40 results on '"Dimitra Skiada"'
Search Results
2. Infected chylopericardium: An unexpected cause of cardiac tamponade
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Renzo Cifuentes, Diego Celli, Gabriel A. Hernandez, Dimitra Skiada, Lilian Abbo, and Cesar E. Mendoza
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Pulmonary and Respiratory Medicine ,Surgery ,Cardiology and Cardiovascular Medicine - Abstract
A 22-year-old immunocompetent female with a history of small pericardial effusion while infant presented with fever and hemodynamic collapse four days after facial trauma. She was found to have cardiac tamponade secondary to infected chylopericardium from bacterial translocation. We report this very unusual case and review of the literature on chylopericardium infections.
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- 2022
3. Development and Implementation of a COVID-19 Disease Response Protocol at a Large Academic Medical Center
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Meshell Maxam, Kailynn J. DeRonde, Ana D. Vega, Dimitra Skiada, Christine A. Vu, Veronica Salazar, Renata Boatwright, Ennie Cano-Casillas, Venessa Goodnow, Kathleen A. Sposato, Peter G. Paige, David Zambrana, Don S. Steigman, Abdul M. Memon, and Lilian M. Abbo
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Academic Medical Centers ,Infection Control ,Inservice Training ,SARS-CoV-2 ,010102 general mathematics ,Public Health, Environmental and Occupational Health ,COVID-19 ,01 natural sciences ,Concepts in Disaster Medicine ,03 medical and health sciences ,0302 clinical medicine ,Clinical Protocols ,Humans ,protocol ,030212 general & internal medicine ,0101 mathematics ,implementation ,development - Abstract
In response to the rapid spread of novel coronavirus disease 2019 (COVID-19), health-care systems should establish procedures for early recognition and management of suspected or confirmed cases. We describe the various steps taken for the development, implementation, and dissemination of the interdisciplinary COVID-19 protocol at Jackson Health System (JHS), a complex tertiary academic health system in Miami, Florida. Recognizing the dynamic nature of COVID-19, the protocol addresses the potential investigational treatment options and considerations for special populations. The protocol also includes infection prevention and control measures and routine care for suspected or proven COVID-19 patients.
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- 2020
4. Favorable Changes in Biomarkers of Potential Harm to Reduce the Adverse Health Effects of Smoking in Smokers Switching to the Menthol Tobacco Heating System 2.2 for 3 Months (Part 2)
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Guillaume de La Bourdonnaye, Patrick Picavet, Christelle Haziza, Frank Lüdicke, Gizelle Baker, Andrea Donelli, Dimitra Skiada, Valerie Poux, and Rolf Weitkunat
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Adult ,Male ,Hot Temperature ,Homocysteine ,medicine.medical_treatment ,Health Behavior ,Physiology ,Original Investigations ,010501 environmental sciences ,Electronic Nicotine Delivery Systems ,01 natural sciences ,Risk Assessment ,law.invention ,Heating ,03 medical and health sciences ,chemistry.chemical_compound ,Young Adult ,0302 clinical medicine ,Randomized controlled trial ,Harm Reduction ,law ,Smoke ,medicine ,AcademicSubjects/SOC02541 ,Humans ,030212 general & internal medicine ,Platelet activation ,Endothelial dysfunction ,0105 earth and related environmental sciences ,Aged ,Smokers ,biology ,business.industry ,C-reactive protein ,Smoking ,Public Health, Environmental and Occupational Health ,Antipruritics ,Middle Aged ,medicine.disease ,Menthol ,Blood pressure ,chemistry ,biology.protein ,Smoking cessation ,Female ,Metabolic syndrome ,business ,AcademicSubjects/MED00010 ,Biomarkers - Abstract
Introduction Tobacco Heating System (THS) 2.2, a candidate modified-risk tobacco product, aims at offering an alternative to cigarettes for smokers while substantially reducing the exposure to harmful and potentially harmful constituents found in cigarette smoke. Methods One hundred and sixty healthy adult US smokers participated in this randomized, three-arm parallel group, controlled clinical study. Subjects were randomized in a 2:1:1 ratio to menthol Tobacco Heating System 2.2 (mTHS), menthol cigarette, or smoking abstinence for 5 days in confinement and 86 subsequent ambulatory days. Endpoints included biomarkers of exposure to harmful and potentially harmful constituents (reported in our co-publication, Part 1) and biomarkers of potential harm (BOPH). Results Compliance (protocol and allocated product exposure) was 51% and 18% in the mTHS and smoking abstinence arms, respectively, on day 90. Nonetheless, favorable changes in BOPHs of lipid metabolism (total cholesterol and high- and low-density cholesterol), endothelial dysfunction (soluble intercellular adhesion molecule-1), oxidative stress (8-epi-prostaglandin F2α), and cardiovascular risk factors (eg, high-sensitivity C-reactive protein) were observed in the mTHS group. Favorable effects in other BOPHs, including ones related to platelet activation (11-dehydrothromboxane B2) and metabolic syndrome (glucose), were more pronounced in normal weight subjects. Conclusions The results suggest that the reduced exposure demonstrated when switching to mTHS is associated with overall improvements in BOPHs, which are indicative of pathomechanistic pathways underlying the development of smoking-related diseases, with some stronger effects in normal weight subjects. Implications Switching to mTHS was associated with favorable changes for some BOPHs indicative of biological pathway alterations (eg, oxidative stress and endothelial dysfunction). The results suggest that switching to mTHS has the potential to reduce the adverse health effects of smoking and ultimately the risk of smoking-related diseases. Switching to mTHS for 90 days led to reductions in a number of biomarkers of exposure in smokers, relative to those who continued smoking cigarettes, which were close to those observed when stopping smoking (reported in our co-publication, Part 1). Initial findings suggest reduced levels of 8-epi-prostaglandin F2α and intercellular adhesion molecule 1, when switching to mTHS for 90 days. These changes are comparable to what is observed upon smoking cessation. In normal weight subjects, additional favorable changes were seen in 11-dehydrothromboxane B2, fibrinogen, homocysteine, hs-CRP, percentage of predicted forced expiratory volume in 1 second, systolic blood pressure, diastolic blood pressure, glucose, high-density lipoprotein, apolipoprotein A1, and triglycerides. Trial registration NCT01989156.
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- 2019
5. Reduction in Exposure to Selected Harmful and Potentially Harmful Constituents Approaching Those Observed Upon Smoking Abstinence in Smokers Switching to the Menthol Tobacco Heating System 2.2 for 3 Months (Part 1)
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Patrick Picavet, Frank Lüdicke, Rolf Weitkunat, Valerie Poux, Andrea Donelli, Christelle Haziza, Dimitra Skiada, Gizelle Baker, and Guillaume de La Bourdonnaye
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Adult ,Male ,medicine.medical_specialty ,Hot Temperature ,Health Behavior ,Original Investigations ,Electronic Nicotine Delivery Systems ,Lower risk ,Risk Assessment ,law.invention ,Heating ,Nicotine ,Young Adult ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Harm Reduction ,Randomized controlled trial ,law ,Smoke ,Internal medicine ,medicine ,Humans ,AcademicSubjects/SOC02541 ,030212 general & internal medicine ,Young adult ,Aged ,Harm reduction ,Smokers ,business.industry ,Smoking ,Public Health, Environmental and Occupational Health ,Antipruritics ,Middle Aged ,Menthol ,chemistry ,Carboxyhemoglobin ,Ambulatory ,Female ,AcademicSubjects/MED00010 ,business ,Biomarkers ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Introduction The Tobacco Heating System (THS) is a “heat-not-burn” tobacco product designed to generate significantly lower levels of harmful and potentially harmful constituents (HPHCs) and present lower risk of harm than cigarettes. This study assessed the exposure reduction to selected HPHCs in smokers switching to menthol Tobacco Heating System (mTHS) 2.2 compared with smokers continuing smoking menthol cigarettes (mCCs) and smoking abstinence (SA) for 5 days in a confined setting, followed by an 86-day ambulatory period. Methods A total of 160 healthy adult US smokers participated in this randomized, three-arm parallel group, controlled clinical study. Biomarkers of exposure to 16 HPHCs were measured in blood and 24-hour urine. Safety was monitored throughout the study. Information was also gathered on product evaluation, product use, subjective effects, and clinical risk markers (co-publication Part 2). Results Nicotine uptake was comparable in both exposure groups (mTHS:mCC ratio of 96% on day 90). On day 5, biomarker of exposure levels to other HPHCs were reduced by 51%–96% in the mTHS group compared with the mCC group, and these reductions were sustained for most biomarkers of exposure over ambulatory period. After 90 days of use, the level of satisfaction with mTHS and suppression of urge to smoke were comparable to mCC. Conclusion Switching from mCCs to mTHS significantly reduced the exposure to HPHCs to levels approaching those observed in subjects who abstained from smoking for the duration of the study. Implications This study compared the impact of switching to mTHS on biomarkers of exposure, relative to continued smoking or SA. Clinical Significance Trial Registration NCT01989156 (ClinicalTrials.gov).
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- 2019
6. Corrigendum to 'A high-volume trauma intensive care unit can be successfully staffed by advanced practitioners at night' [J Crit Care 2016 Jun;33:4–7; doi: 10.1016/j.jcrc.2016.01.024. Epub 2016 Jan 27]
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Kazuhide Matsushima, Kenji Inaba, Dimitra Skiada, Michael Esparza, Jayun Cho, Tim Lee, Aaron Strumwasser, Gregory Magee, Daniel Grabo, Lydia Lam, Elizabeth Benjamin, Howard Belzberg, and Demetrios Demetriades
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Critical Care and Intensive Care Medicine - Published
- 2022
7. Development of a Standardized Data Collection Tool for Evaluation and Management of Coronavirus Disease 2019
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Susanne Doblecki-Lewis, Anmary Fernandez, Jennifer Quevedo, Yoichiro Natori, Meshell Maxam, Jose A Gonzales-Zamora, Christine A. Vu, Maria Virginia Romero Alvarez, Shuba Balan, Stephen R Morris, Lilian M. Abbo, Pablo Barreiro, David P. Serota, Alejandro Mantero, Patricia Raccamarich, Douglas Salguero, Ana D Vega, Ruixuan Ma, Daniela Fatima. de Lima Corvino, Gregory E. Holt, Lauren Bjork, Paola Lichtenberger, Maya Ramanathan, Kailynn DeRonde, Dimitra Skiada, Gio J. Baracco, Maria L. Alcaide, and Alex Lazo
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Quality management ,Psychological intervention ,Enfermedad transmisible ,Disease ,030204 cardiovascular system & hematology ,Major Articles ,Hospital ,03 medical and health sciences ,coronavirus-19 ,0302 clinical medicine ,Health care ,Medicine ,Antimicrobial stewardship ,Medical history ,030212 general & internal medicine ,Pandemia ,Data collection ,business.industry ,medicine.disease ,Coronavirus ,AcademicSubjects/MED00290 ,Infectious Diseases ,Oncology ,Infectious disease (medical specialty) ,data collection tool ,Medical emergency ,business ,hospitalized - Abstract
Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 ) is responsible for coronavirus disease 2019 (COVID-19), a disease that had not been previously described and for which clinicians need to rapidly adapt their daily practice. The novelty of SARS-CoV-2 produced significant gaps in harmonization of definitions, data collection, and outcome reporting to identify patients who would benefit from potential interventions. Methods We describe a multicenter collaboration to develop a comprehensive data collection tool for the evaluation and management of COVID-19 in hospitalized patients. The proposed tool was developed by a multidisciplinary working group of infectious disease physicians, intensivists, and infectious diseases/antimicrobial stewardship pharmacists. The working group regularly reviewed literature to select important patient characteristics, diagnostics, and outcomes for inclusion. The data collection tool consisted of spreadsheets developed to collect data from the electronic medical record and track the clinical course after treatments. Results Data collection focused on demographics and exposure epidemiology, prior medical history and medications, signs and symptoms, diagnostic test results, interventions, clinical outcomes, and complications. During the pilot validation phase, there was, In an era of rapidly evolving knowledge, we developed a data collection tool to efficiently track clinical data pertinent to managing COVID-19 patients. We propose its use to collect harmonized data of individuals hospitalized with confirmed or suspected SARS-CoV-2 infection.
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- 2020
8. Polymyxin B-induced skin hyperpigmentation
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Dimitra Skiada, Yumeng M. Li, Clara Milikowski, Gennaro Selvaggi, Lillian M. Abbo, and Fabrizio Galimberti
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Adult ,medicine.medical_specialty ,medicine.drug_class ,Antibiotics ,030230 surgery ,Nephrotoxicity ,03 medical and health sciences ,0302 clinical medicine ,Dermis ,Hyperpigmentation ,Drug Resistance, Multiple, Bacterial ,Gram-Negative Bacteria ,medicine ,Humans ,Polymyxin B ,Transplantation ,medicine.diagnostic_test ,business.industry ,Dermatology ,Anti-Bacterial Agents ,Infectious Diseases ,medicine.anatomical_structure ,Skin hyperpigmentation ,Skin biopsy ,030211 gastroenterology & hepatology ,Female ,medicine.symptom ,business ,medicine.drug - Abstract
Polymyxin B (PMB) is a potent antibiotic targeting gram-negative bacteria and is associated with serious side effects including nephrotoxicity, neurotoxicity, and hypersensitivity reactions. PMB is a therapeutic option for the management of infections caused by multi-drug-resistant (MDR) bacteria and used in combination with other antibiotics when options are limited. We describe the case of a 30-year-old female patient with a complex medical history who underwent a multi-visceral transplantation complicated by intra-abdominal infections. Subsequently, patient developed diffuse skin darkening after initiation of intravenous PMB for treatment of MDR Pseudomonas aeruginosa. Her skin hyperpigmentation was most prominent on her face and forearms. Hyperpigmentation peaked at around 2 weeks following PMB initiation and was discontinued after 3 weeks when the possibility of PMB hyperpigmentation was raised and other causes were ruled out. Skin biopsy showed hypermelanosis of the basal layer and melanin deposition in the dermis. Overall clinical picture was consistent with PMB-induced hyperpigmentation. The patient demonstrated some improvement in discoloration within 4 weeks of PMB discontinuation.
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- 2020
9. Clinical relevance of the routine daily chest X-Ray in the surgical intensive care unit
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Dimitra Skiada, Demetrios Demetriades, Peep Talving, Obi Okoye, Shelby Resnick, Efstathios Karamanos, Kenji Inaba, and James A. Dollahite
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Adult ,Male ,medicine.medical_specialty ,Pediatrics ,Adolescent ,Critical Care ,medicine.medical_treatment ,Surgical intensive care unit ,Unnecessary Procedures ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Clinical Protocols ,medicine ,Humans ,Clinical significance ,Hospital Mortality ,Prospective Studies ,030212 general & internal medicine ,Aged ,Mechanical ventilation ,Surgical Intensive Care ,business.industry ,030208 emergency & critical care medicine ,General Medicine ,Length of Stay ,Middle Aged ,Los Angeles ,Respiration, Artificial ,Intensive Care Units ,Emergency medicine ,Female ,Radiography, Thoracic ,Surgery ,business ,Resource utilization - Abstract
A daily Chest X-ray (CXR) is obtained in many surgical intensive care units (SICU). This study implemented a selective CXR protocol in a high volume, academic SICU and evaluated its impact on clinical outcomes.All SICU patients admitted in 2/2010 were compared with patients admitted in 2/2012. Between the time periods, a protocol eliminating the routine daily CXRs was instituted.In 02/2010 and 02/2012, 107 and 90 patients were admitted to the SICU, respectively, for a total of 1384 patient days. CXRs decreased from 365 (57.1% of patient-days) in 2010 to 299 (40.9% of patient days; p 0.001) in 2012. A greater proportion of Physician Directed CXRs (PDCXRs) had new findings (80.8%) compared to Automatic Daily CXRs (ADCXRs) (23.5%, p 0.001). There was no difference in overall or SICU length of stay, ventilator-free days, morbidity or mortality.Eliminating ADCXRs decreased the number of CXRs performed, without affecting LOS, mechanical ventilation, morbidity or mortality. Physician-directed ordering of CXRs increased the diagnostic value of the CXR and decreased the number of clinically irrelevant CXRs performed.
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- 2017
10. Biomarker of exposure level data set in smokers switching from conventional cigarettes to Tobacco Heating System 2.2, continuing smoking or abstaining from smoking for 5 days
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Jacek Ancerewicz, Gizelle Baker, Guillaume de La Bourdonnaye, Patrick Picavet, Frank Lüdicke, Christelle Haziza, and Dimitra Skiada
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0301 basic medicine ,Tobacco heating system 2.2 ,lcsh:Computer applications to medicine. Medical informatics ,Toxicology ,Nicotine ,Clinical study ,03 medical and health sciences ,0302 clinical medicine ,Exposure level ,Reduced risk product ,Environmental health ,medicine ,Cigarette smoke ,Pack-year ,lcsh:Science (General) ,Data Article ,Smoke ,Multidisciplinary ,business.industry ,030104 developmental biology ,030228 respiratory system ,Tobacco exposure ,Biomarker (medicine) ,lcsh:R858-859.7 ,business ,medicine.drug ,lcsh:Q1-390 - Abstract
Levels of biomarkers of exposure to selected harmful and potentially harmful smoke constituents found in cigarette smoke, in addition to nicotine were measured in 160 smokers randomized for 5 days to continuing smoking conventional cigarettes (41 participants), switching to Tobacco Heating System 2.2 (THS 2.2) (80 participants), or abstaining from smoking (39 participants). The data reported here are descriptive statistics of the levels of each biomarker of exposure expressed as concentrations adjusted to creatinine; at baseline, and at the end of the study, and their relative change from baseline. Reductions in the levels of biomarkers of exposure when expressed as quantity excreted, are also reported. Detailed descriptions of bioanalytical assays used are also provided. The data presented here are related to the article entitled “Evaluation of the Tobacco Heating System 2.2. Part 8: 5-Day randomized reduced exposure clinical study in Poland” (Haziza et al., 2016) [1].
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- 2017
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11. 549. Clinical Characteristics and Outcomes of Patients with COVID-19 treated with Convalescent Plasma in Miami, Florida
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Shweta Anjan, Dimitra Skiada, Miriam Andrea Duque Cuartas, Douglas Salguero, David P Serota, Jose Gonzales-Zamora, Folusakin Ayoade, Laura Beauchamps, Tanya R Quiroz, Jovanna Bertran-Lopez, Patricia Raccamarich, Emily K Montgomerie, Irma Barreto, Lilian M Abbo, Susanne Doblecki-Lewis, Yanyun Wu, and Maria L Alcaide
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medicine.medical_specialty ,biology ,Septic shock ,business.industry ,Secondary infection ,C-reactive protein ,Retrospective cohort study ,medicine.disease ,AcademicSubjects/MED00290 ,Infectious Diseases ,Oncology ,Internal medicine ,Expanded access ,Poster Abstracts ,Cohort ,medicine ,biology.protein ,Multiple organ dysfunction syndrome ,business ,Adverse effect - Abstract
Background The Coronavirus disease of 2019 (COVID-19) global health crisis caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in unprecedented mortality, impacted society, and strained healthcare systems, yet sufficient data regarding treatment options are lacking. Convalescent plasma, used since 1895 for infectious disease outbreaks, offers promise as a treatment option for COVID-19. Methods This is a retrospective study of patients diagnosed by a nasopharyngeal swab SARS-CoV-2 reverse transcriptase–polymerase chain reaction (RT-PCR), who received convalescent plasma between April to June 2020 at two large hospitals in Miami, Florida, as part of the US FDA Expanded Access Program for COVID-19 convalescent plasma (CCP). Results A total of 23 patients received CCP, 13 (57%) had severe COVID-19 disease, while 8 (35%) had critical or critical with multiorgan dysfunction. Median time of follow up was 26 (range, 7–79) days. Overall, 11 (48%) survived to discharge, 6 (26%) died, while 6 (26%) are currently hospitalized. All deaths reported were due to septic shock from secondary infections. 15 (65%) showed improvement in oxygen requirements 7 days post CCP transfusion. Measured inflammatory markers, c-reactive protein, lactate dehydrogenase, ferritin and d-dimer improved 7 days post transfusion in 13 (57%) patients. No adverse events due to the transfusion were reported. 10 (43.4%) patients had a negative SARS-CoV-2 RT-PCR at a median of 14.5 (range, 4–31) days after receiving convalescent plasma. Conclusion Administration of convalescent plasma was found to be safe, with favorable outcomes in this small cohort of relatively high acuity patients. Larger studies including control arms are needed to establish the efficacy of convalescent plasma on clinical and virologic outcomes for patients with COVID-19. Table Disclosures All Authors: No reported disclosures
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- 2020
12. Evaluation of the Tobacco Heating System 2.2. Part 8: 5-Day randomized reduced exposure clinical study in Poland
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Frank Lüdicke, Guillaume de La Bourdonnaye, Christelle Haziza, Patrick Picavet, Jacek Ancerewicz, Dimitra Skiada, and Gizelle Baker
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Male ,Conventional cigarettes ,Smoking abstinence ,Hot Temperature ,Time Factors ,Smoking Prevention ,Electronic Nicotine Delivery Systems ,010501 environmental sciences ,Toxicology ,01 natural sciences ,law.invention ,Nicotine ,Clinical study ,0302 clinical medicine ,Randomized controlled trial ,law ,Smoke ,030212 general & internal medicine ,Harmful and potentially harmful constituents ,Inhalation Exposure ,Smoking ,Healthy subjects ,Equipment Design ,Tobacco Products ,General Medicine ,Middle Aged ,Female ,Tobacco product ,medicine.drug ,Adult ,medicine.medical_specialty ,NICOTINE EXPOSURE ,Tobacco Industry ,Risk Assessment ,Biomarkers of exposure ,Young Adult ,03 medical and health sciences ,Harm Reduction ,Cytochrome P-450 CYP1A2 ,Internal medicine ,Toxicity Tests ,medicine ,Humans ,Randomized study ,0105 earth and related environmental sciences ,Aerosols ,business.industry ,Tobacco heating system ,Consumer Product Safety ,Smoking Cessation ,Poland ,business ,Biomarkers - Abstract
The Tobacco Heating System (THS) 2.2, a candidate Modified Risk Tobacco Product (MRTP), is designed to heat tobacco without burning it. Tobacco is heated in order to reduce the formation of harmful and potentially harmful constituents (HPHC), and reduce the consequent exposure, compared with combustible cigarettes (CC). In this 5-day exposure, controlled, parallel-group, open-label clinical study, 160 smoking, healthy subjects were randomized to three groups and asked to: (1) switch from CCs to THS 2.2 (THS group; 80 participants); (2) continue to use their own non-menthol CC brand (CC group; 41 participants); or (3) to refrain from smoking (smoking abstinence (SA) group; 39 participants). Biomarkers of exposure, except those associated with nicotine exposure, were significantly reduced in the THS group compared with the CC group, and approached the levels observed in the SA group. Increased product consumption and total puff volume were reported in the THS group. However, exposure to nicotine was similar to CC at the end of the confinement period. Reduction in urge-to-smoke was comparable between the THS and CC groups and THS 2.2 product was well tolerated.
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- 2016
13. A high-volume trauma intensive care unit can be successfully staffed by advanced practitioners at night
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Daniel Grabo, Elizabeth Benjamin, Dimitra Skiada, Demetrios Demetriades, Kazuhide Matsushima, Tim H Lee, Gregory A. Magee, Jayun Cho, Lydia Lam, Kenji Inaba, Aaron Strumwasser, Howard Belzberg, and Michael Esparza
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Adult ,Male ,Night Care ,medicine.medical_specialty ,Critical Care ,Critical Illness ,Personnel Staffing and Scheduling ,Critical Care and Intensive Care Medicine ,law.invention ,Plasma ,03 medical and health sciences ,0302 clinical medicine ,After-Hours Care ,Blood product ,law ,Medical Staff, Hospital ,Humans ,Medicine ,Nurse Practitioners ,030212 general & internal medicine ,Trauma intensive care unit ,Intensive care medicine ,Retrospective Studies ,business.industry ,Critically ill ,Internship and Residency ,030208 emergency & critical care medicine ,Retrospective cohort study ,Middle Aged ,Intensive care unit ,Massive transfusion ,Intensive Care Units ,Physician Assistants ,Workforce ,Wounds and Injuries ,Female ,Fresh frozen plasma ,business ,Hospitals, High-Volume - Abstract
Purpose It remains unknown whether critically ill trauma patients can be successfully managed by advanced practitioners (APs). The purpose of this study was to examine the impact of night coverage by APs in a high-volume trauma intensive care unit (ICU) on patient outcomes and care processes. Materials and methods During the study period, our ICU was staffed by APs during the night shift (7 pm -7 am ) from Sunday to Wednesday and by resident physicians (RPs) from Thursday to Saturday. On-call trauma fellows and attending surgeons in house supervised both APs and RPs. Patient outcomes and care processes by APs was compared with those admitted by RPs. Results A total of 289 patients were identified between July 2013 and February 2014. Median lactate clearance rate within 24 hours of admission was similar between study groups (10.0% vs 9.1%; P = .39). Advanced practitioners and RPs transfused patients requiring massive transfusion with a similar blood product ratio (packed red blood cell:fresh frozen plasma) (2.1:1 vs 1.7:1; P = .32). In a multiple logistic regression analysis, AP coverage was not associated with any clinical outcome differences. Conclusions Our data suggest that, with adequate supervision, a high-volume trauma ICU can be safely staffed by APs overnight.
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- 2016
14. The survival impact of plasma to red blood cell ratio in massively transfused non-trauma patients
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Konstantinos Chouliaras, Pedro G.R. Teixeira, Demetrios Demetriades, Peter Rhee, Ira A. Shulman, Kenji Inaba, Dimitra Skiada, and Efstathios Karamanos
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Male ,medicine.medical_specialty ,Erythrocytes ,Sports medicine ,Resuscitation ,Blood Component Transfusion ,Hemorrhage ,030204 cardiovascular system & hematology ,Critical Care and Intensive Care Medicine ,Plasma ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Emergency surgery ,medicine ,Humans ,Orthopedic Procedures ,Orthopedics and Sports Medicine ,Intensive care medicine ,Emergency Treatment ,business.industry ,030208 emergency & critical care medicine ,Middle Aged ,Survival Analysis ,United States ,Massive transfusion ,Red blood cell ,medicine.anatomical_structure ,Emergency medicine ,Emergency Medicine ,Female ,Surgery ,Packed red blood cells ,business - Abstract
High ratios of Plasma to Packed Red Blood Cells (FFP:PRBC) improve survival in massively transfused trauma patients. We hypothesized that non-trauma patients also benefit from this transfusion strategy.Non-trauma patients requiring massive transfusion from November 2003 to September 2011 were reviewed. Logistic regression was performed to identify independent predictors of mortality. The population was stratified using two FFP:PRBC ratio cut-offs (1:2 and 1:3) and adjusted mortality derived.Over 8 years, 29 % (260/908) of massively transfused surgical patients were non-trauma patients. Mortality decreased with increasing FFP:PRBC ratios (45 % for ratio ≤1:8, 33 % for ratio1:8 and ≤1:3, 27 % for ratio1:3 and ≤1:2 and 25 % for ratio1:2). Increasing FFP:PRBC ratio independently predicted survival (AOR [95 % CI]: 1.91 [1.35-2.71]; p 0.001). Patients achieving a ratio1:3 had improved survival (AOR [95 % CI]: 3.24 [1.24-8.47]; p = 0.016).In non-trauma patients undergoing massive transfusion, increasing FFP:PRBC ratio was associated with improved survival. A ratio1:3 significantly improved survival probability.
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- 2016
15. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers
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Daniel Grabo, Matthew J. Martin, Dimitra Skiada, Demetrios Demetriades, Kenji Inaba, Peter M. Hammer, Efstathios Karamanos, Marc Eckstein, and Maura E. Sullivan
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Adult ,Male ,Emergency Medical Services ,medicine.medical_specialty ,Decompression ,Axillary lines ,Critical Care and Intensive Care Medicine ,Cadaver ,Humans ,Medicine ,In patient ,Military Medicine ,business.industry ,Pneumothorax ,Needle decompression ,Decompression, Surgical ,medicine.disease ,Tension pneumothorax ,Surgery ,Needles ,Female ,Clinical Competence ,business ,Cadaveric spasm - Abstract
BACKGROUND Computed tomographic and cadaveric studies have demonstrated needle decompression of tension pneumothorax at the fifth intercostal space (ICS), anterior axillary line (AAL) has advantages over the second ICS midclavicular line (MCL). The purpose of this study was to compare the ability of prehospital care providers to accurately decompress the chest at these two locations. METHODS Randomly selected US Navy hospital corpsmen (n = 25) underwent a standardized training session followed by timed needle decompression on unmarked fresh cadavers. A 14-gauge angiocatheter was inserted in the right and left second ICS MCL and fifth ICS AAL in a predetermined computer-generated order. Time from needle uncapping to insertion, accuracy, and ease of placement were examined. RESULTS A total of 25 corpsmen inserted 100 needles into 25 cadavers. Mean (SD) age was 25.9 (3.7) years, 72.0% were male, with 4.2 (3.2) years of experience, and 52.0% had previously deployed. A total of 60.0% had attempted decompression previously, 93.3% in a model and 6.7% in a patient. Time to decompression did not differ between the second and fifth ICS (16.8 [10.1] seconds vs. 16.9 [12.3] seconds, p = 0.438). Accuracy however was superior at the fifth ICS, with a misplacement rate of only 22.0% versus 82.0% at the second ICS (p < 0.001). The aggregate distance from the target position was also significantly greater for the second ICS (3.1 [1.7] cm vs. 1.2 [1.5] cm, p < 0.001). Insertion at the fifth ICS was rated as being easier than the second by 76.0% of providers, the same by 12.0%, and more difficult by 12.0%. CONCLUSION For prehospital care providers, the fifth ICS AAL can be localized and decompressed with a higher degree of accuracy than the traditional second ICS MCL. It is rated as easier to perform and can be done just as quickly. Based on these data, the fifth ICS AAL should be considered as an equivalent first-line position for needle decompression in patients with clinical evidence of a tension pneumothorax.
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- 2015
16. Emergent operation for isolated severe traumatic brain injury
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Gene Sung, Stefano Siboni, Gregory A. Magee, Dimitra Skiada, Lydia Lam, Kazuhide Matsushima, Kenji Inaba, Demetrios Demetriades, Elizabeth R. Benjaminm, and Aaron Strumwasser
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Adult ,Male ,Traumatic brain injury ,medicine.medical_treatment ,Critical Care and Intensive Care Medicine ,Risk Assessment ,Neurosurgical Procedures ,Statistics, Nonparametric ,Time-to-Treatment ,Cohort Studies ,Young Adult ,Injury Severity Score ,Predictive Value of Tests ,Intervention (counseling) ,Humans ,Medicine ,Glasgow Coma Scale ,Hospital Mortality ,Registries ,Young adult ,Emergency Treatment ,Craniotomy ,Aged ,Retrospective Studies ,business.industry ,Retrospective cohort study ,Emergency department ,Middle Aged ,Prognosis ,medicine.disease ,Radiography ,Survival Rate ,Logistic Models ,Treatment Outcome ,nervous system ,Brain Injuries ,Anesthesia ,Multivariate Analysis ,Female ,Surgery ,Emergency Service, Hospital ,business - Abstract
It remains unclear whether the timing of neurosurgical intervention impacts the outcome of patients with isolated severe traumatic brain injury (TBI). We hypothesized that a shorter time between emergency department (ED) admission to neurosurgical intervention would be associated with a significantly higher rate of patient survival.Our institutional trauma registry was queried for patients (2003-2013) who required an emergent neurosurgical intervention (craniotomy, craniectomy) for TBI within 300 minutes after the ED admission. We included patients with altered mental status upon presentation in the ED (Glasgow Coma Scale [GCS] score9). Patients with associated severe injuries (Abbreviated Injury Scale [AIS] score ≥ 2) in other body regions were excluded. In-hospital mortality of patients who underwent surgery in less than 200 minutes (early group) was compared with those who underwent surgery in 200 minutes or longer (late group) using univariate and multivariate analyses.A total of 161 patients were identified during the study time frame. Head computed tomographic scan demonstrated subdural hematoma in 85.8%, subarachnoid hemorrhage in 55.5%, and equal numbers of epidural hematoma and intraparenchymal hemorrhage in 22.6%. Median time between ED admission and neurosurgical intervention was 133 minutes. In univariate analysis, a significantly lower in-hospital mortality rate was identified in the early group (34.5% vs. 59.1%, p = 0.03). After adjusting for clinically important covariates in a logistic regression model, early neurosurgical intervention was significantly associated with a higher odds of patient survival (odds ratio, 7.41; 95% confidence interval, 1.66-32.98; p = 0.009).Our data suggest that the survival rate of isolated severe TBI patients who required an emergent neurosurgical intervention could be time dependent. These patients might benefit from expedited process (computed tomographic scan, neurosurgical consultation, etc.) to shorten the time to surgical intervention.Prognostic study, level IV.
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- 2015
17. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma
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Kenji, Inaba, Lauren, Nosanov, Jay, Menaker, Patrick, Bosarge, Lashonda, Williams, David, Turay, Riad, Cachecho, Marc, de Moya, Marko, Bukur, Jordan, Carl, Leslie, Kobayashi, Stephen, Kaminski, Alec, Beekley, Mario, Gomez, Dimitra, Skiada, and Fausto Y, Vinces
- Subjects
Adult ,Diagnostic Imaging ,Male ,musculoskeletal diseases ,medicine.medical_specialty ,Adolescent ,MEDLINE ,Physical examination ,Wounds, Nonpenetrating ,Critical Care and Intensive Care Medicine ,Sensitivity and Specificity ,Thoracic Vertebrae ,Decision Support Techniques ,Trauma Centers ,Risk Factors ,medicine ,Humans ,Prospective Studies ,Derivation ,Prospective cohort study ,Physical Examination ,Aged ,Aged, 80 and over ,Lumbar Vertebrae ,medicine.diagnostic_test ,business.industry ,fungi ,Thoracolumbar spine ,Middle Aged ,musculoskeletal system ,United States ,Surgery ,Spinal Injuries ,Blunt trauma ,Female ,Observational study ,business ,Nexus (standard) - Abstract
Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury.Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested.Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery.Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries.Diagnostic test, level III.
- Published
- 2015
18. Large animal evaluation of riboflavin and ultraviolet light-treated whole blood transfusion in a diffuse, nonsurgical bleeding porcine model
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Efstathios Karamanos, Shelby Resnick, Heather L. Reddy, Dimitra Skiada, Obi Okoye, Kenji Inaba, Monica D. Wong, Raymond P. Goodrich, and Suzann K. Doane
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Prothrombin time ,medicine.medical_specialty ,Resuscitation ,medicine.diagnostic_test ,business.industry ,Immunology ,Blood volume ,Hematology ,Gastroenterology ,Thromboelastography ,Surgery ,Red blood cell ,medicine.anatomical_structure ,Internal medicine ,Ultraviolet light ,medicine ,Immunology and Allergy ,business ,Whole blood ,Partial thromboplastin time - Abstract
Background The Mirasol system has been demonstrated to effectively inactivate white blood cells (WBCs) and reduce pathogens in whole blood in vitro. The purpose of this study was to compare the safety and efficacy of Mirasol-treated fresh whole blood (FWB) to untreated FWB in an in vivo model of surgical bleeding. Study Design and Methods A total of 18 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 33°C, and a standardized liver injury. Animals were then randomly assigned to resuscitation with either Mirasol-treated or untreated FWB, and intraoperative blood loss was measured. After abdominal closure, the animals were observed for 14 days, after which the animals were euthanized and tissues were obtained for histopathologic examination. Mortality, tissue near-infrared spectroscopy, red blood cell (RBC) variables, platelets (PLTs), WBCs, and coagulation indices were analyzed. Results Total intraoperative blood loss was similar in test and control arms (8.3 ± 3.2 mL/kg vs. 7.7 ± 3.9 mL/kg, p = 0.720). All animals survived to Day 14. Trended values over time did not show significant differences—tissue oxygenation (p = 0.605), hemoglobin (p = 0.461), PLTs (p = 0.807), WBCs (p = 0.435), prothrombin time (p = 0.655), activated partial thromboplastin time (p = 0.416), thromboelastography (TEG)–reaction time (p = 0.265), or TEG–clot formation time (p = 0.081). Histopathology did not show significant differences between arms. Conclusions Mirasol-treated FWB did not impact survival, blood loss, tissue oxygen delivery, RBC indices, or coagulation variables in a standardized liver injury model. These data suggest that Mirasol-treated FWB is both safe and efficacious in vivo.
- Published
- 2015
19. The Effect of Statin Use on Outcomes after Trauma
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Kenji Inaba, Peep Talving, Lydia Lam, Andrew Cunningham, Obi Okoye, Hande Aksoy, Rondi B. Gelbard, Demetrios Demetriades, and Dimitra Skiada
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Adult ,Male ,medicine.medical_specialty ,Treatment outcome ,MEDLINE ,California ,Internal medicine ,medicine ,Humans ,Aged ,Retrospective Studies ,business.industry ,Incidence ,Incidence (epidemiology) ,Retrospective cohort study ,General Medicine ,Middle Aged ,Statin treatment ,Intensive Care Units ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,Treatment Outcome ,Cardiovascular Diseases ,Wounds and Injuries ,Female ,business - Published
- 2015
20. Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study
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Jason L. Sperry, Todd W. Costantini, Brenton Robinson, Tianhua Zhou, Robert C. Mackersie, Richard D. Catalano, Jeanette M. Podbielski, Dimitra Skiada, Lashonda Williams, Joseph P. Minei, Brian Williams, Raul Coimbra, Scott Keeney, Deborah M. Stein, Kenji Inaba, John B. Holcomb, Joseph Conflitti, Christy Hoey, Thomas M. Scalea, Alicia Privette, Allie Blackburn, and Forrest O. Moore
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Severe bleeding ,Adult ,Male ,medicine.medical_specialty ,Hemorrhage ,030230 surgery ,Critical Care and Intensive Care Medicine ,Wounds, Nonpenetrating ,03 medical and health sciences ,Fractures, Bone ,0302 clinical medicine ,Trauma Centers ,Intervention (counseling) ,medicine ,Humans ,Blood Transfusion ,Prospective Studies ,Prospective cohort study ,Pelvic Bones ,business.industry ,Hemostatic Techniques ,Age Factors ,030208 emergency & critical care medicine ,Middle Aged ,medicine.disease ,Hemostatic technique ,Surgery ,body regions ,Multicenter study ,Pelvic fracture ,Hemorrhage control ,Observational study ,Female ,business - Abstract
Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention.This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure90 mm Hg or heart rate120 beats/min and base deficit5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses.A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis.Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention.Prognostic/epidemiologic study, level III.
- Published
- 2017
21. Optimal training for emergency needle thoracostomy placement by prehospital personnel
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Maura E. Sullivan, Daniel Grabo, Kenji Inaba, Matthew J. Martin, Demetrios Demetriades, Peter M. Hammer, Efstathios Karamanos, and Dimitra Skiada
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Adult ,Male ,Emergency Medical Services ,medicine.medical_specialty ,Thoracostomy ,Critical Care and Intensive Care Medicine ,Needle Thoracostomy ,Simulation training ,law.invention ,Young Adult ,Randomized controlled trial ,Cadaver ,law ,medicine ,Humans ,Second intercostal space ,Military Medicine ,business.industry ,Teaching ,Pneumothorax ,Tension pneumothorax ,Emergency Medical Technicians ,Emergency medicine ,Physical therapy ,Needle placement ,Female ,Surgery ,Clinical Competence ,Training program ,business - Abstract
Background Tension pneumothorax can rapidly progress to cardiac arrest and death if not promptly recognized and appropriately treated. We sought to evaluate the effectiveness of traditional didactic slide-based lectures (SBLs) as compared with fresh tissue cadaver-based training (CBT) for placement of needle thoracostomy (NT). Methods Forty randomly selected US Navy corpsmen were recruited to participate from incoming classes of the Navy Trauma Training Center at the LAC + USC Medical Center and were then randomized to one of two NT teaching methods. The following outcomes were compared between the two study arms: (1) time required to perform the procedure, (2) correct placement of the needle, and (3) magnitude of deviation from the correct position. Results During the study period, a total of 40 corpsmen were enrolled, 20 randomized to SBL and 20 to CBT arms. When outcomes were analyzed, time required to NT placement was not different between the two arms. Examination of the location of needle placement revealed marked differences between the two study groups. Only a minority of the SBL group (35%) placed the NT correctly in the second intercostal space. In comparison, the majority of corpsmen assigned to the CBT group demonstrated accurate placement in the second intercostal space (75%). Conclusion In a CBT module, US Navy corpsmen were better trained to place NT accurately than their traditional didactic SBL counterparts. Further studies are indicated to identify the optimal components of effective simulation training for NT and other emergent interventions.
- Published
- 2014
22. Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis
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Dimitra Skiada, Melanie Osby, Kenji Inaba, Lydia Lam, Peep Talving, Ozgur Albuz, Efstathios Karamanos, and Demetrios Demetriades
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Adult ,Male ,Emergency Medical Services ,medicine.medical_treatment ,Emergency Nursing ,Hospitals, Urban ,Trauma Centers ,Intubation, Intratracheal ,medicine ,Craniocerebral Trauma ,Humans ,Intubation ,Glasgow Coma Scale ,Hospital Mortality ,Propensity Score ,Retrospective Studies ,Abbreviated Injury Scale ,business.industry ,Head injury ,Trauma center ,Retrospective cohort study ,Length of Stay ,Middle Aged ,medicine.disease ,Treatment Outcome ,Case-Control Studies ,Anesthesia ,Emergency Medicine ,Injury Severity Score ,Female ,Airway management ,Blood Gas Analysis ,business - Abstract
IntroductionPrehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant.HypothesisOutcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.MethodsThis was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS).ResultsCases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS.ConclusionIn isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.KaramanosE, TalvingP, SkiadaD, OsbyM, InabaK, LamL, AlbuzO, DemetriadesD. Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis. Prehosp Disaster Med. 2013;28(6):1-5.
- Published
- 2013
23. Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study
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Pedro G.R. Teixeira, Efstathios Karamanos, Howard Belzberg, Dimitra Skiada, Peep Talving, Kenji Inaba, Demetrios Demetriades, and Lydia Lam
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medicine.medical_specialty ,Abbreviated Injury Scale ,Traumatic brain injury ,business.industry ,musculoskeletal, neural, and ocular physiology ,Glasgow Coma Scale ,Guideline ,medicine.disease ,Brain herniation ,nervous system diseases ,Anesthesia ,Emergency medicine ,medicine ,Intracranial pressure monitoring ,Prospective cohort study ,business ,Intracranial pressure - Abstract
Object The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes. Methods This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes. Results A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring. Conclusions Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.
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- 2013
24. Emergency surgery for acute diverticulitis
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Demetrios Demetriades, Anthony J. Senagore, Kenji Inaba, Efstathios Karamanos, Dimitra Skiada, Peep Talving, and Mathew D. Tadlock
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Male ,Laparoscopic surgery ,medicine.medical_specialty ,Databases, Factual ,Colon ,medicine.medical_treatment ,Anastomosis ,Critical Care and Intensive Care Medicine ,Diverticulitis, Colonic ,Cohort Studies ,Postoperative Complications ,Colon surgery ,Colostomy ,medicine ,Humans ,Colectomy ,business.industry ,Anastomosis, Surgical ,Acute kidney injury ,Odds ratio ,Middle Aged ,Diverticulitis ,medicine.disease ,Quality Improvement ,Surgery ,Outcome and Process Assessment, Health Care ,Acute Disease ,Multivariate Analysis ,Female ,Emergencies ,business ,Cohort study - Abstract
Background The optimal surgical management of acute diverticulitis is still a controversial and unresolved issue. While the Hartmann's procedure (`) is the most commonly performed operation, primary anastomosis (PA), with or without proximal diversion, has also been used with increasing frequency. Methods This is a National Surgical Quality Improvement Program database study including all patients requiring emergency surgery for acute diverticulitis. Three operative approaches were analyzed: HP, colectomy with PA, and colectomy with PA with proximal diversion (PAPD). Mortality and postoperative outcomes were compared between the three groups using a logistical regression model. Results There were 1,314 patients who required emergent operation for acute diverticulitis, 75.4% underwent HP, 21.7% underwent PA, and 2.9% underwent PAPD. Thirty-day mortality was 7.3%, 4.6%, and 1.6% for HP, PA, and PAPD respectively (p = 0.163), while surgical site infections occurred in 19.7%, 17.9%, and 13.2%, respectively (p = 0.59). After multivariable analysis adjusting for age, alcohol consumption, comorbidities, steroid use, preoperative laboratory values, hemorrhage at admission and laparoscopic surgery, the adjusted odds ratio for 30-day mortality comparing PA with HP was 0.77 (95% confidence interval [CI], 0.38-1.56; p = 0.465), 0.47 (95% CI, 0.06-3.74; p = 0.479) comparing PAPD with HP, and 1.62 (95% CI, 0.19-13.78; p = 0.658) comparing PA with PAPD. In addition, the three groups did not have significantly different adjusted odds ratio for the development of surgical infectious complications, acute kidney injury, cardiovascular incidents, or venous thromboembolism after surgery. Conclusion Resection and PA in patients undergoing an emergency operation for acute diverticulitis is a safe alternative to the HP, with no significant difference in mortality or postoperative surgical site infections. Level of evidence Therapeutic study, level IV.
- Published
- 2013
25. Relationship of creatine kinase elevation and acute kidney injury in pediatric trauma patients
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Demetrios Demetriades, Peep Talving, Kenji Inaba, Jeffrey L. Johnson, Pedro G.R. Teixeira, Lydia Lam, Efstathios Karamanos, and Dimitra Skiada
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Male ,medicine.medical_specialty ,Adolescent ,Critical Care and Intensive Care Medicine ,Risk Assessment ,California ,Rhabdomyolysis ,Internal medicine ,Humans ,Medicine ,Child ,Intensive care medicine ,Creatine Kinase ,Retrospective Studies ,Trauma Severity Indices ,Abbreviated Injury Scale ,biology ,business.industry ,Incidence ,Trauma center ,Acute kidney injury ,Glasgow Coma Scale ,Infant ,Odds ratio ,Acute Kidney Injury ,Prognosis ,medicine.disease ,Child, Preschool ,biology.protein ,Wounds and Injuries ,Injury Severity Score ,Female ,Surgery ,Creatine kinase ,business ,Biomarkers ,Pediatric trauma - Abstract
BACKGROUND Rhabdomyolysis following trauma has been associated with renal impairment. Nevertheless, the literature is scant in risk assessment of acute kidney injury (AKI) and survival in children experiencing posttraumatic rhabdomyolysis. METHODS After institutional review board approval was obtained, the registry of an urban trauma center was reviewed for pediatric (age < 18 years) trauma admissions with available creatine kinase (CK) values. Variables extracted included demographics and trauma severity indices along with serum creatine, CK, and Blood Urea Nitrogen (BUN) values. AKI was defined per pediatric RIFLE (Risk, Injury, Failure, Loss, End stage) definition. Regression models were deployed to determine the independent risk factors for AKI and CK levels. RESULTS Overall, 521 patients constituted the study sample. AKI occurred in 70 patients (13.4%), with correlation to CK values in excess of 3,000 IU/L (41.4% vs. 4.9%, adjusted p < 0.001). Independent risk factors for AKI proved to be CK level of 3,000 or greater (adjusted odds ratio [AOR], 11.02; 95% confidence interval [CI], 4.56-26.64; p < 0.001), Injury Severity Score (ISS) of 15 or less (AOR, 0.25; 95% CI, 0.10-0.61), Glasgow Coma Scale (GCS) score of 8 or less (AOR, 15.00; 95% CI, 4.98-44.94), abdominal Abbreviated Injury Scale (AIS) score of 3 or less (AOR, 3.14; 95% CI, 1.04-5.36), imaging studies with contrast of 3 or less (AOR, 3.81; 95% CI, 1.37-10.57), blunt mechanism of injury (AOR, 2.76; 95% CI, 1.17-6.49), administration of nephrotoxic agents (AOR, 4.81; 95% CI, 1.23-18.79), and requirement for fluids administration in the emergency department (AOR, 2.36; 95% CI, 1.04-5.36). Mortality in the study sample with CK values of 3,000 or greater versus less than 3,000 IU/L did not reach statistical significance (25.0% vs. 9.3%, adjusted p = 0.787). CONCLUSION AKI in pediatric posttraumatic rhabdomyolysis occurs in 13% of trauma patients. CK values of 3,000 IU/L or greater pose a significant adjusted risk for AKI. Aggressive monitoring of CK values in pediatric trauma patients is warranted. LEVEL OF EVIDENCE Prognostic study, level III.
- Published
- 2013
26. Development and Implementation of a Zika Virus Disease Response Protocol at a Large Academic Medical Center
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Lilian M. Abbo, Dimitra Skiada, Kathleen Sposato, Kailynn DeRonde, Don S. Steigman, Renata Boatwright, David Zambrana, Meshell Maxam, Peter G. Paige, Abdul M. Memon, Christine A. Vu, Ennie Cano-Casillas, Venessa Goodnow, Veronica Salazar, and Ana D Vega
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medicine.medical_specialty ,Special populations ,Disease Response ,Coronavirus disease 2019 (COVID-19) ,030231 tropical medicine ,Disaster Planning ,Disease Outbreaks ,03 medical and health sciences ,0302 clinical medicine ,Health care ,Infection control ,Medicine ,Humans ,030212 general & internal medicine ,Program Development ,Routine care ,Protocol (science) ,Academic Medical Centers ,business.industry ,Zika Virus Infection ,Public Health, Environmental and Occupational Health ,Treatment options ,Zika Virus ,medicine.disease ,Family medicine ,Florida ,Medical emergency ,business - Abstract
In response to the rapid spread of novel coronavirus disease 2019 (COVID-19), health-care systems should establish procedures for early recognition and management of suspected or confirmed cases. We describe the various steps taken for the development, implementation, and dissemination of the interdisciplinary COVID-19 protocol at Jackson Health System (JHS), a complex tertiary academic health system in Miami, Florida. Recognizing the dynamic nature of COVID-19, the protocol addresses the potential investigational treatment options and considerations for special populations. The protocol also includes infection prevention and control measures and routine care for suspected or proven COVID-19 patients.
- Published
- 2016
27. The Role of Radio Frequency Detection System Embedded Surgical Sponges in Preventing Retained Surgical Sponges: A Prospective Evaluation in Patients Undergoing Emergency Surgery
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Elizabeth Benjamin, Kenji Inaba, Dimitra Skiada, Stephen F. Sener, Lydia Lam, Obi Okoye, Glenn T. Ault, Demetrios Demetriades, and Hande Aksoy
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Adult ,Male ,Surgical Sponges ,medicine.medical_specialty ,Adolescent ,Radio Waves ,030230 surgery ,Prospective evaluation ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Postoperative Complications ,Emergency surgery ,medicine ,Humans ,In patient ,Prospective Studies ,Prospective cohort study ,Child ,Aged ,Aged, 80 and over ,Laparotomy ,business.industry ,Infant ,Middle Aged ,Foreign Bodies ,Sternotomy ,Surgery ,Thoracotomy ,030220 oncology & carcinogenesis ,Child, Preschool ,Female ,business - Abstract
To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges to mitigate the incidence of retained surgical sponges (RSS) after emergency surgery.Emergency surgery patients are at high risk for retained foreign bodies.All emergent trauma and nontrauma cavitary operations over a 5-year period (January 2010-December 2014) were prospectively enrolled. For damage-control procedures, only the definitive closure was included. RFD sponges were used exclusively throughout the study period. Before closure, the sponge and instrument count was followed by RFD scanning and x-ray evaluation for retained sponges. RSS and near-misses averted using the RFD system were analyzed.In all, 2051 patients [median (range)], aged 41 (1-101) years, 72.2% male, 46.8% trauma patients, underwent 2148 operations (1824 laparotomy, 100 thoracotomy, 30 sternotomy, and 97 combined). RFD detected retained sponges in 11 (0.5%) patients (81.8%laparotomy, 18.2% sternotomy) before cavitary closure. All postclosure x-rays were negative. No retained sponges were missed by the RFD system. Body mass index was 29 (23-43), estimated blood loss 1.0 L (0-23), and operating room time 160 minutes (71-869). Procedures started after 18:00 to 06:00 hours in 45.5% of the patients. The sponge count was incorrect in 36.4%, not performed due to time constraints in 45.5%, and correct in 18.2%. The additional cost of using RFD-embedded disposables was $0.17 for a 4X18 laparotomy sponge and $0.46 for a 10 pack of 12ply, 4X8.Emergent surgical procedures are high-risk for retained sponges, even when sponge counts are performed and found to be correct. Implementation of a RFD system was effective in preventing this complication and should be considered for emergent operations in an effort to improve patient safety.
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- 2016
28. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA)
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Andrew W. Kirkpatrick, Dimitra Skiada, Nathaniel Poulin, David Skarupa, Joseph J. DuBose, David Turay, John B. Holcomb, Megan Brenner, James Xiao, Thomas M. Scalea, Kenji Inaba, Cassra N. Arbabi, Jeremy Cannon, and Laura Moore
- Subjects
Adult ,Male ,Resuscitation ,medicine.medical_specialty ,Hemodynamics ,Aorta, Thoracic ,Hemorrhage ,Critical Care and Intensive Care Medicine ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Occlusion ,Medicine ,Humans ,030212 general & internal medicine ,Aorta, Abdominal ,Prospective Studies ,Registries ,Prospective cohort study ,Aorta ,Resuscitative thoracotomy ,business.industry ,Endovascular Procedures ,Aortic occlusion ,030208 emergency & critical care medicine ,Balloon Occlusion ,United States ,Surgery ,Traumatic Shock ,cardiovascular system ,Wounds and Injuries ,Female ,business - Abstract
Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative.The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO.From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently90 mm Hg,5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120].Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes.Therapeutic/care management study, level IV.
- Published
- 2016
29. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial
- Author
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Tianhua Zhou, Alicia Privette, Robert C. Mackersie, Thomas M. Scalea, Dimitra Skiada, Jason L. Sperry, Todd W. Costantini, Deborah M. Stein, Scott Keeney, Joseph P. Minei, Ghada Suleiman, Richard D. Catalano, Allie Blackburn, Joseph Conflitti, Jeanette M. Podbielski, Brian Williams, Forrest O. Moore, Lashonda Williams, Raul Coimbra, Kenji Inaba, John B. Holcomb, and Brenton Robinson
- Subjects
Adult ,Male ,medicine.medical_specialty ,Adolescent ,medicine.medical_treatment ,Hemorrhage ,030230 surgery ,Critical Care and Intensive Care Medicine ,law.invention ,03 medical and health sciences ,Fractures, Bone ,Young Adult ,0302 clinical medicine ,Injury Severity Score ,Randomized controlled trial ,Trauma Centers ,law ,Fracture Fixation ,Fracture fixation ,Medicine ,Humans ,Embolization ,Hospital Mortality ,Prospective Studies ,Prospective cohort study ,Pelvic Bones ,Survival rate ,business.industry ,030208 emergency & critical care medicine ,Middle Aged ,medicine.disease ,Embolization, Therapeutic ,United States ,Surgery ,Survival Rate ,Treatment Outcome ,Pelvic fracture ,Observational study ,Female ,business ,Follow-Up Studies - Abstract
There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being used in clinical practice.This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (systolic blood pressure90 mm Hg or heart rate120 beats per minute or base deficit-5), method of hemorrhage control, transfusion requirements, and outcome were collected.A total of 1,339 patients with pelvic fracture were enrolled from 11 Level I trauma centers. Fifty-seven percent of the patients were male, with a mean ± SD age of 47.1 ± 21.6 years, and Injury Severity Score (ISS) of 19.2 ± 12.7. In-hospital mortality was 9.0 %. Angioembolization and external fixator placement were the most common method of hemorrhage control used. A total of 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ± SD ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. Thirty patients (16.9%) were treated with therapeutic angioembolization. Resuscitative endovascular balloon occlusion of the aorta was performed on five patients in shock and used by only one of the participating centers. Mortality was 32.0% for patients with pelvic fracture admitted in shock.Patients with pelvic fracture admitted in shock have high mortality. Several methods were used for hemorrhage control with significant variation across institutions. The use of resuscitative endovascular balloon occlusion of the aorta may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers.Prognostic study, level II; therapeutic study, level III.
- Published
- 2016
30. Changes in Clinical Risk Endpoints Linked to Cardiovascular and Other Smoking-Related Diseases after Switching from Cigarettes to the THS for Six Months
- Author
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Jacek Ancerewicz, Frank Luedicke, Nicola Lama, Patrick Picavet, Marija Bosilkovska, Gizelle Baker, Christelle Haziza, Dimitra Skiada, S.M. Ansari, and Nicolas Blanc
- Subjects
medicine.medical_specialty ,business.industry ,Internal medicine ,Internal Medicine ,medicine ,General Medicine ,Cardiology and Cardiovascular Medicine ,business ,Clinical risk factor - Published
- 2018
31. Management of patients with evisceration after abdominal stab wounds
- Author
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Demetrios Demetriades, Kenji Inaba, Obi Okoye, Kristina J. Nicholson, Dimitra Skiada, Lydia Lam, Elizabeth Benjamin, and Daniel Grabo
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Adult ,Male ,medicine.medical_specialty ,Adolescent ,medicine.medical_treatment ,Vital signs ,Abdominal Injuries ,Wounds, Stab ,Young Adult ,Trauma Centers ,Laparotomy ,medicine ,Operative report ,Humans ,Stab wound ,Evisceration (ophthalmology) ,Aged ,Retrospective Studies ,business.industry ,Trauma center ,Glasgow Coma Scale ,Retrospective cohort study ,General Medicine ,Middle Aged ,medicine.disease ,Surgery ,Female ,business ,Tomography, X-Ray Computed - Abstract
In the era of nonoperative management of abdominal stab wounds, the optimal management of patients with evisceration remains unclear. Furthermore, the role of imaging in guiding management of these patients has not been defined. Patients admitted to a Level I trauma center (2005 to 2012) with evisceration after an abdominal stab wound were retrospectively identified. Demographics, admission vital signs, topography and contents of evisceration, Glasgow Coma Score, indications for exploration, and imaging and operative reports were abstracted. Clinical outcomes measured were: injuries identified on exploration, hospital length of stay, and mortality. Descriptive analysis was performed. Ninety-three patients with evisceration were identified. Ninety-two (98.9%) were male and 60 (64.5%) were Hispanic. Mean age was 31.9 ± 13 years. Forty-seven (50.5%) had evisceration of the omentum, 41 (44.1%) had evisceration of abdominal organs, and two (2.2%) had both. Seventy-four (80.4%) had positive laparotomies. Ten (10.8%) underwent computed tomography (CT) preoperatively. Sixty per cent of CT findings were congruent with operative findings. CT did not impact clinical management. In conclusion, the rate of intra-abdominal injury in patients with evisceration remains high. Even in the age of nonoperative management, evisceration continues to be an indication for immediate laparotomy. The diagnostic yield of CT is low and CT should not impact management of these patients.
- Published
- 2014
32. Blunt abdominal aortic injury: a Western Trauma Association multicenter study
- Author
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Mark J. Seamon, Cayce B. Nawaf, Dimitra Skiada, Evert A. Eriksson, Lisa Capano-Wehrle, S. Rob Todd, David J. Ciesla, Krista L. Kaups, Walter L. Biffl, Megan Brenner, Ben L. Zarzaur, Benjamin W. Starnes, Jasmeet S. Paul, Kenji Inaba, Rosemary A. Kozar, Sherene Shalhub, Ali Azizzadeh, Samir M. Fakhry, and Gregory J. Jurkovich
- Subjects
Adult ,Male ,medicine.medical_specialty ,Adolescent ,Poison control ,Critical Care and Intensive Care Medicine ,Wounds, Nonpenetrating ,Pseudoaneurysm ,Young Adult ,Injury Severity Score ,medicine ,Humans ,Aorta, Abdominal ,Aortic rupture ,Child ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Multiple Trauma ,Length of Stay ,Middle Aged ,medicine.disease ,Hemothorax ,Surgery ,Radiography ,Pneumothorax ,Blunt trauma ,Female ,business ,Abdominal surgery - Abstract
BACKGROUND: Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level. METHODS: The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications. RESULTS: Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6-88; median Injury Severity Score [ISS], 34; range, 16-75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges. CONCLUSION: This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted. LEVEL OF EVIDENCE: Multicenter retrospective review, level IV. Language: en
- Published
- 2014
33. Large animal evaluation of riboflavin and ultraviolet light-treated whole blood transfusion in a diffuse, nonsurgical bleeding porcine model
- Author
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Obi T, Okoye, Heather, Reddy, Monica D, Wong, Suzann, Doane, Shelby, Resnick, Efstathios, Karamanos, Dimitra, Skiada, Raymond, Goodrich, and Kenji, Inaba
- Subjects
Erythrocyte Indices ,Male ,Hemodilution ,Laparotomy ,Blood Cells ,Swine ,Ultraviolet Rays ,Blood Safety ,Resuscitation ,Riboflavin ,Sus scrofa ,Hemorrhage ,Lacerations ,Thrombelastography ,Random Allocation ,Blood ,Liver ,Blood Preservation ,Hypothermia, Induced ,Animals ,Blood Transfusion ,Female ,Blood Coagulation Tests - Abstract
The Mirasol system has been demonstrated to effectively inactivate white blood cells (WBCs) and reduce pathogens in whole blood in vitro. The purpose of this study was to compare the safety and efficacy of Mirasol-treated fresh whole blood (FWB) to untreated FWB in an in vivo model of surgical bleeding.A total of 18 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 33°C, and a standardized liver injury. Animals were then randomly assigned to resuscitation with either Mirasol-treated or untreated FWB, and intraoperative blood loss was measured. After abdominal closure, the animals were observed for 14 days, after which the animals were euthanized and tissues were obtained for histopathologic examination. Mortality, tissue near-infrared spectroscopy, red blood cell (RBC) variables, platelets (PLTs), WBCs, and coagulation indices were analyzed.Total intraoperative blood loss was similar in test and control arms (8.3 ± 3.2 mL/kg vs. 7.7 ± 3.9 mL/kg, p = 0.720). All animals survived to Day 14. Trended values over time did not show significant differences-tissue oxygenation (p = 0.605), hemoglobin (p = 0.461), PLTs (p = 0.807), WBCs (p = 0.435), prothrombin time (p = 0.655), activated partial thromboplastin time (p = 0.416), thromboelastography (TEG)-reaction time (p = 0.265), or TEG-clot formation time (p = 0.081). Histopathology did not show significant differences between arms.Mirasol-treated FWB did not impact survival, blood loss, tissue oxygen delivery, RBC indices, or coagulation variables in a standardized liver injury model. These data suggest that Mirasol-treated FWB is both safe and efficacious in vivo.
- Published
- 2014
34. Effects of diabetes mellitus in patients presenting with diverticulitis: clinical correlations and disease characteristics in more than 1,000 patients
- Author
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Dimitra Skiada, Anthony J. Senagore, Elizabeth Beale, Kenji Inaba, Kyle G. Cologne, and Demetrios Demetriades
- Subjects
Blood Glucose ,Male ,medicine.medical_specialty ,Comorbidity ,Critical Care and Intensive Care Medicine ,Severity of Illness Index ,Diverticulitis, Colonic ,Diabetes Complications ,Sex Factors ,Internal medicine ,Diabetes mellitus ,Severity of illness ,Medicine ,Humans ,Aged ,Retrospective Studies ,business.industry ,Incidence (epidemiology) ,Mortality rate ,Acute kidney injury ,Age Factors ,Retrospective cohort study ,Diverticulitis ,Middle Aged ,medicine.disease ,Surgery ,Hospitalization ,Female ,business - Abstract
BACKGROUND: The epidemic increase in the incidence of diabetes mellitus (DM) worldwide represents a potential source of surgical morbidity. The impact of DM on the need for surgical management and its effect on surgical outcomes for colonic diverticulitis have not been well defined. METHODS: We investigated all DM versus non-DM patients admitted with a diagnosis of acute diverticulitis between January 1, 2003, and December 31, 2011, to a large urban safety net hospital. An administrative database search for patients with diverticulitis was divided into two groups: those with and without DM. They were retrospectively analyzed for severity of diverticulitis (Hinchey and Ambrosetti scores), mortality, length of hospital stay, need for operation, postoperative complications, and readmission rates. RESULTS: There were 1,019 admissions with acute diverticulitis, 164 (16.1%) of which had DM. DM versus non-DM patients presented with a higher Hinchey score of 3 or 4 (12.2% vs. 9.2%, p < 0.001), a more severe computed tomographic Ambrosetti score (43.9% vs. 31.7%, p < 0.001), older age, and significantly more comorbid conditions. There was no significant difference in the failure of nonoperative management (2.2% DM vs. 2.5% non-DM, p = 1.000), readmission, or death rates. Operated DM patients had a higher incidence of in-hospital infectious complications (28.7% vs. 8.2%, p < 0.001) and a higher incidence of acute renal failure (5.5% vs. 0.7%, p < 0.001). CONCLUSION: Although diabetic patients with colonic diverticulitis present at a more advanced level (as measured by Hinchey and Ambrosetti scores), the nonoperative success rate is similar to non-DM patients. Surgical management in DM patients is associated with a higher incidence of infectious complications and acute kidney injury. However, DM did not appear to increase operative mortality in surgically managed patients. These data suggest that greater attention should be placed on steps to reduce the negative impact of DM on both immune response and renal function in patients requiring surgery of colonic diverticulitis. LEVEL OF EVIDENCE: Epidemiologic study, level III.
- Published
- 2014
35. The impact of temporal, environmental, and sociocultural factors on blunt and penetrating trauma admission volumes: review of 41,613 patient admissions
- Author
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Pedro G.R. Teixeira, Kenji Inaba, Demetrios Demetriades, Robert G. Fovell, Dimitra Skiada, Obi Okoye, Vincent Cheng, and Regan J. Berg
- Subjects
Patient admissions ,medicine.medical_specialty ,Blunt ,business.industry ,Emergency medicine ,medicine ,Surgery ,Medical emergency ,medicine.disease ,business ,Penetrating trauma - Published
- 2015
36. Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study
- Author
-
Peep, Talving, Efstathios, Karamanos, Pedro G, Teixeira, Dimitra, Skiada, Lydia, Lam, Howard, Belzberg, Kenji, Inaba, and Demetrios, Demetriades
- Subjects
Adult ,Male ,Hernia ,Trauma Severity Indices ,Intracranial Pressure ,Age Factors ,Brain ,Length of Stay ,Middle Aged ,Subarachnoid Hemorrhage ,Patient Outcome Assessment ,Brain Injuries ,Humans ,Female ,Prospective Studies ,Monitoring, Physiologic - Abstract
The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes.This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes.A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring.Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.
- Published
- 2013
37. Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis
- Author
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Demetrius Demetriades, John B. Holcomb, Bryan A. Cotton, Kenji Inaba, Chrissy Guidry, Norman E. McSwain, Peter Meade, Juan Duchesne, Dimitra Skiada, Mitchell J. Cohen, Martin A. Schreiber, Charles E. Wade, and Jiselle Bock Heaney
- Subjects
Adult ,Male ,medicine.medical_specialty ,Resuscitation ,medicine.medical_treatment ,Hemorrhage ,Critical Care and Intensive Care Medicine ,Risk Assessment ,Cohort Studies ,Trauma Centers ,Laparotomy ,Medicine ,Humans ,Blood Transfusion ,Hospital Mortality ,Survival analysis ,Aged ,Retrospective Studies ,Respiratory distress ,business.industry ,Hemostatic Techniques ,Odds ratio ,Crystalloid Solutions ,Middle Aged ,medicine.disease ,Confidence interval ,Surgery ,Logistic Models ,Treatment Outcome ,Bacteremia ,Anesthesia ,Multivariate Analysis ,Wounds and Injuries ,Female ,Fresh frozen plasma ,Isotonic Solutions ,business ,human activities ,Follow-Up Studies - Abstract
Although minimization of crystalloids is a widely adopted practice in the resuscitation of patients with severe hemorrhage, its direct impact on high-ratio resuscitation (HRR) outcomes has not been analyzed. We hypothesize that HRR patients will have worse outcomes from crystalloid use.This was a 4-year retrospective multi-institutional analysis (MIA) of patients who received massive transfusion protocol (MTP) managed with damage-control laparotomy. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in two groups: HRR (1-1:2) and low-ratio resuscitation (LRR1:2). Major outcome of interest was to analyze the direct impact of 24-hour crystalloid volume on HRR MTP patients who received 10 or more units of PRBC. Statistical analysis included analysis of variance, Fisher's exact, Kaplan-Meier (KM) survival curves, and multiple logistic regression.Total of five Level I trauma centers participated with 451 patients who received MTP with 10 or more units of PRBC (fresh frozen plasma/PRBC ratios, n = 365 (80.9%) HRR vs. n = 86 (19.0%) LRR. Overall 24-hour KM survival for the HRR versus LRR was 85.2% versus 68.6% (p = 0.0004). The volume of crystalloids on KM survival curve in HRR MTP patients was not significant for mortality (p = 0.52). Morbidity odds ratios (95% confidence interval) for complications were not significant for HRR but were for crystalloids: bacteremia, 1.05 (1.0-1.1); adult respiratory distress syndrome, 1.13 (1.0-1.2), and acute renal failure, 1.05 (1.0-1.1).Our MIA results support previous studies with decreased mortality in HRR group when compared with LRR. This is the first MIA to demonstrate increased morbidity from crystalloid use in HRR. Within all MTPs with 10 or more units of PRBC, HRR was not a predictor of morbidity, but crystalloid volume was. Caution in overzealous use of crystalloid during HRR is warranted.Therapeutic study, level IV.
- Published
- 2013
38. Colonic metastasis of a renal cell carcinoma: Case report and brief review of the literature
- Author
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Andreas Larentzakis, Dimitrios Theodorou, Dimitrios Tsamis, Konstantinos Toutouzas, Stylianos Katsaragakis, Dimitra Skiada, and Sotirios-Georgios Panousopoulos
- Subjects
medicine.medical_specialty ,Pathology ,renal cell carcinoma ,business.industry ,Anemia ,medicine.medical_treatment ,General Medicine ,medicine.disease ,Nephrectomy ,Intestinal bleeding ,Renal cell carcinoma ,right colectomy ,Right Colectomy ,medicine ,Curative surgery ,Ascending colon ,Medicine ,Radiology ,Colonic metastasis ,business ,large bowel metastasis - Abstract
Introduction. Colonic metastasis following curative surgery for renal cell carcinoma has rarely been described in the literature. Case Presentation. We present a case of a 64-year-old man who previously had a left nephrectomy for renal cell carcinoma. Five months post-operatively the patient presented with microscopic intestinal bleeding and anemia. Colonoscopic surveillance revealed a metastatic lesion in the ascending colon, and a right hemicolectomy was subsequently performed. Discussion. Colonic metastasis following resection for renal cell carcinoma is a rare entity, as evidenced by its lack of description in the literature. Imaging scans, such as computed tomography, have little diagnostic value and an increased medical suspicion is warranted for prompt diagnosis.
- Published
- 2012
39. [Untitled]
- Author
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Dimitra Skiada, Jennifer R. Smith, Matthew D. Tadlock, Stacy Cantwell, Fatmata Jalloh, Michael Minetti, Heidi L. Frankel, and Peep Talving
- Subjects
medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,medicine.medical_treatment ,education ,Thoracentesis ,Critical Care and Intensive Care Medicine ,Credentialing ,Thoracostomy ,Surgery ,Dissection ,medicine.anatomical_structure ,Intensive care ,Acute care ,medicine ,Paracentesis ,Vein ,business - Abstract
Introduction: Emerging data suggests that Acute Care Nurse Practioners (ACNP) have successfully been integrated into Intensive Care Units (ICU) across the United States. While the ACNP scope of practice and how to bill for procedures has been described, the ideal method to train and credential ACNPs to perform invasive procedures has not. We describe our initial experience training ACNPs to perform invasive critical care procedures utilizing our Fresh Tissue Dissection Lab (FTDL) and simulation program. Methods: Seven ACNP were given a self-directed didactic followed by a four-hour practicum utilizing perfused fresh tissue cadavers. The cadavers were perfused via femoral artery and vein cannulation with colored pressurized fluids simulating arterial and venous blood. Procedures performed included central venous landmark guided subclavian (SC) and ultrasound (US) guided internal jugular (IJ) vein catheter insertion, orotracheal intubation, tube thoracostomy, thoracentesis, and paracentesis. Pretest and posttest knowledge assessments were administered. Overall and specific procedural confidence was evaluated utilizing a retrospective pre-practicum and post-practicum analysis with a 5-point Likert scale (1, least confident and 5, most confident). Results: The mean years of clinical experience for the group was 4.1 years (range 4 months to 13 years). Each ACNP scored a 100% on both the pretest and posttest knowledge assessment. The overall procedural confidence for all procedures improved by 1.44, from 2.53 (SD± 0.629) to 3.97 (SD± 0.320) (p
- Published
- 2013
40. Prospective Evaluation of Treatment of Open Fractures
- Author
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Beat Schnüriger, Marissa K. Srour, Kenji Inaba, Carney Chan, Obi Okoye, Mark E Trump, Dimitra Skiada, Demetrios Demetriades, and Lydia Lam
- Subjects
Adult ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,Nonunion ,Therapeutic irrigation ,Time-to-Treatment ,Fractures, Open ,Postoperative Complications ,Trauma Centers ,Humans ,Surgical Wound Infection ,Medicine ,Prospective Studies ,Therapeutic Irrigation ,Prospective cohort study ,Debridement ,business.industry ,Incidence ,Incidence (epidemiology) ,Odds ratio ,medicine.disease ,Surgery ,Treatment Outcome ,Blunt trauma ,Mechanism of injury ,Female ,business ,Follow-Up Studies - Abstract
The standard practice of irrigation and debridement (ID) of open fractures within 6 hours of injury remains controversial.To prospectively evaluate the effect of the time from injury to the initial ID on infectious complications.A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to ID, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of ID (6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to ID on outcomes.Development of local infectious complications at early (30 days) or late (30 days and1 year) intervals from admission.The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent ID within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to ID did not affect the rate of nonunion, hardware failure, length of stay, or mortality.In this prospective analysis, time to ID did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.
- Published
- 2015
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