):1213-9. · 1.54 Impact Factor
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ABSTRACT: Our primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative surgical site infections (SSI) after trauma laparotomy.
Although intraoperative normothermia is an important quality performance measure for patients undergoing colorectal surgery, the effects of intraoperative hypothermia on SSI remain unstudied in trauma.
A review of all patients (July 2003-June 2008) who survived 4 days or more after urgent trauma laparotomy at a level I trauma center revealed 524 patients. Patient characteristics, along with preoperative and intraoperative care focusing on SSI risk factors, including the depth and duration of intraoperative hypothermia, were evaluated. The primary outcome measure was the diagnosis of SSI within 30 days of surgery. Cut-point analysis of the entire range of lowest intraoperative temperature measurements established the temperature nadir that best predicted SSI development. Single and multiple variable logistic regression determined SSI predictors.
The mean intraoperative temperature nadir of the study population (n = 524) was 35.2°C ± 1.1°C and 30.5% had at least 1 temperature measurement less than 35°C. Patients who developed SSI (36.1%) had a lower mean intraoperative temperature nadir (P = 0.009) and had a greater number of intraoperative temperature measurements <35°C (P < 0.001) than those who did not. Cut-point analysis revealed an intraoperative temperature of 35°C as the nadir temperature most predictive of SSI development. Multivariate analysis determined that a single intraoperative temperature measurement less than 35°C independently increased the site infection risk 221% per degree below 35°C (OR: 2.21; 95% CI: 1.24-3.92, P = 0.007).
Just as intraoperative hypothermia is an SSI risk factor in patients undergoing elective colorectal procedures, intraoperative hypothermia less than 35°C adversely affects SSI rates after trauma laparotomy. Our results suggest that intraoperative normothermia should be strictly maintained in patients undergoing operative trauma procedures.
Annals of surgery 03/2012; 255(4):789-95. · 7.90 Impact Factor
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ABSTRACT: To characterize and compare total lung capacity (TLC) measured by plethysmography with high-resolution computed tomography (HRCT), and to identify variables that predict the difference between the two modalities.
Fifty-nine consecutive patients referred for the evaluation of COPD were retrospectively reviewed. Patients underwent full pulmonary function testing and HRCT within 3 months. TLC was obtained by plethysmography as per American Thoracic Society/European Respiratory Society standards and by HRCT using custom software on 0.75 and 5 mm thick contiguous slices performed at full inspiration (TLC).
TLC measured by plethysmography correlated with TLC measured by inspiratory HRCT (r = 0.92, P < 0.01). TLC measured by plethysmography was larger than that determined by inspiratory HRCT in most patients (mean of 6.46 ± 1.28 L and 5.34 ± 1.20 L respectively, P < 0.05). TLC measured by both plethysmography and HRCT correlated significantly with indices of airflow obstruction (forced expiratory volume in 1 second/forced vital capacity [FVC] and FVC%), static lung volumes (residual volume, percent predicted [RV%], total lung capacity, percent predicted [TLC%], functional residual capacity, percent predicted [FRC%], and inspiratory capacity, percent predicted), and percent emphysema. TLC by plethysmography and HRCT both demonstrated significant inverse correlations with diffusion impairment. The absolute difference between TLC measured by plethysmography and HRCT increased as RV%, TLC%, and FRC% increased. Gas trapping (RV% and FRC%) independently predicted the difference in TLC between plethysmography and HRCT.
In COPD, TLC by plethysmography can be up to 2 L greater than inspiratory HRCT. Gas trapping independently predicts patients for whom TLC by plethysmography differs significantly from HRCT.
International Journal of COPD 01/2012; 7:119-26.
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ABSTRACT: Despite limited prospective data, it is commonly believed that human immunodeficiency virus (HIV) and hepatitis infections are widespread in the penetrating trauma population, placing healthcare workers at risk for occupational exposure. Our primary study objective was to measure the prevalence of HIV (anti-HIV), hepatitis B (HB surface antigen [HBsAg]), and hepatitis C virus (anti-HCV) in our penetrating trauma population.
We prospectively analyzed penetrating trauma patients admitted to Temple University Hospital between August 2008 and February 2010. Patients (n = 341) were tested with an oral swab for anti-HIV and serum evaluated for HBsAg and anti-HCV. Positives were confirmed with western blot, neutralization immunoassay, and reverse transcription polymerase chain reaction, respectively. Demographics, risk factors, and clinical characteristics were analyzed.
Of 341 patients, 4 patients (1.2%) tested positive for anti-HIV and 2 had a positive HBsAg (0.6%). Hepatitis C was the most prevalent measured infection as anti-HCV was detected in 26 (7.6%) patients. Overall, 32 (9.4%) patients were tested positive for anti-HIV, HBsAg, or anti-HCV. Twenty-eight (75%) of these patients who tested positive were undiagnosed before study enrollment. When potential risk factors were analyzed, age (odds ratio, 1.07, p = 0.031) and intravenous drug use (odds ratio 14.4, p < 0.001) independently increased the likelihood of anti-HIV, HBsAg, or anti-HCV-positive markers.
Greater than 9% of our penetrating trauma study population tested positive for anti-HIV, HBsAg, or anti-HCV although patients were infrequently aware of their seropositive status. As penetrating trauma victims frequently require expedient, invasive procedures, universal precautions are essential. The prevalence of undiagnosed HIV and hepatitis in penetrating trauma victims provides an important opportunity for education, screening, and earlier treatment of this high-risk population.
The Journal of trauma 08/2011; 71(2):306-10; discussion 311. · 2.48 Impact Factor
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ABSTRACT: To evaluate the interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in children with chronic spinal cord injury (SCI), and to define the lower age limit at which the examinations have clinical utility.
Repeated measures, multicenter reliability study.
Two U.S. pediatric specialty hospitals with recognized SCI programs.
Children (N=236) with chronic SCI.
Subjects underwent 4 examinations by 2 raters: sensory tests (pin prick [PP] and light touch [LT]), a motor test, and a test of anal sensation (AS) and anal contraction (AC).
A 2-way general linear model analysis of variance was used for analysis. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were calculated for PP, LT, motor, AS, and AC.
No child younger than 6 years completed the examination. When examined as a function of age, interrater reliability for motor, PP, LT, AS, and AC was moderate (ICC=.89) to high (ICC=.99). There was poor reliability for AS (ICC=.49) in subjects with complete injuries but moderate reliability for all other variables. There was moderate to high reliability for classification of type (tetraplegia/paraplegia) and severity (complete/incomplete) of injury across age groups.
The ISNCSCI does not have utility for children younger than 6 years. For children older than 6 years, interrater reliability of PP, LT, and motor examinations is high.
Archives of physical medicine and rehabilitation 08/2011; 92(8):1264-9. · 2.18 Impact Factor
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ABSTRACT: Cardiac fluorine-18-fluorodeoxyglucose (FDG) uptake is known to be variable in fasting oncologic positron emission tomography computed tomography studies. Increased posterolateral and basal FDG activity have been reported with the basal pattern ascribed to radiation injury. The purpose of this study was to investigate the spectrum of normal cardiac FDG findings seen in oncologic patients.
Men <35 years of age and women <45 years of age seen over a 3-year period were included. A visual assessment of FDG cardiac activity was performed using a 12-segment model of the heart by 2 observers. Focal papillary muscle activity was not included in the analysis.
Of 65 patients who met the entry criteria, increased FDG activity was observed in the base of the heart in 37 (57%) patients. This was most common in the lateral-basal wall in 35 (54%) patients, followed by posterior-basal wall in 21 (32%) patients, anterior-basal wall in 10 (15%) patients, and basal-septum in 10 (15%) patients. Suppression of total cardiac activity was present in only 6 (9%) patients in spite of adequate fasting. Diffuse cardiac activity was seen in 9 (14%) patients. The previously reported increased posterolateral pattern was present in only 9 (14%) patients.
This study confirms variable fasting FDG cardiac activity with a predominant basal pattern not associated with radiation injury. Knowledge of these patterns is important for recognition of possible underlying cardiac ischemia, tumor, or other inflammatory conditions encountered during interpretation of oncologic positron emission tomography computed tomography studies.
Journal of thoracic imaging 06/2011; 27(4):263-8. · 1.42 Impact Factor
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ABSTRACT: Sleep quality is poor in severe emphysema. We hypothesized that in addition to nocturnal oxygen desaturation, the severity of airflow obstruction and degree of thoracic hyperinflation are responsible.
Twenty-five patients (14 males, 64 ± 6 [ ± SD] yrs, BMI 24.7 ± 4.2 kg/m(2)) with severe emphysema (FEV(1) = 28 ± 8% predicted, TLC = 125 ± 14% predicted) were studied. Measurements included spirometry, lung volumes, arterial blood gas, length of the diaphragm's zone of apposition (LZAP) and a polysomnogram.
Total sleep time (TST) was 227 ± 93 minutes with a sleep efficiency (SE) of 56 ± 21%. The mean SaO(2), lowest SaO(2), and% TST with a SaO(2) < 90% were 90 ± 5%, 83 ± 8% and 29 ± 40%, respectively. TST correlated with FEV(1)% (r = 0.5, p = 0.02), FVC% (r = 0.4, p = 0.03) and LZAP (r = 0.5, p = 0.01). SE correlated with FEV(1)% (r = 0.5, p = 0.02) and LZAP (r = 0.5, p = 0.01), but not with FVC% (r = 0.4, p = 0.07). Additionally, TST and SE correlated negatively with residual volume% (r = -0.4, p = 0.046, and r = -0.4, p = 0.03, respectively). There was no correlation between TST and SE and measures of nocturnal oxygenation. Multiple linear regression was used to predict TST, with 50% (r(2) = 0.49) explained by a combination of LZAP (27%), mean SaO(2) (23%), and the lowest SaO(2) (< 1%). To predict SE, 44% (r(2) = 0.43) was explained by a combination of LZAP (29%), mean SaO(2) (14%), and the lowest SaO(2) (1%).
Although parameters of respiratory function and mechanics correlate with sleep quality, both nocturnal oxygenation and measurements of respiratory function/mechanics predict sleep quality in severe emphysema.
COPD Journal of Chronic Obstructive Pulmonary Disease 06/2011; 8(3):182-8. · 1.79 Impact Factor
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ABSTRACT: Nausea is a common symptom of gastroparesis (GP). The study is to determine the manifestations and impact of nausea in GP and to determine if there are any differences in diabetic (DG) and idiopathic gastroparesis (IG).
The patients referred for GP symptoms underwent gastric emptying scintigraphy and completed the Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM), Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life (PAGI-QOL), SF-36v2 Health-Related Quality-of-Life survey, and the Nausea Profile (NP).
Fifty-nine GP patients (20 diabetic, 39 idiopathic; 52 female; mean age 43 y) with delayed gastric emptying were enrolled. Nausea was an important symptom in these patients as assessed by PAGI-SYM (2.3±0.2) and it correlated with worse quality of life by PAGI-QOL (r=-0.299; P=0.021). The nausea and vomiting scores were similar in DG and IG, but DG had more severe retching (2.6±0.3 vs. 1.4±0.3; P=0.02) and more episodes of vomiting per week (4.4±1.4 vs. 3.5±1.3; P=0.037) compared with IG. Using the NP, total nausea scores in DG (61±3) were found to be greater than IG (49 (3; P=0.03) with somatic distress scores (60±5 vs. 44±4; P=0.03), and the gastrointestinal (GI) distress scores (84±4 vs. 73±4; P=0.05) were found to be greater in DG than IG. Although DG had slower gastric emptying than IG, there was no significant correlation between the NP scores and the degree of gastric retention on gastric emptying scintigraphy.
Nausea and vomiting symptoms correlate with worse quality of life in GP patients. The DG patients experience greater nausea and increased somatic distress than IG. The differential perception of nausea in DG versus IG might be because of distinct pathophysiologic mechanisms.
Journal of clinical gastroenterology 04/2011; 45(4):317-21. · 2.21 Impact Factor
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ABSTRACT: Chronic sputum production is a significant but variable complaint in COPD; its effect on symptom burden has not been comprehensively described. We sought to characterize the daily burden of chronic sputum production in severe COPD and the phenotype of those with chronic sputum symptoms.
We studied 50 outpatients with severe COPD who used an electronic diary to document peak expiratory flow (PEF) and respiratory symptoms daily for up to 2 years. A sputum index was derived based on complaints of sputum quantity, color, and consistency, and patients were divided into groups based on average daily sputum index (Low, Medium, High). The presence and severity of respiratory symptoms were scored by a novel method using daily changes in symptoms and PEF from baseline and were categorized into mild, moderate, and severe. Percent emphysema was measured using quantitative CT.
In the 14,500 observation days, severe symptom days were greater in the Medium and High groups (379/6089, 1609/4091, and 2624/4317 observation days in Low, Medium, and High, p < 0.0001). The same trend was found even when sputum complaints were removed from the symptom severity score. Observed/predicted PEF ratio was lower in the High group (0.56 ± 0.24, 0.55 ± 0.19, and 0.42 ± 0.12 in each group, p < 0.05 for High compared to Medium and Low). Percent emphysema inversely correlated with average sputum index and quantity (r = -0.449 and r = -0.584, respectively, p < 0.05).
Increased sputum production in severe COPD is frequently encountered daily and is associated with more respiratory symptoms, worse airflow obstruction, and less emphysema.
COPD Journal of Chronic Obstructive Pulmonary Disease 04/2011; 8(2):114-20. · 1.79 Impact Factor
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ABSTRACT: Vascular function, as measured by flow mediated dilation (FMD) and nitroglycerin mediated dilation (NMD), is impaired in COPD. Increases in systemic inflammatory mediators during acute exacerbations of COPD (AECOPD) may further impair vascular function and may account for the increased prevalence of cardiovascular disease in COPD patients. Similarly it may account for the increased morbidity and mortality in COPD patients hospitalized with acute exacerbations. We hypothesized that FMD and NMD would be impaired during AECOPD requiring hospitalization and that vascular function would improve upon AECOPD resolution. We used FMD and NMD to evaluate vascular function in 19 patients hospitalized with AECOPD. FMD and NMD were repeated approximately three months later in 8 of these patients. In these eight patients significant improvements were observed in FMD (2.6 ± 1.5% vs 5.1 ± 2.4%, p = 0.04) and NMD (5.0 ± 2.6% vs 13.3 ± 4.5, p = 0.02) after resolution of their exacerbation. We conclude that endothelial and vascular smooth muscle function is markedly impaired during AECOPD requiring hospitalization and improves following resolution. The systemic vascular impairment that occurs during AECOPD may partially explain the observed increased in cardiac morbidity and mortality that occur in this population.
COPD Journal of Chronic Obstructive Pulmonary Disease 04/2011; 8(2):60-5. · 1.79 Impact Factor
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ABSTRACT: Prolonged mechanical ventilation is increasingly common. It is expensive and associated with significant morbidity and mortality. Our objective is to comprehensively characterize patients admitted to a Ventilator Rehabilitation Unit (VRU) for weaning and identify characteristics associated with survival.
182 consecutive patients over 3.5 years admitted to Temple University Hospital (TUH) VRU were characterized. Data were derived from comprehensive chart review and a prospectively collected computerized database. Survival was determined by hospital records and social security death index and mailed questionnaires.
Upon admission to the VRU, patients were hypoalbuminemic (albumin 2.3 ± 0.6 g/dL), anemic (hemoglobin 9.6 ± 1.4 g/dL), with moderate severity of illness (APACHE II score 10.7 + 4.1), and multiple comorbidities (Charlson index 4.3 + 2.3). In-hospital mortality (19%) was related to a higher Charlson Index score (P = 0.006; OR 1.08-1.6), and APACHE II score (P = 0.016; OR 1.03-1.29). In-hospital mortality was inversely related to admission albumin levels (P = 0.023; OR 0.17-0.9). The presence of COPD as a comorbid illness or primary determinant of respiratory failure and higher VRU admission APACHE II score predicted higher long-term mortality. Conversely, higher VRU admission hemoglobin was associated with better long term survival (OR 0.57-0.90; P = 0.0006).
Patients receiving prolonged ventilation are hypoalbuminemic, anemic, have moderate severity of illness, and multiple comorbidities. Survival relates to these factors and the underlying illness precipitating respiratory failure, especially COPD.
Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine 01/2011; 5:17-26.
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ABSTRACT: Domperidone is a useful alternative to metoclopramide for treatment of gastroparesis due to better tolerability. Effectiveness and side-effects from domperidone may be influenced by patient-related factors including polymorphisms in genes encoding drug-metabolizing enzymes, drug transporters, and domperidone targets.
The aim of this study was to determine if demographic and pharmacogenetic parameters of patients receiving domperidone are associated with response to treatment or side-effects.
Patients treated with domperidone for gastroparesis provided saliva samples from which DNA was extracted. Fourteen single-nucleotide polymorphisms (SNPs) in seven candidate genes (ABCB1, CYP2D6, DRD2, KCNE1, KCNE2, KCNH2, KCNQ1) were used for genotyping. SNP microarrays were used to assess single-nucleotide polymorphisms in the ADRA1A, ADRA1B, and ADRA1D loci.
Forty-eight patients treated with domperidone participated in the study. DNA was successfully obtained from each patient. Age was associated with effectiveness of domperidone (p=0.0088). Genetic polymorphism in KCNH2 was associated with effectiveness of domperidone (p=0.041). The efficacious dose was associated with polymorphism in ABCB1 gene (p=0.0277). The side-effects of domperidone were significantly associated with the SNPs in the promoter region of ADRA1D gene.
Genetic characteristics associated with response to domperidone therapy included polymorphisms in the drug transporter gene ABCB1, the potassium channel KCNH2 gene, and α1D--adrenoceptor ADRA1D gene. Age was associated with a beneficial response to domperidone. If verified in a larger population, this information might be used to help determine which patients with gastroparesis might respond to domperidone and avoid treatment in those who might develop side-effects.
Digestive Diseases and Sciences 11/2010; 56(1):115-24. · 2.12 Impact Factor
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ABSTRACT: To evaluate the association between apolipoprotein E (APOE) polymorphisms (E2, C/T Arg158Cys; E4, T/C Cys112Arg; and promoter, g-219t) and the history of concussion in college athletes. We hypothesized that carrying 1 or more APOE rare (or minor) allele assessed in this study would be associated with having a history of 1 or more concussions.
Multicenter cross-sectional study.
University athletic facilities.
One hundred ninety-six male football (n = 163) and female soccer (n = 33) college athletes volunteered.
Written concussion history questionnaire and saliva samples for genotyping.
Self-reported history of a documented concussion and rare APOE genotype (E2, E4, promoter).
There was a significant association (Wald χ² = 3.82; P = 0.05; odds ratio = 9.8) between carrying all APOE rare alleles and the history of a previous concussion. There was also a significant association (Wald χ² = 3.96, P = 0.04, odds ratio = 8.4) between carrying the APOE promoter minor allele and experiencing 2 or more concussions.
Carriers of all 3 APOE rare (or minor) alleles assessed in this study were nearly 10 times more likely to report a previous concussion and may be at a greater risk of concussion versus noncarriers. Promoter minor allele carriers were 8.4 times more likely to report multiple concussions and may be at a greater risk of multiple concussions versus noncarriers. Research involving larger samples of individuals with multiple concussions and carriers of multiple APOE rare alleles is warranted.
Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine 11/2010; 20(6):464-8. · 1.50 Impact Factor
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ABSTRACT: Although the Child-Turcotte-Pugh (CTP) score is an established outcome prediction tool for patients with liver disease, the Model for End-Stage Liver Disease (MELD) score has recently supplanted CTP for patients awaiting transplantation. Currently, data regarding the use of CTP in trauma is limited, whereas MELD remains unstudied. We compared MELD and CTP to determine which scoring system is a better clinical outcome predictor after trauma.
A review of trauma admissions during 2003-2008 revealed 68 patients with chronic liver disease. Single and multiple variable analyses determined predictors of hepatic complications and survival. MELD and CTP were compared using odds ratios and area under the receiver operating curve (AUC) analyses. A p value ≤0.05 was significant.
The mean MELD and CTP scores of the population were 13.1 ± 6.0 and 8.3 ± 1.8, respectively (mean ± SD). Overall, 73.5% had one or more complications and 29.4% died. When survivors were compared with nonsurvivors, no difference in mean MELD scores was found, although mean CTP score (survivors, 7.7 ± 1.5; nonsurvivors, 9.4 ± 1.9; p = 0.001) and class ("C" survivors, 12.1%; "C" nonsurvivors, 56.3%; p = 0.002) were different, with survival relating to liver disease severity. Odds ratios and AUC determined that MELD was not predictive of hepatic complications or hospital survival (p > 0.05), although both CTP score and class were predictive (p < 0.05; AUC > 0.70).
Trauma patients suffering from cirrhosis can be expected to have poorer than predicted outcomes using traditional trauma scoring systems, regardless of injury severity. Scoring systems for chronic liver disease offer a more effective alternative. We compared two scoring systems, MELD and CTP, and determined that CTP was the better predictor of hepatic complications and survival in our study population.
The Journal of trauma 09/2010; 69(3):568-73. · 2.48 Impact Factor
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ABSTRACT: We hypothesized that positional therapy would be equivalent to continuous positive airway pressure (CPAP) at normalizing the apnea-hypopnea index (AHI) in patients with positional obstructive sleep apnea (OSA).
Thirty-eight patients (25 men, 49 +/- 12 years of age, body mass index 31 +/- 5 kg/m2) with positional OSA (nonsupine AHI <5 events/h) identified on a baseline polysomnogram were studied. Patients were randomly assigned to a night with a positional device (PD) and a night on CPAP (10 +/- 3 cm H2O).
Positional therapy was equivalent to CPAP at normalizing the AHI to less than 5 events per hour (92% and 97%, respectively [p = 0.16]). The AHI decreased from a median of 11 events per hour (interquartile range 9-15, range 6-26) to 2 (1-4, 0-8) and 0 events per hour (0-2, 0-7) with the PD and CPAP, respectively; the difference between treatments was significant (p < 0.001). The percentage of total sleep time in the supine position decreased from 40% (23%-67%, 7%-82%) to 0% (0%-0%, 0%-27%) with the PD (p < 0.001) but was unchanged with CPAP (51% [36%-69%, 0%-100%]). The lowest SaO2 increased with the PD and CPAP therapy, from 85% (83%-89%, 76%-93%) to 89% (86%-9%1, 78%-95%) and 89% (87%-91%, 81%-95%), respectively (p < 0.001). The total sleep time was unchanged with the PD, but decreased with CPAP, from 338 (303-374, 159-449) minutes to 334 (287-366, 194-397) and 319 (266-343, 170-386) minutes, respectively (p = 0.02). Sleep efficiency, spontaneous arousal index, and sleep architecture were unchanged with both therapies.
Positional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA, with similar effects on sleep quality and nocturnal oxygenation.
Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 06/2010; 6(3):238-43. · 3.23 Impact Factor
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ABSTRACT: Single, isolated hypotensive blood pressure (BP) measurements frequently are ignored or considered "erroneous." Although their clinical significance remains unknown, we hypothesized that single, isolated hypotensive BP readings during trauma resuscitations signify the presence of severe injuries that often warrant immediate intervention.
A prospective observational study was performed on all trauma patients admitted from June 2008 to January 2009. Patients with a single systolic blood pressure (SBP) reading <110 mm Hg during their trauma resuscitation were evaluated, and demographics, hemodynamics, resuscitation (fluids, blood products, and duration), injuries, and operative or endovascular management were analyzed. Single and multiple variable logistic regression analyses were performed. Cutpoint analysis of the entire range of lowest single SBP measurements determined which SBP value best predicted the need for immediate therapeutic intervention.
Patients (n = 145) were predominantly male (77.2%) but age (mean, 35.1 +/- 15.3 years) and injury mechanisms varied (penetrating, 46.2%; blunt, 53.8%). Cutpoint analysis determined that a single SBP reading <105 mm Hg best predicted the need for immediate therapeutic intervention. Although 38.1% patients with isolated SBP <105 mm Hg measurements underwent immediate therapeutic operative or endovascular procedures, only 10.4% (p < 0.001) with isolated SBP >or=105 mm Hg required these procedures. Patients were 12.4 times (confidence interval: 2.6-59.2; p = 0.002) more likely to undergo immediate therapeutic intervention than those with a single SBP >or=105 mm Hg.
Single, isolated hypotensive BP measurements during trauma resuscitations should not be ignored or dismissed. Instead, our results suggest that a single SBP reading <105 mm Hg is associated with severe injuries that often require immediate operative or endovascular treatment and surgical intensive care unit admission.
The Journal of trauma 06/2010; 68(6):1289-94; discussion 1294-1295. · 2.48 Impact Factor
