Maragatha Kuchibhatla’s research while affiliated with Duke University Medical Center and other places

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Publications (232)


Emergency scenarios used in the survey
Household demographics by emergency care incidence in the previous 12 months
Emergency situations
Access to treatment of emergency conditions by limited/delayed emergency care
Delayed access to healthcare

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Emergency care knowledge, utilization, and barriers in Northern Tanzania: A community-based survey
  • Article
  • Full-text available

January 2025

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22 Reads

Frida Shayo

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Gregory Goodluck Zaccheus

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Anjni P. Joiner

Background Emergency care systems are critical to improving care for time-sensitive emergency conditions. The growth and development of these systems in Sub-Saharan Africa is becoming a priority. Layperson knowledge and recognition of emergency symptoms and subsequent care-seeking behavior are key to achieving timely access to care and appropriate treatment. This study aimed to assess community knowledge of emergency conditions as well as barriers to accessing the emergency care system in Northern Tanzania. Methods This was a cross-sectional study of households in three districts in Kilimanjaro, Tanzania from June to September 2021. The primary outcome was an inappropriate response to any of five hypothetical emergency conditions. Secondary outcomes were the incidence of household emergencies and delay in care access for those with emergency conditions. Data were analyzed using descriptive statistics. Associations between the outcome of interest and select household characteristics were analyzed using Fisher’s Exact tests for categorical measures and Wilcoxon rank-sum tests for continuous measures. Results A total of 539 households were interviewed with 2,274 participants. The majority (46.8%) were from Moshi District Council. 73.7% used cash and/or had no insurance. The mean monthly household income was 226,107.6 Tanzanian Shillings. 76 (14.1%) households reported experiencing an emergency condition in the past year and 225 (41.7%) of respondents had an inappropriate response to at least one hypothetical emergency condition. A higher proportion of those with delayed access to healthcare paid with personal cash and a lower proportion had national health insurance. A higher proportion of those with inappropriate responses to hypothetical emergency conditions lived in rural districts, were uninsured, and had a lower mean income. Conclusion Community-dwelling adults in Northern Tanzania have significant gaps in understanding of emergency care conditions and delayed access to care for these conditions. Distance to the healthcare facilities, cost, and lack of insurance may contribute to care delays. Increasing insurance coverage and developing emergency medical services may improve access to care.

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Complement Activation As a Biomarker for Platelet Activating Antibodies in Heparin-Induced Thrombocytopenia (HIT)

November 2024

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8 Reads

Blood

Background: IgG antibodies (Abs) to platelet factor 4 and heparin (PF4/H) commonly occur after heparin exposure, but cause life-threatening complications of HIT in only a subset of patients. To date, only platelet activation assays can reliably distinguish anti-PF4/heparin Abs that cause disease (HIT Abs) from those more likely to be asymptomatic (AAbs). In recent studies, we showed that complement activation by HIT Abs is essential for downstream FcgRIIA-mediated cellular activation. Study Objectives: As pathogenic HIT Abs also bind and cross-link platelet FcgRIIA, we asked if there was a correlation between complement and platelet activating properties of anti-PF4/heparin Abs. To address this question, we studied a clinically annotated cohort of patients with (HIT; n=8) or without HIT (AAb+, n=14) to compare clinical and laboratory features with serologic properties of Ab titers, platelet and complement activation. Methods: Patients testing positive for polyclonal anti-PF4/heparin Abs in the Duke Coagulation Laboratory were consented and included in the study based on sample availability. Plasma or whole blood from consented healthy donors was used as controls or as a source of complement in complement activation assays. Demographics, platelet counts, 4Ts and HEP score, % decline in platelet count, serologic data (anti-PF4/heparin polyclonal and IgG assay, and serotonin release assay or SRA results) were recorded. Endpoint titers were calculated using an in-house ELISA. Complement activation was measured, as previously described (Khandelwal, Blood 2021), using patient plasma (10% v/v) added to undiluted healthy donor plasma with buffer or PF4 (25 µg/ml) and heparin to generate in situ immune complexes (ICs). Complement-fixed ICs were measured using an immunocapture assay, using KKO, a monoclonal anti-PF4/heparin Ab, as the capture Ab and an anti-C3c (Quidel, San Diego) Ab for detection of captured immune complexes. MMP9 and IL-8 were measured after incubation of patient plasma (10% v/v) added to undiluted whole blood for 30 minutes (MMP9) or 6 hours (IL-8), with respective proteins detected using commercial immunoassays (R&D Systems, Minneapolis, MN). Results: As compared to AAb+ patients, HIT patients had significantly lower mean + standard deviation (SD) platelet counts (AAb+ vs. HIT: 67 +31 v39 +16; p<0.02), greater % drop in platelet counts (AAb+ vs. HIT: 65% + 14% v 79% +12%; p<0.03), higher 4Ts (AAb+ vs. HIT: 3.4 + 0.8 v 6.5 +1.1; p<0.0001), HEP scores (AAb+ vs. HIT: 4.4 +1.7 v 11.1 +2.5; p<0.0002), anti-PF4 polyclonal (AAb+ vs. HIT: 3.9 + 4.0 v 8.5 + 5.8; p<0.03) and IgG Ab levels (AAb+ vs. HIT: 0.7 +0.7 v 2.2 +0.9; p<0.008). Serologic properties also significantly differed between the two cohorts, with HIT patients showing median higher Ab titers (AAb+ vs. HIT: 900 v 7400; p<0.009), higher mean + SD% serotonin release or SRA+ (AAb+ vs. HIT: 5+7 v 91 +8; p<0.0001) and greater mean + SD complement activation, as determined by a C3c immunoassay (AAb+ vs. HIT: 0.8 +0.6 v 3.4 +0.6; p<0.0002). All HIT patients (8/8) showed strong complement activation, while 2/14 AAb+ patients showed increased complement activation over background levels of healthy donors. The extent of complement activation closely correlated with % serotonin release by anti-PF4/heparin Abs (r=0.754; p<0.001 by Spearman), as well as other clinical and laboratory parameters including, clinical 4Ts score (r = 0.64, p = 0.001), % drop in platelet count (r = 0.256, p = .023) and anti-PF4/heparin IgG levels (r = 0.444, p = .038). Complement activation also showed strong correlation with properties of cellular activation as gauged by MMP9 secretion (r = 0.680, p = 0.001) and release of IL-8 (r = 0.799, p = 0.0001) in whole blood. Conclusions: Our findings support that complement activation strongly correlates with other cellular activation endpoints, including platelet and monocyte/neutrophil activation and importantly distinguish anti-PF4/heparin Abs with and without disease potential. If these findings are confirmed in a larger cohort, complement activation can likely serve as “functional” biomarker for detecting pathogenic HIT Abs, perhaps obviating the need for a functional platelet activation assay.


Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma: A Longitudinal Study

October 2024

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8 Reads

Craniomaxillofacial Trauma and Reconstruction

Study Design Single-institution retrospective financial analysis. Objective Trauma care is consistently linked to inadequate reimbursement, posing a significant financial burden for large trauma centers. Data show that declining Medicare reimbursement rates have indirectly led to declining payment for all procedures covered by insurance. The goals of this study are to investigate the opportunity cost associated with contemporary surgical management of CMF trauma at our institution and to evaluate longitudinal financial trends. Methods Patients with operative facial fractures between 2015 and 2022 at Duke University Medical Center were included and compared to patients undergoing general otolaryngology, plastic surgery and oral surgery operations in the same period. Procedural codes, payor type, charges billed, collections, relative value units (RVUs) and other financial data were obtained and analyzed among the 2 patient populations. Comparative analysis was performed to assess the financial trends in data reported previously from 2007-2015. Results The collection rate at Duke University Medical Center for operatively managed CMF fractures remains significantly lower than non-CMF counterparts. Interestingly, the collection rate gap between CMF and non-CMF surgeries has narrowed when comparing to the data from 2007-2013. This is largely due to a decrease in collection rates for non-CMF procedures from 29.61% (2007-2013) to 26.57% (2015-2022) [ P = 0.0001] and an increase in collection rates for CMF procedures from 17.25% (2007-2013) to 18.05% (2015-2022) [ P = 0.0001]. Conclusions Despite a slight improvement of the gap in reimbursement rates for CMF and non-CMF surgeries over the last several years, trauma care continues to have a negative financial impact on health care institutions.


Flow diagram of cohort creation. Abbreviations: MBSAQIP = Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, BMI = body mass index, RYGB = Roux-en-Y gastric bypass, N.O.T.E.S. = natural orifice translumenal endoluminal surgery, CPT = current procedural terminology, OTHCPT = CPT code listed in addition to the main bariatric surgery performed. CPT 43771, 43772, 43773, and 43774 represent single stage adjustable gastric band or port removal
Venous Thromboembolic Events Following Revisional Gastric Bypass: An Analysis of the MBSAQIP Database from 2015 to 2019 Using Propensity Matching

Obesity Surgery

Background Primary bariatric surgery is associated with moderate-to-high risk of venous thromboembolic events (VTE); however, the risk for revisional surgery lacks granularity. Our primary objective was to define the risk of VTE following revisional Roux-en-Y gastric bypass (RYGB) compared to primary RYGB. Methods Adults who underwent primary or revision/conversion RYGB between January 1, 2015, and December 31, 2019, with a BMI ≥ 35 kg/m² were identified in a bariatric specific database. VTE was defined as pulmonary embolus and/or deep venous thrombosis. Thirty-day VTE and transfusion rates were compared between the two groups using propensity score matching of 3:1. Results Primary RYGB was performed in 197,186 (92.4%) patients compared to 16,144 (7.6%) in the revisional group. Patients in the revisional group had fewer comorbidities than those undergoing primary RYGB. In the matched cohort of 64,258 procedures, there were 48,116 (74.9%) primary RYGB cases compared to 16,142 (25.1%) RYGB revisions. The rate of VTE was similar in the revisional surgery group compared to the propensity matched primary RYGB group (0.4% vs. 0.3%, p > 0.580); however, transfusion was more common in the revisional group (1.4% vs. 1.0%, p = 0.005). Revisional group had higher rates of readmission, reoperation, increased length of stay, and operation length ≥ 180 min compared to matched primary RYGB group (p < 0.001). Conclusions VTE rates for both primary and revisional RYGB are similar. Revisional RYGB cases impose increased risk of bleeding among other outcomes. Thus, identifying those at higher risk of complications is critical.





Figure 1
Venous Thromboembolic Events Following Revisional Gastric Bypass: An Analysis of the MBSAQIP Database From 2015 to 2019 Using Propensity Matching

June 2024

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12 Reads

Background Primary bariatric surgery is associated with moderate to high risk of venous thromboembolic events (VTE), however the risk for revisional surgery lacks granularity. Our primary objective was to define the risk of VTE following revisional Roux-en-Y gastric bypass (RYGB) compared to primary RYGB. Methods Adults who underwent primary or revision/conversion RYGB between January 1, 2015 and December 31, 2019 with a BMI ≥ 35 kg/m² were identified in a bariatric specific database. VTE was defined as pulmonary embolus and/or deep venous thrombosis. 30-day VTE and transfusion rates were compared between the two groups using propensity score matching of 3:1. Results Primary RYGB was performed in 197,186 (92.4%) patients compared to 16,144 (7.6%) in the revisional group. Patients in the revisional group had fewer comorbidities than those undergoing primary RYGB. In the matched cohort of 64,258 procedures, there were 48,116 (74.9%) primary RYGB cases compared to 16,142 (25.1%) RYGB revisions. The rate of VTE was similar in the revisional surgery group compared to the propensity matched primary RYGB group (0.4% vs. 0.3%, p > 0.580), however transfusion was more common in the revisional group (1.4% vs. 1.0%, p = 0.005). Revisional group had higher rates of readmission, reoperation, increased length of stay and operation length ≥ 180 minutes compared to matched primary RYGB group (p < 0 .001). Conclusions VTE rates for both primary and revisional RYGB are similar. Revisional RYGB cases impose increased risk of bleeding amongst other outcomes. Thus, identifying those at higher risk of complications is critical.



Citations (60)


... This interdisciplinary approach is essential for unraveling the complex mechanisms governing platelet function and their role in disease progression. The large datasets generated, coupled with the use of AI and Big Data, allow us to better understand each patient's pathology and medical needs [189,190]. ...

Reference:

How Protein Depletion Balances Thrombosis and Bleeding Risk in the Context of Platelet’s Activatory and Negative Signaling
Bleeding recurrence risk among hospitalized patients undergoing therapeutic plasma exchange: a multi-center study
  • Citing Article
  • July 2024

... We conducted qualitative interviews with a sample of patients enrolled in the initial pilot phase of the parent study [15,16]. We aimed to understand the acceptability and experiences of patients receiving acupuncture for acute musculoskeletal pain in an emergency setting, and identify ways to improve those experiences. ...

An Adaptive Pragmatic Randomized Controlled Trial of Emergency Department Acupuncture for Acute Musculoskeletal Pain Management
  • Citing Article
  • May 2024

Annals of Emergency Medicine

... Briefly, VA ED leadership (ED Chief, deputy director, committee and educational leads) and ultrasound faculty met and developed a co-designed educational curriculum, plus optimal processes for POCUS image acquisition, documentation, archiving, and quality assurance review. We convened monthly to analyze and provide direct feedback on further improving our POCUS program [16]. ...

(O-F6) A Mixed-methods Study of Barriers and Facilitators to Point-of-care Ultrasound Implementation for Emergency Department Providers at the Durham Veterans Affairs Healthcare System

The Western Journal of Emergency Medicine

... This capability significantly enhanced the flexibility of the device, enabling it to accommodate probes with various imaging characteristics, thereby substantially expanding its potential applications and adaptability. Anterior segment imaging and ophthalmic imaging in the emergency room introduce two additional contexts where slit lamp-based imaging and the ability to accommodate different probes may benefit from our approach [6,7,20]. ...

Accuracy and Feasibility of Three-Dimensional Ultrasound Testing in Eye Clinic and Emergency Department Patients with Vision Complaints
  • Citing Article
  • November 2023

Journal of Emergency Medicine

... However, the specific type of BaS procedure does not independently affect the risk of MACE. These insights can be a useful tool in guiding better patient selection as well as in asserting preoperative potential risks, therefore improving surgical outcomes and patient counseling [50,51]. ...

Short-term cardiovascular events after bariatric surgery in patients with metabolic syndrome
  • Citing Article
  • August 2023

Surgery for Obesity and Related Diseases

... ADAMTS13 activity should also be tested using a different test method before initiating plasma exchange, as the results can vary between methods [12,13]. At this stage, the patient should also be tested for antibodies, VWF: Ag and complement Factor H. Since ADAMTS13 activity results are not immediately available, the empiric initiation of plasma exchange while awaiting the final result is necessary and recommended [12,14], and can reduce the mortality rate of TTP patients from approximately 90-10%~20% [6]. At the same time, in patients with moderate to high clinical suspicion of TTP or in confirmed cases, corticosteroid therapy should be initiated immediately, and combination therapy with rituximab may be considered [3,15]. ...

In patients with suspected immune TTP, admission source impacts hospital length of stay and time to therapeutic plasma exchange impacts clinical outcomes
  • Citing Article
  • May 2023

Thrombosis Research

... Patients undergoing SRS were older (10 years older than surgical group) and had larger tumors (possibly because they were deferred from surgery due to high risk of post-operative complications). [69] These results corroborate with Ivan et al., who showed an 86% tumor control rate with gross total resection (only 69% with sub-total resection) vs 95% following SRS in a systematic review and meta-analysis of 109 studies. [70] The growing body of evidence favours Stereotactic surgery with a two-fold advantage of higher tumor control rate and significantly lower post-operative complications. ...

Systematic Review and Meta-analysis for Surgery Versus Stereotactic Radiosurgery for Jugular Paragangliomas
  • Citing Article
  • December 2022

Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology

... Despite promising results in NHPs, sensitized NHPs under standard of care [SOC; tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone] immunosuppression all developed ABMR and allograft failure within 6 months of transplant, suggesting that additional maintenance therapy is needed to durably control the humoral response. Addition of belatacept to SOC immunosuppression led to long-term ABMR-free graft survival, but at the expense of increased incidence of viral complications and posttransplant lymphoproliferative disorder (PTLD) (21,22). Hence, there is still a need to develop effective and optimal approaches that adequately control the posttransplant humoral response without overimmunosuppression in sensitized recipients. ...

Belatacept-Based Maintenance Immunosuppression Controls the Post-Transplant Humoral Immune Response in Highly Sensitized Nonhuman Primates
  • Citing Article
  • October 2022

Kidney360

... A series of performance measures for DA-CPR quality assessments have been proposed by the American Heart Association and include the rate of OHCA correctly identified and where DA-CPR was provided, and the times of OHCA recognition (goal < 90 s) and the beginning of chest compressions (goal <150 s) under a dispatcher's guidance [27]. Despite the survey by Su er et al. (2015) underscoring the importance of emergency call review and feedback mechanisms in enhancing DA-CPR quality and effectiveness [8], it is worth considering that performance metrics may be difficult to achieve in real-world se ings and its assessment requires consistent resources [28]. Furthermore, disseminating data on patient outcomes with dispatchers improves awareness and performances on cardiac arrest identification and the provision of DA-CPR [29,30]. ...

Evaluation of Telephone-Assisted Cardiopulmonary Resuscitation Recommendations for Out-Of-Hospital Cardiac Arrest
  • Citing Article
  • July 2022

Resuscitation

... The readmission rate for any cause after BS was 4.4% in 2014 in the United States, slightly higher for sleeve gastrectomy and gastric bypass than adjustable gastric banding. 28 Fistulas and leaks are considered the most significant complications, contributing to increased postsurgical morbidity and mortality in these patients, with reported incidences ranging from 0.1-8.0%. 24 in general, there are no standardized treatment protocols for any of these complications, and patients usually require different management strategies that may include enteral and/ or parenteral nutrition, transfusion of blood products, antibiotic therapy, surgical drainage, and advanced endoscopic management. ...

Trends in Risk Factors for Readmission after Bariatric Surgery 2015-2018
  • Citing Article
  • January 2022

Surgery for Obesity and Related Diseases