111 results on '"Matthew J. Bradley"'
Search Results
2. Outcomes of tranexamic acid administration in military trauma patients with intracranial hemorrhage: a cohort study
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Patrick F. Walker, Joseph D. Bozzay, Luke R. Johnston, Eric A. Elster, Carlos J. Rodriguez, and Matthew J. Bradley
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Tranexamic acid ,TXA ,Traumatic brain injury ,TBI ,Military ,Special situations and conditions ,RC952-1245 ,Medical emergencies. Critical care. Intensive care. First aid ,RC86-88.9 - Abstract
Abstract Background Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI. Methods This was a retrospective cohort study of military casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE. Results Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 h of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p = 0.003), similar discharge GCS (13.3 ± 4.0 vs. 13.8 ± 3.2, p = 0.58), and a larger improvement between initial and discharge GCS (3.7 ± 3.9 vs. 1.3 ± 3.1, p = 0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p = 1.00), progression of ICH (45.5% vs. 14.7%, p = 0.09), frequency of cranial decompression (50.0% vs. 42.1%, p = 0.76), or mean GOS (3.5 ± 0.9 vs. 3.8 ± 1.0, p = 0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p = 0.01). On multivariate analysis, however, TXA was not independently associated with VTE. Conclusions Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in military casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.
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- 2020
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3. Development of an emergency general surgery process improvement program
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Matthew J. Bradley, Angela T. Kindvall, Ashley E. Humphries, Elliot M. Jessie, John S. Oh, Debra M. Malone, Jeffrey A. Bailey, Philip W. Perdue, Eric A. Elster, and Carlos J. Rodriguez
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Surgery ,RD1-811 - Abstract
Abstract Background The Joint Trauma System has demonstrated improved outcomes through coordinated research and process improvement programs. With fewer combat trauma patients, our military American College of Surgeons level 2 trauma center’s ability to maintain a strong trauma Process Improvement (PI) program has become difficult. As emergency general surgery (EGS) patients are similar to trauma patients, our Trauma and Acute Care Surgery (TACS) service developed an EGS PI program analogous to what is done in trauma. We describe the implementation of our novel EGS PI program and its effect on institutional PI proficiency. Methods An EGS registry was developed in 2013. Inclusion criteria were based on AAST published literature. In 2015, EGS registrar and PI coordinator positions were developed and filled with existing trauma staff. A formal EGS PI program began January 1, 2016. Pre- and post-program data was compared to determine the effect including EGS PI events had on increasing yield into our trauma PI program. Results In 2016, TACS saw 1001 EGS consults. Four hundred forty-four met criteria for registry inclusion. Eighty-two patients had 131 PI events; re-admission within 30 days, unplanned therapeutic intervention, and unplanned ICU admission were the most common events. Capture of EGS PI events yielded a 49% increase compared with 2015. Conclusion Overall patient volume and PI events post EGS PI program initiation exceeded those prior to implementation. These data suggest that extending trauma PI principles to EGS may be beneficial in maintaining inter-war military and/or lower volume trauma center readiness.
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- 2018
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4. The impact of septic stimuli on the systemic inflammatory response and physiologic insult in a preclinical non-human primate model of polytraumatic injury
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Diego A. Vicente, Matthew J. Bradley, Benjamin Bograd, Crystal Leonhardt, Eric A. Elster, and Thomas A. Davis
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Inflammation ,Trauma ,Sepsis ,Hemorrhage ,Animal model ,Cytokines ,Therapeutics. Pharmacology ,RM1-950 - Abstract
Abstract Background Established animal trauma models are limited in recapitulating the pathophysiology of human traumatic injury. Herein, we characterize the physiologic insult and inflammatory response in two clinically relevant non-human primate (NHP) trauma models. Methods Mauritian Cynomolgus Macaques underwent either a laparoscopic closed abdomen liver injury (laparoscopic 60% left-lobe hepatectomy) in an established uncontrolled severe hemorrhage model (THM), or a polytrauma hemorrhage model (PHM) involving combined liver and bowel injury, uncontrolled severe hemorrhage as well as an open full-thickness cutaneous flank wound. Fixed volume resuscitation strategies were employed in the THM and goal directed resuscitation was used in the PHM. Complete peripheral blood and critical clinical chemistry parameters, serum biomarkers of systemic inflammation, tissue perfusion parameters, as well as survival, were compared between the models throughout the 2-week study period. Results NHPs in both the THM (n = 7) and the PHM (n = 21) demonstrated tissue hypoperfusion (peak lactate 6.3 ± 0.71 mmol/L) with end organ injury (peak creatinine 3.08 ± 0.69 mg/dL) from a similar liver injury (60% left hemi-hepatectomy), though the PHM NHPs had a significantly higher blood loss (68.1% ± 12.7% vs. 34.3% ± 2.3%, p = 0.02), lower platelet counts (59 ± 25 vs. 205 ± 46 K/uL, p = 0.03) and a trend towards higher mortality (90.5% vs. 33.3%, p = 0.09). The inflammatory response was robust in both models with peak cytokine (IL-6 > 6000-fold above baseline) and peak leukocyte values (WBC 27 K/uL) typically occurring around t = 240 min from the time of hepatic injury. A more robust systemic inflammatory response was appreciated in the PHM resulting in marked elevations in peak serum IL-6 (7887 ± 2521 pg/mL vs.1076 ± 4833 pg/mL, p = 0.02), IL-1ra (34,499 ± 5987 pg/mL vs. 2511 ± 1228 pg/mL, p
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- 2018
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5. Host responses to concurrent combined injuries in non-human primates
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Matthew J. Bradley, Diego A. Vicente, Benjamin A. Bograd, Erin M. Sanders, Crystal L. Leonhardt, Eric A. Elster, and Thomas A. Davis
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Non-human primate ,Trauma ,Immune response ,Military ,Therapeutics. Pharmacology ,RM1-950 - Abstract
Abstract Background Multi-organ failure (MOF) following trauma remains a significant cause of morbidity and mortality related to a poorly understood abnormal inflammatory response. We characterized the inflammatory response in a non-human primate soft tissue injury and closed abdomen hemorrhage and sepsis model developed to assess realistic injury patterns and induce MOF. Methods Adult male Mauritan Cynomolgus Macaques underwent laparoscopy to create a cecal perforation and non-anatomic liver resection along with a full-thickness flank soft tissue injury. Treatment consisted of a pre-hospital phase followed by a hospital phase after 120 minutes. Blood counts, chemistries, and cytokines/chemokines were measured throughout the study. Lung tissue inflammation/apoptosis was confirmed by mRNA quantitative real-time PCR (qPCR), H&E, myeloperoxidase (MPO) and TUNEL staining was performed comparing age-matched uninjured controls to experimental animals. Results Twenty-one animals underwent the protocol. Mean percent hepatectomy was 64.4 ± 5.6; percent blood loss was 69.0 ± 12.1. Clinical evidence of end-organ damage was reflected by a significant elevation in creatinine (1.1 ± 0.03 vs. 1.9 ± 0.4, p=0.026). Significant increases in systemic levels of IL-10, IL-1ra, IL-6, G-CSF, and MCP-1 occurred (11-2986-fold) by 240 minutes. Excessive pulmonary inflammation was evidenced by alveolar edema, congestion, and wall thickening (H&E staining). Concordantly, amplified accumulation of MPO leukocytes and significant pulmonary inflammation and pneumocyte apoptosis (TUNEL) was confirmed using qRT-PCR. Conclusion We created a clinically relevant large animal multi-trauma model using laparoscopy that resulted in a significant systemic inflammatory response and MOF. With this model, we anticipate studying systemic inflammation and testing innovative therapeutic options.
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- 2017
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6. FTY720 Effects on Inflammation and Liver Damage in a Rat Model of Renal Ischemia-Reperfusion Injury
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Anthony D. Foster, Diego Vicente, Nicholas Clark, Crystal Leonhardt, Eric A. Elster, Thomas A. Davis, and Matthew J. Bradley
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Pathology ,RB1-214 - Abstract
Objective. Ischemia-reperfusion injury (IRI) produces systemic inflammation with the potential for causing organ failure in tissues peripheral to the initial site of injury. We speculate that treatment strategies that dampen inflammation may be therapeutically beneficial to either the initial site of injury or peripheral organs. To test this, we evaluated the impact of FTY720-induced sequestration of circulating mature lymphocytes on renal IRI and secondary organ injury. Methods. A microvascular clamp was surgically placed around the left renal pedicle of anesthetized male Sprague-Dawley rats with either vehicle or FTY720 treatment (0.3 mg/kg) intravenously injected after 15 min of ischemia. Blood flow was restored after 60 min. Cohorts of anesthetized rats were euthanized at 6, 24, or 72 hrs with tissue samples collected for analysis. Results. FTY720 treatment resulted in profound T lymphocyte reduction in peripheral blood. Histopathologic examination, clinical chemistries, and gene transcript expression measurements revealed that FTY720 treatment reduced hepatocellular degeneration, reduced serum markers of liver injury (ALT/AST), and reduced the expression of gene targets associated with IRI. Conclusion. These findings support an anti-inflammatory effect of FTY720 in the liver where the expression of genes associated with apoptosis, chemotaxis, and the AP-1 transcription factor was reduced. Findings presented here provide the basis for future studies evaluating FTY720 as a potential therapeutic agent to treat complications resulting from renal IRI.
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- 2019
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7. Evaluation of CO2 Hydrogenation in a Modular Fixed-Bed Reactor Prototype
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Heather D. Willauer, Matthew J. Bradley, Jeffrey W. Baldwin, Joseph J. Hartvigsen, Lyman Frost, James R. Morse, Felice DiMascio, Dennis R. Hardy, and David J. Hasler
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carbon dioxide ,hydrogenation ,catalyst ,gas hourly space velocity (GHSV) ,fixed-bed reactor ,Chemical technology ,TP1-1185 ,Chemistry ,QD1-999 - Abstract
Low-cost iron-based CO2 hydrogenation catalysts have shown promise as a viable route to the production of value-added hydrocarbon building blocks. It is envisioned that these hydrocarbons will be used to augment industrial chemical processes and produce drop-in replacement operational fuel. To this end, the U.S. Naval Research Laboratory (NRL) has been designing, testing, modeling, and evaluating CO2 hydrogenation catalysts in a laboratory-scale fixed-bed environment. To transition from the laboratory to a commercial process, the catalyst viability and performance must be evaluated at scale. The performance of a Macrolite®-supported iron-based catalyst in a commercial-scale fixed-bed modular reactor prototype was evaluated under different reactor feed rates and product recycling conditions. CO2 conversion increased from 26% to as high as 69% by recycling a portion of the product stream and CO selectivity was greatly reduced from 45% to 9% in favor of hydrocarbon production. In addition, the catalyst was successfully regenerated for optimum performance. Catalyst characterization by X-ray diffraction (XRD) and X-ray photoelectron spectroscopy (XPS), along with modeling and kinetic analysis, highlighted the potential challenges and benefits associated with scaling-up catalyst materials and processes for industrial implementation.
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- 2020
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8. Administration of FTY720 during Tourniquet-Induced Limb Ischemia Reperfusion Injury Attenuates Systemic Inflammation
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Anthony D. Foster, Diego Vicente, Jonathan J. Sexton, Luke Johnston, Nick Clark, Crystal Leonhardt, Eric A. Elster, Thomas A. Davis, and Matthew J. Bradley
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Pathology ,RB1-214 - Abstract
Acute ischemia-reperfusion injury (IRI) of the extremities leads to local and systemic inflammatory changes which can hinder limb function and can be life threatening. This study examined whether the administration of the T-cell sequestration agent, FTY720, following hind limb tourniquet-induced skeletal muscle IRI in a rat model would attenuate systemic inflammation and multiple end organ injury. Sprague-Dawley rats were subjected to 1 hr of ischemia via application of a rubber band tourniquet. Animals were randomized to receive an intravenous bolus of either vehicle control or FTY720 15 min after band placement. Rats (n=10/time point) were euthanized at 6, 24, and 72 hr post-IRI. Peripheral blood as well as lung, liver, kidney, and ischemic muscle tissue was analyzed and compared between groups. FTY720 treatment markedly decreased the number of peripheral blood T cells (p
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- 2017
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9. The Effect of Copper Addition on the Activity and Stability of Iron-Based CO2 Hydrogenation Catalysts
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Matthew J. Bradley, Ramagopal Ananth, Heather D. Willauer, Jeffrey W. Baldwin, Dennis R. Hardy, and Frederick W. Williams
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CO2 conversion ,selectivity ,activity ,modelling ,iron-based ,copper ,Organic chemistry ,QD241-441 - Abstract
Iron-based CO2 catalysts have shown promise as a viable route to the production of olefins from CO2 and H2 gas. However, these catalysts can suffer from low conversion and high methane selectivity, as well as being particularly vulnerable to water produced during the reaction. In an effort to improve both the activity and durability of iron-based catalysts on an alumina support, copper (10–30%) has been added to the catalyst matrix. In this paper, the effects of copper addition on the catalyst activity and morphology are examined. The addition of 10% copper significantly increases the CO2 conversion, and decreases methane and carbon monoxide selectivity, without significantly altering the crystallinity and structure of the catalyst itself. The FeCu/K catalysts form an inverse spinel crystal phase that is independent of copper content and a metallic phase that increases in abundance with copper loading (>10% Cu). At higher loadings, copper separates from the iron oxide phase and produces metallic copper as shown by SEM-EDS. An addition of copper appears to increase the rate of the Fischer–Tropsch reaction step, as shown by modeling of the chemical kinetics and the inter- and intra-particle transport of mass and energy.
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- 2017
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10. The Last Days: United States and Allied Military Medical Response During the Afghanistan Exodus
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Joe Bozzay, Timothy P. Murphy, Michael D. Baird, Marvin E. Dingle, Omar A. Rokayak, Chris Renninger, Shawn E. Boomsma, Brian P. Milam, Tim Horrell, Bradley A. Rittenhouse, Patrick J. McGlone, Harris W. Kashtan, Mark Buzzelli, Remealle A. How, Bruce A. Lynch, Lauren Heyda, Ashley E. Humphries, Elliot M. Jessie, Jigarkumar A Patel, Ronald Hardin, Kenneth J. Nelson, Jean-Claude G. D’Alleyrand, Matthew J. Bradley, Benjamin K. Potter, and Jennifer M. Gurney
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Surgery ,Critical Care and Intensive Care Medicine - Published
- 2023
11. Risk Factors for Urgent or Emergent Cholecystectomy Mid-workup for Symptomatic Cholelithiasis
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Sydney E. Dishman, Rathnayaka M.K.D. Gunasingha, William P. Hennrikus, Brittany H. Strahan, Megan C. Bartel, Carolyn E. Gosztyla, and Matthew J. Bradley
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Adult ,Elective Surgical Procedures ,Risk Factors ,Humans ,Cholecystectomy ,Gallstones ,General Medicine ,Retrospective Studies - Abstract
Background Patients who undergo cholecystectomy often do so for diagnoses related to the sequelae of gallstones. Many patients present acutely, requiring urgent removal due to complications of cholelithiasis. This study aims to characterize the patient population likely to present acutely during ongoing workup for cholelithiasis to better identify those who may benefit from expedited care. Methods Medical records of all adult patients who underwent cholecystectomy for indications related to cholelithiasis between 2015 and 2016 were reviewed retrospectively. Qualitative data was analyzed using Chi square test and quantitative data was analyzed using independent t-tests. Results One hundred and seventy-four cholecystectomies were performed. Overall, 74.2% of the procedures were done electively while 25.8% were done urgently. And 42.2% of patients who underwent acute surgical intervention had evidence of prior workup. Patients requiring urgent intervention during ongoing diagnostic evaluation were more likely to have initially presented to an emergency department (ED) than another provider (68.4% vs 31.3%, P < .001) and had an odds ratio of 4.7 for undergoing acute intervention if they initially presented to the ED. They also tended to be more temporally remote from their initial diagnosis (119 ± 142 vs 74.6 ± 68.2 days, P < .19) relative to those who underwent elective operations. Discussion Patients who require urgent intervention during ongoing workup for cholelithiasis have prolonged courses of care and present to the ED more often for initial evaluation when compared to those who undergo elective intervention. These findings suggest that an emphasis on expedited workup of cholelithiasis and early surgical referral may be warranted, especially for those who initially present in the ED.
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- 2022
12. Infectious Disease
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Rathnayaka M. K. Gunasingha, Patrick Benoit, and Matthew J. Bradley
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- 2022
13. To Scan or Not to Scan: Development of a Clinical Decision Support Tool to Determine if Imaging Would Aid in the Diagnosis of Appendicitis
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Elizabeth McMillan, Scott F. Grey, Rathnayaka M K D Gunasingha, Eric A. Elster, Joseph Lee, Desiree Unselt, Seth Schobel, Matthew J. Bradley, Casey Erwin, Beau Munoz, and Thomas Irons
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medicine.medical_specialty ,Receiver operating characteristic ,business.industry ,Gold standard (test) ,medicine.disease ,Clinical decision support system ,Appendicitis ,Random forest ,Support vector machine ,Alvarado score ,Chart review ,medicine ,Surgery ,Radiology ,business - Abstract
Appendicitis is one of the most common surgically treated diseases in the world. CT scans are often over-utilized and ordered before a surgeon has evaluated the patient. Our aim was to develop a tool using machine learning (ML) algorithms that would help determine if there would be benefit in obtaining a CT scan prior to surgeon consultation. Retrospective chart review of 100 randomly selected cases who underwent appendectomy and 100 randomly selected controls was completed. Variables included components of the patient’s history, laboratory values, CT readings, and pathology. Pathology was used as the gold standard for appendicitis diagnosis. All variables were then used to build the ML algorithms. Random Forest (RF), Support Vector Machine (SVM), and Bayesian Network Classifiers (BNC) models with and without CT scan results were trained and compared to CT scan results alone and the Alvarado score using area under the Receiver Operator Curve (ROC), sensitivity, and specificity measures as well as calibration indices from 500 bootstrapped samples. Among the cases that underwent appendectomy, 88% had pathology-confirmed appendicitis. All the ML algorithms had better sensitivity, specificity, and ROC than the Alvarado score. SVM with and without CT had the best indices and could predict if imaging would aid in appendicitis diagnosis. This study demonstrated that SVM with and without CT results can be used for selective imaging in the diagnosis of appendicitis. This study serves as the initial step and proof-of-concept to externally validate these results with larger and more diverse patient population.
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- 2021
14. Cellular microRNAs correlate with clinical parameters in multiple injury patients
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Diego A. Vicente, Seth A. Schobel, Simone Anfossi, Hannah Hensman, Felipe Lisboa, Henry Robertson, Vivek Khatri, Matthew J. Bradley, Masayoshi Shimizu, Timothy G. Buchman, Thomas A. Davis, Christopher J. Dente, Allan D. Kirk, George A. Calin, and Eric A. Elster
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Inflammation ,Vascular Endothelial Growth Factor A ,MicroRNAs ,2021 Aast Podium Paper ,Multiple Trauma ,Humans ,Surgery ,Convalescence ,Critical Care and Intensive Care Medicine ,Severity of Illness Index ,Biomarkers ,Chemokine CCL2 ,Interleukin-10 - Abstract
The pathophysiology of the inflammatory response after major trauma is complex, and the magnitude correlates with severity of tissue injury and outcomes. Study of infection-mediated immune pathways has demonstrated that cellular microRNAs may modulate the inflammatory response. The authors hypothesize that the expression of microRNAs would correlate to complicated recoveries in polytrauma patients (PtPs). METHODS: Polytrauma patients enrolled in the prospective observational Tissue and Data Acquisition Protocol with Injury Severity Score of >15 were selected for this study. Polytrauma patients were divided into complicated recoveries and uncomplicated recovery groups. Polytrauma patients' blood samples were obtained at the time of admission (T0). Established biomarkers of systemic inflammation, including cytokines and chemokines, were measured using multiplexed Luminex-based methods, and novel microRNAs were measured in plasma samples using multiplex RNA hybridization. RESULTS: Polytrauma patients (n = 180) had high Injury Severity Score (26 [20–34]) and complicated recovery rate of 33%. MicroRNAs were lower in PtPs at T0 compared with healthy controls, and bivariate analysis demonstrated that variations of microRNAs correlated with age, race, comorbidities, venous thromboembolism, pulmonary complications, complicated recovery, and mortality. Positive correlations were noted between microRNAs and interleukin 10, vascular endothelial growth factor, Acute Physiology and Chronic Health Evaluation, and Sequential Organ Failure Assessment scores. Multivariable Lasso regression analysis of predictors of complicated recovery based on microRNAs, cytokines, and chemokines revealed that miR-21-3p and monocyte chemoattractant protein-1 were predictive of complicated recovery with an area under the curve of 0.78. CONCLUSION: Systemic microRNAs were associated with poor outcomes in PtPs, and results are consistent with previously described trends in critically ill patients. These early biomarkers of inflammation might provide predictive utility in early complicated recovery diagnosis and prognosis. Because of their potential to regulate immune responses, microRNAs may provide therapeutic targets for immunomodulation. LEVEL OF EVIDENCE: Diagnostic Tests/Criteria; Level II.
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- 2022
15. Predicting Outcomes in Emergency General Surgery Patients Using Preoperative Model for End-Stage Liver Disease Score
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Thomas D Irons, Rathnayaka M KD Gunasingha, Scott F Grey, Carolyn E Gosztyla, and Matthew J Bradley
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Surgery - Published
- 2022
16. Jejunal Mesenteric Heterotopic Pancreas Causing Necrotizing Pancreatitis and Small Bowel Obstruction
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Kimberly A. Gerling, Robert W. DesPain, and Matthew J. Bradley
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General Medicine - Published
- 2022
17. Development, refinement, and characterization of a nonhuman primate critical care environment
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Joseph D. Bozzay, Patrick F. Walker, Rex E. Atwood, Robert W. DeSpain, William J. Parker, Daniel S. Chertow, John A. Mares, Crystal L. Leonhardt, Eric A. Elster, and Matthew J. Bradley
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Multidisciplinary - Abstract
Background Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers. Methods Eight adult male rhesus macaques underwent ventilation with sedation for 48–96 hours in a critical care setting. Three of these NHPs underwent “sham” procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy. Results Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72–96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed. Conclusions A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model.
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- 2023
18. Comment on 'A Proposed Blueprint for Operative Performance Training, Assessment, and Certification'
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Pamela Andreatta, Mark W. Bowyer, Matthew J. Bradley, Brenton R. Franklin, and Eric A. Elster
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Engineering management ,business.industry ,Blueprint ,Training assessment ,Medicine ,Surgery ,Certification ,business - Published
- 2021
19. Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study
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Jennifer Mull, Janika San Roman, Jason Pasley, Martin A. Schreiber, Alexis Cralley, Crystal Szczepanski, Morgan Collom, Maryam B. Tabrizi, Daniel Vazquez, Jocelyn To, Rondi B. Gelbard, Jeffrey Wild, Brandon Behrens, Ahmed E Elsharkawy, Richard D. Catalano, Elena Lita, Kaitlyn Proulx, Reginald Alouidor, D. Dante Yeh, Kailyn Kwong Hing, David C. Evans, Saskya Byerly, Victoria Sharp, Muhammad Zeeshan, David Turay, Marie Crandall, Matthew J. Bradley, Lewis E. Jacobson, Katelyn Young, Thomas Serena, Peter K. Kim, Stacie L. Allmond, Christopher M. Dodgion, Tala Kana’an, Ahmed I Eid, Jonathan M. Saxe, Savo Bou Zein Eddine, Daniel C. Cullinane, Jeffry Nahmias, Jennifer C. Roberts, Leon Naar, Steven D. Eyer, Lindsay O'Meara, Hang Zhang, Ali Fuat Kann Gok, Ryan A. Lawless, Erik J. Teicher, Bruce Long, David L. Morris, Carlos Rodriguez, Bellal Joseph, Nadine Barth, Haytham M.A. Kaafarani, Mohamed D. Ray-Zack, Georgia Vasileiou, Beatrice Sun, Victor Portillo, and Laura Juarez
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education.field_of_study ,medicine.medical_specialty ,business.industry ,Incidence (epidemiology) ,Population ,030230 surgery ,Malignancy ,medicine.disease ,Appendix ,Confidence interval ,Appendicitis ,03 medical and health sciences ,0302 clinical medicine ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Relative risk ,Post-hoc analysis ,medicine ,Surgery ,Radiology ,education ,business - Abstract
Background The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy. Methods Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit. Results A total of 3,293 patients were included. The median age was 38 (27–53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma [60.4%], neuroendocrine [37.5%], and lymphoma [2.1%]). Patients with malignancy were older (56 [34.5–67] vs 37 [27–52] years, P 40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients ≤40 years old with appendiceal diameter ≤10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24–7.42; P = .02). Conclusion The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.
- Published
- 2020
20. Military experience in the management of pelvic fractures from OIF/OEF
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Eric A. Elster, Robert W DesPain, William J Parker, Carlos J Rodriguez, Jeffrey A. Bailey, and Matthew J. Bradley
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medicine.medical_specialty ,External fixator ,business.industry ,Incidence (epidemiology) ,Process improvement ,030208 emergency & critical care medicine ,Context (language use) ,General Medicine ,medicine.disease ,Blast injury ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Concomitant ,medicine ,Pelvic fracture ,Injury Severity Score ,030212 general & internal medicine ,business - Abstract
IntroductionPelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures.MethodsWe conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined.ResultsOf 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy.ConclusionsPelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.
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- 2020
21. Pelvic Binder Utilization in Combat Casualties: Does It Matter?
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Robert W DesPain, Matthew J. Bradley, Carlos J Rodriguez, Dean E. Baird, Adam Delgado, Eric A. Elster, and William J Parker
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business.industry ,Dentistry ,Hemorrhage ,030208 emergency & critical care medicine ,General Medicine ,030230 surgery ,medicine.disease ,Orthopedic Fixation Devices ,Fractures, Bone ,03 medical and health sciences ,Military Personnel ,0302 clinical medicine ,Fracture Fixation ,Blood product ,Pelvic fracture ,Humans ,Medicine ,Pelvic Bones ,business ,Retrospective Studies - Abstract
IntroductionThe purpose of this study was to evaluate the utilization of pelvic binders, the proper placement of binders, and to determine any differences in blood product transfusions between combat casualties with and without a pelvic binder identified on initial imaging immediately after the injury.MethodsWe conducted a retrospective review of all combat-injured patients who arrived at our military treatment hospital between 2010 and 2012 with a documented pelvic fracture. Initial imaging (X-ray or computed tomography) immediately after injury were evaluated by 2 independent radiologists. Young-Burgess (YB) classification, pelvic diastasis, correct binder placement over the greater trochanters, and the presence of a pelvic external fixator (ex-fix) was recorded. Injury severity score (ISS), whole blood, and blood component therapy administered within the first 24-hours after injury were compared between casualties with and without a pelvic binder.Results39 casualties had overseas imaging to confirm and radiographically classify a YB pelvic ring injury. The most common fracture patterns were anteroposterior (53%) and lateral compression (28%). 49% (19/39) did not have a binder or ex-fix identified on initial imaging or in any documentation after injury. Ten patients had a binder, with 30% positioned incorrectly over the iliac crest. ISS (34 ± 1.6) was not statistically different between the binder and the no-binder group. Pubic symphysis diastasis was significantly lower in the binder group (1.4 ± 0.2 vs 3.7 ± 0.5, P < .001). There was a trend toward decreased 24-hour total blood products between the binder and no-binder groups (75 ± 11 vs 82 ± 13, P = .67). This was due to less cryoprecipitate in the binder group (6 ± 2 vs 19 ± 5, P = .01).ConclusionsPelvic binder placement in combat trauma may be inconsistent and an important area for continued training. While 24-hour total transfusions do not appear to be different, no-binder patients received significantly more cryoprecipitate.
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- 2020
22. Outcomes of tranexamic acid administration in military trauma patients with intracranial hemorrhage: a cohort study
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Joseph D. Bozzay, Carlos J Rodriguez, Luke R. Johnston, Eric A. Elster, Patrick F. Walker, and Matthew J. Bradley
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Adult ,Male ,Tranexamic acid ,Traumatic brain injury ,lcsh:Special situations and conditions ,Glasgow Outcome Scale ,Context (language use) ,03 medical and health sciences ,0302 clinical medicine ,Military ,TBI ,medicine ,Humans ,030212 general & internal medicine ,Retrospective Studies ,business.industry ,lcsh:RC952-1245 ,Glasgow Coma Scale ,lcsh:Medical emergencies. Critical care. Intensive care. First aid ,030208 emergency & critical care medicine ,Retrospective cohort study ,Venous Thromboembolism ,lcsh:RC86-88.9 ,medicine.disease ,Antifibrinolytic Agents ,United States ,Massive transfusion ,TXA ,Military Personnel ,Anesthesia ,Disease Progression ,Emergency Medicine ,Female ,business ,Intracranial Hemorrhages ,Venous thromboembolism ,Research Article ,Cohort study ,medicine.drug - Abstract
Background Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI. Methods This was a retrospective cohort study of military casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE. Results Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 h of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p = 0.003), similar discharge GCS (13.3 ± 4.0 vs. 13.8 ± 3.2, p = 0.58), and a larger improvement between initial and discharge GCS (3.7 ± 3.9 vs. 1.3 ± 3.1, p = 0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p = 1.00), progression of ICH (45.5% vs. 14.7%, p = 0.09), frequency of cranial decompression (50.0% vs. 42.1%, p = 0.76), or mean GOS (3.5 ± 0.9 vs. 3.8 ± 1.0, p = 0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p = 0.01). On multivariate analysis, however, TXA was not independently associated with VTE. Conclusions Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in military casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.
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- 2020
23. Prediction of venous thromboembolism using clinical and serum biomarker data from a military cohort of trauma patients
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Matthew J. Bradley, Seth Schobel, Allan D. Kirk, E Silvius, Vivek Khatri, Audrey Shi, Eric A. Elster, Timothy G. Buchman, and John S. Oh
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Vascular Endothelial Growth Factor A ,Venous Thrombosis ,medicine.medical_specialty ,Resuscitation ,business.industry ,Deep vein ,Area under the curve ,Venous Thromboembolism ,General Medicine ,Logistic regression ,medicine.disease ,Thrombosis ,Pulmonary embolism ,Military Personnel ,medicine.anatomical_structure ,Internal medicine ,Cohort ,medicine ,Humans ,Injury Severity Score ,business ,Biomarkers - Abstract
IntroductionVenous thromboembolism (VTE) is a frequent complication of trauma associated with high mortality and morbidity. Clinicians lack appropriate tools for stratifying trauma patients for VTE, thus have yet to be able to predict when to intervene. We aimed to compare random forest (RF) and logistic regression (LR) predictive modelling for VTE using (1) clinical measures alone, (2) serum biomarkers alone and (3) clinical measures plus serum biomarkers.MethodsData were collected from 73 military casualties with at least one extremity wound and prospectively enrolled in an observational study between 2007 and 2012. Clinical and serum cytokine data were collected. Modelling was performed with RF and LR based on the presence or absence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). For comparison, LR was also performed on the final variables from the RF model. Sensitivity/specificity and area under the curve (AUC) were reported.ResultsOf the 73 patients (median Injury Severity Score=16), nine (12.3%) developed VTE, four (5.5%) with DVT, four (5.5%) with PE, and one (1.4%) with both DVT and PE. In all sets of predictive models, RF outperformed LR. The best RF model generated with clinical and serum biomarkers included five variables (interleukin-15, monokine induced by gamma, vascular endothelial growth factor, total blood products at resuscitation and presence of soft tissue injury) and had an AUC of 0.946, sensitivity of 0.992 and specificity of 0.838.ConclusionsVTE may be predicted by clinical and molecular biomarkers in trauma patients. This will allow the development of clinical decision support tools which can help inform the management of high-risk patients for VTE.
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- 2020
24. Advanced Modeling to Predict Pneumonia in Combat Trauma Patients
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Hannah Hensman, Matthew J. Bradley, Christopher J. Dente, Audrey Shi, Seth Schobel, Eric A. Elster, Felipe A. Lisboa, Vivek Khatri, Timothy G. Buchman, and Allan D. Kirk
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Adult ,Male ,medicine.medical_specialty ,Logistic regression ,Risk Assessment ,Sensitivity and Specificity ,Machine Learning ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Blast Injuries ,Risk Factors ,Clinical Decision Rules ,medicine ,Humans ,Retrospective Studies ,Cross Infection ,Models, Statistical ,Abbreviated Injury Scale ,business.industry ,Incidence ,Incidence (epidemiology) ,Extremities ,Retrospective cohort study ,Pneumonia ,medicine.disease ,United States ,Logistic Models ,Military Personnel ,030220 oncology & carcinogenesis ,Cohort ,Emergency medicine ,Biomarker (medicine) ,030211 gastroenterology & hepatology ,Surgery ,Risk assessment ,business ,Algorithms - Abstract
Tools to assist clinicians in predicting pneumonia could lead to a significant decline in morbidity. Therefore, we sought to develop a model in combat trauma patients for identifying those at highest risk of pneumonia. This was a retrospective study of 73 primarily blast-injured casualties with combat extremity wounds. Binary classification models for pneumonia prediction were developed with measurements of injury severity from the Abbreviated Injury Scale (AIS), transfusion blood products received before arrival at Walter Reed National Military Medical Center (WRNMMC), and serum protein levels. Predictive models were generated with leave-one-out-cross-validation using the variable selection method of backward elimination (BE) and the machine learning algorithms of random forests (RF) and logistic regression (LR). BE was attempted with two predictor sets: (1) all variables and (2) serum proteins alone. Incidence of pneumonia was 12% (n = 9). Different variable sets were produced by BE when considering all variables and just serum proteins alone. BE selected the variables ISS, AIS chest, and cryoprecipitate within the first 24 h following injury for the first predictor set 1 and FGF-basic, IL-2R, and IL-6 for predictor set 2. Using both variable sets, a RF was generated with AUCs of 0.95 and 0.87—both higher than LR algorithms. Advanced modeling allowed for the identification of clinical and biomarker data predictive of pneumonia in a cohort of predominantly blast-injured combat trauma patients. The generalizability of the models developed here will require an external validation dataset.
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- 2019
25. Upper-Extremity Vascular Exposures for Trauma: Comparative Performance Outcomes for General Surgeons and Orthopedic Surgeons
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Matthew J Bradley, Brenton R Franklin, Christopher H Renninger, John Christopher Graybill, Mark W Bowyer, and Pamela B Andreatta
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Public Health, Environmental and Occupational Health ,General Medicine - Abstract
Introduction As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention. Methods This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P Results Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons). Conclusion There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings.
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- 2021
26. Risk Factors for Abdominal Surgical Site Infection after Exploratory Laparotomy among Combat Casualties
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Laveta Stewart, Faraz Shaikh, David Schechtman, Carlos J. Rodriguez, Patrick F. Walker, Matthew J. Bradley, Joseph D. Bozzay, M. Leigh Carson, and David R. Tribble
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Adult ,Male ,medicine.medical_specialty ,Exploratory laparotomy ,medicine.medical_treatment ,Abdominal Injuries ,Critical Care and Intensive Care Medicine ,Article ,Young Adult ,Injury Severity Score ,Risk Factors ,Laparotomy ,Epidemiology ,Medicine ,Humans ,Surgical Wound Infection ,Registries ,Iraq War, 2003-2011 ,Retrospective Studies ,Afghan Campaign 2001 ,business.industry ,medicine.disease ,Confidence interval ,United States ,Surgery ,medicine.anatomical_structure ,Abdominal trauma ,Relative risk ,Duodenum ,War-Related Injuries ,Female ,business ,Surgical site infection - Abstract
BACKGROUND Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties. METHODS Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors. RESULTS Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58-6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73-25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non-intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood. CONCLUSION Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma. LEVEL OF EVIDENCE Epidemiological, level III.
- Published
- 2021
27. Viral Micro-RNAs Are Detected in the Early Systemic Response to Injury and Are Associated With Outcomes in Polytrauma Patients
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Matthew J. Bradley, Christopher J. Dente, Diego Vicente, George A. Calin, Thomas A. Davis, Hannah Hensman, Henry Robertson, Simone Anfossi, Eric A. Elster, Masayoshi Shimizu, Vivek Khatri, Timothy G. Buchman, Seth Schobel, Felipe A. Lisboa, and Allan D. Kirk
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Subset Analysis ,Adult ,Male ,medicine.medical_specialty ,Herpesvirus 4, Human ,medicine.medical_treatment ,Inflammation ,Critical Care and Intensive Care Medicine ,Virus ,Text mining ,Internal medicine ,medicine ,Humans ,Mechanical ventilation ,Univariate analysis ,business.industry ,Multiple Trauma ,Reverse Transcriptase Polymerase Chain Reaction ,Area under the curve ,Middle Aged ,medicine.disease ,Polytrauma ,MicroRNAs ,Herpesvirus 8, Human ,RNA, Viral ,Female ,medicine.symptom ,business - Abstract
Objectives To evaluate early activation of latent viruses in polytrauma patients and consider prognostic value of viral micro-RNAs in these patients. Design This was a subset analysis from a prospectively collected multicenter trauma database. Blood samples were obtained upon admission to the trauma bay (T0), and trauma metrics and recovery data were collected. Setting Two civilian Level 1 Trauma Centers and one Military Treatment Facility. Patients Adult polytrauma patients with Injury Severity Scores greater than or equal to 16 and available T0 plasma samples were included in this study. Patients with ICU admission greater than 14 days, mechanical ventilation greater than 7 days, or mortality within 28 days were considered to have a complicated recovery. Interventions None. Measurements and main results Polytrauma patients (n = 180) were identified, and complicated recovery was noted in 33%. Plasma samples from T0 underwent reverse transcriptase-quantitative polymerase chain reaction analysis for Kaposi's sarcoma-associated herpesvirus micro-RNAs (miR-K12_10b and miRK-12-12) and Epstein-Barr virus-associated micro-RNA (miR-BHRF-1), as well as Luminex multiplex array analysis for established mediators of inflammation. Ninety-eight percent of polytrauma patients were found to have detectable Kaposi's sarcoma-associated herpesvirus and Epstein-Barr virus micro-RNAs at T0, whereas healthy controls demonstrated 0% and 100% detection rate for Kaposi's sarcoma-associated herpesvirus and Epstein-Barr virus, respectively. Univariate analysis revealed associations between viral micro-RNAs and polytrauma patients' age, race, and postinjury complications. Multivariate least absolute shrinkage and selection operator analysis of clinical variables and systemic biomarkers at T0 revealed that interleukin-10 was the strongest predictor of all viral micro-RNAs. Multivariate least absolute shrinkage and selection operator analysis of systemic biomarkers as predictors of complicated recovery at T0 demonstrated that miR-BHRF-1, miR-K12-12, monocyte chemoattractant protein-1, and hepatocyte growth factor were independent predictors of complicated recovery with a model complicated recovery prediction area under the curve of 0.81. Conclusions Viral micro-RNAs were detected within hours of injury and correlated with poor outcomes in polytrauma patients. Our findings suggest that transcription of viral micro-RNAs occurs early in the response to trauma and may be associated with the biological processes involved in polytrauma-induced complicated recovery.
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- 2021
28. Primary Lung Hernia After Blunt Chest Trauma: Chest Wall Repair Strategies
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Emad S. Madha, Elliot Jessie, Matthew J. Bradley, Leonid Belyayev, and William J. Parker
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medicine.medical_specialty ,Lung ,business.industry ,Lung hernia ,Trauma chest ,030208 emergency & critical care medicine ,General Medicine ,respiratory system ,medicine.disease ,respiratory tract diseases ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Blunt ,medicine.anatomical_structure ,Cardiothoracic surgery ,030220 oncology & carcinogenesis ,medicine ,Hernia ,business ,Thoracic trauma - Abstract
Lung herniation is a rare pathology seen after trauma. A case of acquired lung hernia is presented after blunt thoracic trauma that was repaired primarily. Surgical management and decision-making for this process are discussed.
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- 2021
29. Surgery at Sea: Exploring the Training Gap for Isolated Military Surgeons
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W. Brian Sweeney, Carlos J. Rodriguez, Elliot Jessie, Matthew D. Nealeigh, Matthew J. Bradley, Walter B. Kucera, and E. Matthew Ritter
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Adult ,Male ,medicine.medical_specialty ,Specialties, Surgical ,Education ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Case mix index ,medicine ,Humans ,Hernia ,030212 general & internal medicine ,Naval Medicine ,Ships ,Retrospective Studies ,Career Choice ,business.industry ,Vasectomy ,Internship and Residency ,medicine.disease ,United States ,Surgery ,Navy ,Military Personnel ,Education, Medical, Graduate ,030220 oncology & carcinogenesis ,Preparedness ,Orthopedic surgery ,Needs assessment ,Female ,Clinical Competence ,business ,Surgical Specialty ,Mobile Health Units - Abstract
Newly-graduated military general surgeons often find themselves isolated at sea, solely responsible for all surgical care of several thousand sailors, regardless of the surgical specialty training required for any individual procedure. This educational need assessment explored trends in afloat surgical care over the last 25 years, and assessed trainees' preparedness for their expected role as an isolated surgeon.A sample of deidentified US Navy Ship's Surgeon case logs were reviewed to determine afloat case load trends in 5 common afloat case categories (urologic/gynecologic, anorectal, hernia, appendectomy, and hand/orthopedic/trauma) from 1990s to 2017. Individual procedures were mapped to American College of Surgeons/Military Health System Knowledge, Skills, and Attitudes line items to ensure afloat-relevant skills were identified. Recent military resident case logs were then compared with afloat cases to evaluate relevant trainee experience.US Navy ships at sea from 1995 to 2017.US Navy afloat-deployed surgeons, totaling 1340 cases within the study period.Case log analysis of 1340 surgeries, comprising200 months at sea, reflected 46 named procedures; 34 of 46 (74%) correlated to an intraoperative knowledge, skills, and attitudes item. The most common surgeries were vasectomy, (304 of 1340, 23%). No difference in case mix was apparent comparing pre- and post-2000 deployments (representing afloat laparoscopic integration) in 4 of 5 categories, while hernias proportionally declined. Case volume per deployment markedly declined overall (p0.001) and in each category. Resident case log analysis from 2012 to 2016 showed experience was limited in urologic/gynecologic, orthopedic, and open appendectomy categories.No formal case repository exists for afloat surgery, making detailed analysis problematic. Current training provides excellent surgical education but minimal exposure to rare-but-real cases expected on deployments, which may not translate to competency for the isolated, afloat surgeon. Military surgical leadership should embrace training for these cases and assertively invest in the development of the military's newest surgeons.
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- 2019
30. Postoperative Pneumonia Increases the Risk of Venous Thromboembolism in Patients: A Propensity Score Analysis
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Matthew J. Bradley, Eric A. Elster, Patrick Benoit, Scott F. Grey, Peter A. Learn, Carolyn Gosztyla, and Rathnayaka M. Kalpanee D. Gunasingha
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medicine.medical_specialty ,business.industry ,Internal medicine ,Propensity score matching ,Medicine ,Surgery ,In patient ,Postoperative pneumonia ,business ,Venous thromboembolism - Published
- 2021
31. Treatment Effect or Effective Treatment? Cardiac Compression Fraction and End-tidal Carbon Dioxide Are Higher in Patients Resuscitative Endovascular Balloon Occlusion of the Aorta Compared with Resuscitative Thoracotomy and Open-Chest Cardiac Massage
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William A. Teeter, Matthew J. Bradley, Deborah M. Stein, Anna Romagnoli, Thomas M. Scalea, Yao Li, Peter Hu, and Megan Brenner
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Resuscitation ,Aorta ,Resuscitative thoracotomy ,business.industry ,medicine.medical_treatment ,030208 emergency & critical care medicine ,General Medicine ,030204 cardiovascular system & hematology ,medicine.disease ,Constriction ,03 medical and health sciences ,0302 clinical medicine ,Balloon occlusion ,medicine.artery ,Anesthesia ,Medicine ,Embolization ,business ,Prospective cohort study ,Penetrating trauma - Abstract
The purpose of this study is to compare end-tidal carbon dioxide (EtCO2) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group ( P = 2 values, but mean, median, peak, and final EtCO2 values were lower in OCCM ( P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA ( P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently ( P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO2 and cardiac compression fraction before and after AO compared with patients who receive OCCM.
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- 2018
32. The Isolated Surgeon: A Scoping Review
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Matthew J. Bradley, Anthony R. Artino, Walter B. Kucera, Holly S. Meyer, and Matthew D. Nealeigh
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medicine.medical_specialty ,Urology ,Specialty ,Patient care ,03 medical and health sciences ,0302 clinical medicine ,Professional Role ,Health care ,medicine ,Humans ,Varied practice ,Surgeons ,Scope (project management) ,business.industry ,Professional development ,Vascular surgery ,medicine.disease ,Obstetrics ,Orthopedics ,Gynecology ,Military Deployment ,030220 oncology & carcinogenesis ,General Surgery ,Orthopedic surgery ,030211 gastroenterology & hepatology ,Surgery ,Medical emergency ,Clinical Competence ,Rural Health Services ,business ,Vascular Surgical Procedures - Abstract
Background Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care. Methods We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role. Results From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, “rare-but-real” cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings. Conclusions This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.
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- 2020
33. Evaluation of CO2 Hydrogenation in a Modular Fixed-Bed Reactor Prototype
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David J. Hasler, Dennis R. Hardy, Lyman J Frost, Jeffrey W. Baldwin, Felice DiMascio, James R. Morse, Matthew J. Bradley, Joseph J. Hartvigsen, and Heather D. Willauer
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Chemical process ,fixed-bed reactor ,Materials science ,010402 general chemistry ,lcsh:Chemical technology ,01 natural sciences ,Catalysis ,lcsh:Chemistry ,X-ray photoelectron spectroscopy ,lcsh:TP1-1185 ,Physical and Theoretical Chemistry ,Process engineering ,Naval research ,chemistry.chemical_classification ,010405 organic chemistry ,business.industry ,Fixed bed ,gas hourly space velocity (GHSV) ,carbon dioxide ,Modular design ,0104 chemical sciences ,Hydrocarbon ,chemistry ,lcsh:QD1-999 ,hydrogenation ,business ,Selectivity ,catalyst - Abstract
Low-cost iron-based CO2 hydrogenation catalysts have shown promise as a viable route to the production of value-added hydrocarbon building blocks. It is envisioned that these hydrocarbons will be used to augment industrial chemical processes and produce drop-in replacement operational fuel. To this end, the U.S. Naval Research Laboratory (NRL) has been designing, testing, modeling, and evaluating CO2 hydrogenation catalysts in a laboratory-scale fixed-bed environment. To transition from the laboratory to a commercial process, the catalyst viability and performance must be evaluated at scale. The performance of a Macrolite®, supported iron-based catalyst in a commercial-scale fixed-bed modular reactor prototype was evaluated under different reactor feed rates and product recycling conditions. CO2 conversion increased from 26% to as high as 69% by recycling a portion of the product stream and CO selectivity was greatly reduced from 45% to 9% in favor of hydrocarbon production. In addition, the catalyst was successfully regenerated for optimum performance. Catalyst characterization by X-ray diffraction (XRD) and X-ray photoelectron spectroscopy (XPS), along with modeling and kinetic analysis, highlighted the potential challenges and benefits associated with scaling-up catalyst materials and processes for industrial implementation.
- Published
- 2020
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34. NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis
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Matthew J. Bradley, Somer Blair, Carlos J. Rodriguez, Cathryn Coleman, Mandy J Fisk, and Rex E. Atwood
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Adult ,Male ,medicine.medical_specialty ,Abdominal pain ,Adolescent ,Adult population ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Medicine ,Humans ,False Negative Reactions ,Aged ,Ultrasonography ,business.industry ,Ultrasound ,Middle Aged ,medicine.disease ,Appendicitis ,Predictive value ,Quality Improvement ,Acs nsqip ,030220 oncology & carcinogenesis ,Acute appendicitis ,030211 gastroenterology & hepatology ,Surgery ,Female ,Radiology ,medicine.symptom ,business ,Indeterminate - Abstract
Background It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis. Study Design The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results. Results Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI. Conclusions Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.
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- 2020
35. Outcomes following administration of tranexamic acid in combat-related intracranial hemorrhage: a cohort study
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Luke R. Johnston, Eric A. Elster, Patrick F. Walker, Matthew J. Bradley, Joseph D. Bozzay, and Carlos J. Rodriguez
- Subjects
medicine.medical_specialty ,Text mining ,business.industry ,Internal medicine ,medicine ,business ,Administration (government) ,Tranexamic acid ,Cohort study ,medicine.drug - Abstract
BACKGROUND: Tranexamic acid (TXA) may be a useful adjunct for military patients with severe traumatic brain injury (TBI). These patients are often treated in austere settings without immediate access to neurosurgical intervention. The purpose of this study was to evaluate any association between TXA use and progression of intracranial hemorrhage (ICH), neurologic outcomes, and venous thromboembolism (VTE) in TBI.METHODS: This was a retrospective cohort study of combat casualties from October 2010 to December 2015 who were transferred to a military treatment facility (MTF) in the United States. Data collected included: demographics, types of injuries, initial and interval head computerized tomography (CT) scans, Glasgow Coma Scores (GCS), and six-month Glasgow Outcome Scores (GOS). Results were stratified based on TXA administration, progression of ICH, and VTE.RESULTS: Of the 687 active duty service members reviewed, 71 patients had ICH (10.3%). Most casualties were injured in a blast (80.3%), with 36 patients (50.7%) sustaining a penetrating TBI. Mean ISS was 28.2 ± 12.3. Nine patients (12.7%) received a massive transfusion within 24 hours of injury, and TXA was administered to 14 (19.7%) casualties. Patients that received TXA had lower initial reported GCS (9.2 ± 4.4 vs. 12.5 ± 3.4, p=0.003), similar discharge GCS (13.3 ±4.0 vs. 13.8±3.2, p=0.58), and a larger improvement between initial and discharge GCS (3.7±3.9 vs. 1.3±3.1, p=0.02). However, there was no difference in mortality (7.1% vs. 7.0%, p=1.00), progression of ICH (45.5% vs. 14.7%, p=0.09), frequency of cranial decompression (50.0% vs. 42.1%, p=0.76), or mean GOS (3.5±0.9 vs. 3.8±1.0, p=0.13). Patients administered TXA had a higher rate of VTE (35.7% vs. 7.0%, p=0.01). On multivariate analysis, however, TXA was not independently associated with VTE.CONCLUSIONS: Patients that received TXA were associated with an improvement in GCS but not in progression of ICH or GOS. TXA was not independently associated with VTE, although this may be related to a paucity of patients receiving TXA. Decisions about TXA administration in combat casualties with ICH should be considered in the context of the availability of neurosurgical intervention as well as severity of extracranial injuries and need for massive transfusion.
- Published
- 2020
36. Small molecule inhibition of non-canonical (TAK1-mediated) BMP signaling results in reduced chondrogenic ossification and heterotopic ossification in a rat model of blast-associated combat-related lower limb trauma
- Author
-
Amy L. Strong, Charles Hwang, Amanda K. Huber, Kenneth D. Westover, Simone Marini, Matthew J. Bradley, Devaveena Dey, Benjamin Levi, Patrick D. Grimm, Chase A. Pagani, Ryan M. Haskins, Thomas A. Davis, Philip J. Spreadborough, Yuji Mishina, and Keiko Kaneko
- Subjects
0301 basic medicine ,Histology ,Physiology ,Endocrinology, Diabetes and Metabolism ,030209 endocrinology & metabolism ,Bone morphogenetic protein ,Article ,03 medical and health sciences ,Mice ,0302 clinical medicine ,In vivo ,Osteogenesis ,Medicine ,Animals ,Progenitor cell ,business.industry ,Ossification ,Ossification, Heterotopic ,Mesenchymal stem cell ,medicine.disease ,Rats ,030104 developmental biology ,Lower Extremity ,Cell culture ,Knockout mouse ,Cancer research ,Quality of Life ,Heterotopic ossification ,medicine.symptom ,business ,Chondrogenesis - Abstract
Heterotopic ossification (HO) is defined as ectopic bone formation around joints and in soft tissues following trauma, particularly blast-related extremity injuries, thermal injuries, central nerve injuries, or orthopaedic surgeries, leading to increased pain and diminished quality of life. Current treatment options include pharmacotherapy with non-steroidal anti-inflammatory drugs, radiotherapy, and surgical excision, but these treatments have limited efficacy and have associated complication profiles. In contrast, small molecule inhibitors have been shown to have higher specificity and less systemic cytotoxicity. Previous studies have shown that bone morphogenetic protein (BMP) signaling and downstream non-canonical (SMAD-independent) BMP signaling mediated induction of TGF-β activated kinase-1 (TAK1) contributes to HO. In the current study, small molecule inhibition of TAK1, NG-25, was evaluated for its efficacy in limiting ectopic bone formation following a rat blast-associated lower limb trauma and a murine burn tenotomy injury model. A significant decrease in total HO volume in the rat blast injury model was observed by microCT imaging with no systemic complications following NG-25 therapy. Furthermore, tissue-resident mesenchymal progenitor cells (MPCs) harvested from rats treated with NG-25 demonstrated decreased proliferation, limited osteogenic differentiation capacity, and reduced gene expression of Tac1, Col10a1, Ibsp, Smad3, and Sox2 (P < 0.05). Single cell RNA-sequencing of murine cells harvested from the injury site in a burn tenotomy injury model showed increased expression of these genes in MPCs during stages of chondrogenic differentiation. Additional in vitro cell cultures of murine tissue-resident MPCs and osteochondrogenic progenitors (OCPs) treated with NG-25 demonstrated reduced chondrogenic differentiation by 10.2-fold (P < 0.001) and 133.3-fold (P < 0.001), respectively, as well as associated reduction in chondrogenic gene expression. Induction of HO in Tak1 knockout mice demonstrated a 7.1-fold (P < 0.001) and 2.7-fold reduction (P < 0.001) in chondrogenic differentiation of murine MPCs and OCPs, respectively, with reduced chondrogenic gene expression. Together, our in vivo models and in vitro cell culture studies demonstrate the importance of TAK1 signaling in chondrogenic differentiation and HO formation and suggest that small molecule inhibition of TAK1 is a promising therapy to limit the formation and progression of HO.
- Published
- 2020
37. Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry
- Author
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Eric A. Elster, Carlos J. Rodriguez, Angela T. Kindvall, William J Parker, Robert W DesPain, Peter A. Learn, Elliot Jessie, and Matthew J. Bradley
- Subjects
medicine.medical_specialty ,Quality management ,medicine.medical_treatment ,MEDLINE ,Process improvement ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,medicine ,Humans ,Sampling (medicine) ,030212 general & internal medicine ,Registries ,Retrospective Studies ,business.industry ,030503 health policy & services ,Health Policy ,General surgery ,Public Health, Environmental and Occupational Health ,Hernia repair ,medicine.disease ,Quality Improvement ,Acs nsqip ,Bowel obstruction ,General Surgery ,0305 other medical science ,business ,Complication ,Emergency Service, Hospital - Abstract
Background The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes. Methods A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases. Results In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications. Conclusions National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.
- Published
- 2020
38. Use of negative pressure wound therapy on conflict-related wounds
- Author
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Matthew J. Bradley, Eric A. Elster, and Rex E. Atwood
- Subjects
medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,lcsh:Public aspects of medicine ,MEDLINE ,lcsh:RA1-1270 ,General Medicine ,Text mining ,Negative-pressure wound therapy ,medicine ,Humans ,Musculoskeletal Diseases ,Intensive care medicine ,business ,Negative-Pressure Wound Therapy - Published
- 2020
39. Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties
- Author
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David R. Tribble, Laveta Stewart, Matthew J. Bradley, David Schechtman, Faraz Shaikh, Patrick F. Walker, and Joseph D. Bozzay
- Subjects
Adult ,Male ,medicine.medical_specialty ,Exploratory laparotomy ,medicine.medical_treatment ,Abdominal Injuries ,Article ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Injury Severity Score ,Battlefield ,Interquartile range ,Risk Factors ,Laparotomy ,Abdominal exploration ,Surgical site ,Medicine ,Humans ,Surgical Wound Infection ,business.industry ,Abdominal Infection ,Surgical procedures ,Surgery ,Survival Rate ,Military Personnel ,Treatment Outcome ,Military Deployment ,030220 oncology & carcinogenesis ,War-Related Injuries ,030211 gastroenterology & hepatology ,Female ,business - Abstract
Background Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties. Methods Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals. Results Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively. Conclusions Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.
- Published
- 2020
40. Damage Control Surgery
- Author
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Jennifer M. Gurney, Jacob J. Glaser, Douglas M. Pokorny, Matthew J. Bradley, and John B. Holcomb
- Subjects
Damage control ,medicine.medical_specialty ,Resuscitation ,business.industry ,Damage control resuscitation ,medicine.disease ,Intensive care unit ,Blast injury ,Patient care ,law.invention ,law ,Damage control surgery ,medicine ,Intensive care medicine ,business ,Surgical interventions - Abstract
Damage control is the process of counteracting an unfavorable situation in order to curtail losses. First utilized by the United States Navy, a “damage controlman” was responsible for temporary salvage of a vessel under duress so that it could make its way to a port for formal repairs. This principle, rapid salvage to stabilize long enough for definitive repair, was adopted by numerous surgical fields and is now considered the gold standard in the care of significantly injured patients. This concept encompasses the entirety of patient care from the point of injury and initial resuscitation to the control of hemorrhage and contamination to stabilization in the critical care unit and back to the operating room for definitive anatomic repair. In this chapter, we will review the history of damage control, provide a guide to damage control procedures with specific focus on blast injuries, and reinforce the necessity of proper damage control resuscitation in concert with the surgical interventions.
- Published
- 2020
41. Vascular Injuries
- Author
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William J. Parker, Robert W. DesPain, Matthew J. Bradley, and Todd E. Rasmussen
- Published
- 2020
42. Military Trauma System Response to Blast MCI
- Author
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Robert W. DesPain, Matthew J. Bradley, William J. Parker, and Todd E. Rasmussen
- Subjects
Mass-casualty incident ,business.industry ,Incident management ,Trauma management ,Medical record ,medicine ,Medical emergency ,medicine.disease ,business ,Triage ,Trauma Surgeon ,Blast injury ,Patient identification - Abstract
Explosions were the most common source of injury during Operation Enduring Freedom and Operation Iraqi Freedom. A single blast can generate numerous casualties with complex injuries. When these patients overwhelm a medical system, a mass casualty incident occurs. The United States Military has been at the forefront of trauma management, and this includes the management of blast injuries and mass casualty incidents. Following the establishment of scene and medical facility security, the management of a mass casualty incident begins with appropriate triage. The ultimate goal of triage is to provide the greatest good for the greatest number of patients. The triage officer, ideally an experienced trauma surgeon, assigns patients to four possible triage categories: immediate, delayed, minimal, and expectant. While most civilian emergency departments are concerned with undertriage, overtriage can be especially dangerous during a mass casualty incident due to the resulting resource misallocation. During the triage process, patients should be entered into a patient identification system and medical record should be generated. Mass casualty incidents require a surge of resources to include blood products. Blast injury patients are more likely to require massive transfusions as compared to injuries from small arms. A potential source of blood products is fresh whole blood. For the military, the management of injuries is divided amongst defined four roles of care. Each role has a set amount of resources and skills that the next higher role builds upon. This ensures the orderly flow of injured patients from austere environments back to United States medical centers, such as the Walter Reed National Military Medical Center. Ultimately, effective mass casualty incident management depends on an established system that has undergone simulations and practice before the real event. In addition, each mass casualty incident should provide “lessons-learned” to ensure proper preparation for the next event.
- Published
- 2020
43. Diagnosis and Management of Penetrating Thoracic Vascular Injury
- Author
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Thomas M. Scalea and Matthew J. Bradley
- Subjects
medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,medicine.medical_treatment ,medicine.disease ,Abnormal pulse ,Trauma Surgeon ,Hematoma ,Great vessels ,Angiography ,medicine ,Radiology ,Thoracotomy ,business ,Thoracic trauma ,Computed tomography angiography - Abstract
Although penetrating vascular injuries only account for a small portion of thoracic trauma, they are challenging and can be lethal. Thus, it is imperative that the trauma surgeon understands how to diagnose and manage them. An abnormal pulse exam, an expanding hematoma, or active external hemorrhage are clear signs of a vascular injury. Imaging studies, such as CT angiography, provide valuable information in the hemodynamically normal patient. The patient who is hemodynamically compromised or hypotensive or both requires emergent exploration.
- Published
- 2020
44. Assessing Risk and Related Complications after Reversal of Combat-Associated Ostomies
- Author
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Matthew J. Bradley, Luke R. Johnston, Eric A. Elster, James E. Duncan, Michael P. McNally, and Carlos J. Rodriguez
- Subjects
Adult ,Male ,medicine.medical_specialty ,Multivariate analysis ,Risk Assessment ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Older patients ,Risk Factors ,Colostomy ,medicine ,Humans ,In patient ,Registries ,Risk factor ,Retrospective Studies ,Ileostomy ,business.industry ,Military Treatment Facility ,Curve analysis ,030208 emergency & critical care medicine ,Odds ratio ,Surgery ,Military Personnel ,030220 oncology & carcinogenesis ,War-Related Injuries ,Complication ,business - Abstract
Background During the past decade of conflict, numerous patients with combat-associated injuries required the formation of an ostomy. However, outcomes in those patients undergoing ostomy reversal have yet to be analyzed. We review the experience and identify risk factors for complications after ostomy reversal in a series of patients with combat injuries at our military treatment facility. Study Design A retrospective review of patients with combat-associated injuries managed with a diverting ostomy who underwent ostomy reversal at our military treatment facility during a 13-year period. Demographic and clinical data were collected for all patients and postoperative complications were identified. Multivariate analysis was performed to identify independent risk factors for complications after reversal. Complication rates were calculated for 90-day periods of time after ostomy creation and best-fit curve analysis was conducted. Results Ninety-nine patients were identified who underwent ostomy reversal. Forty patients (40.4%) suffered a post-reversal complication. On multivariate analysis, older age (odds ratio 1.11/y; p = 0.038), severe perineal injury indication for diversion (odds ratio 4.37; p = 0.028), and increased time interval between ostomy creation and reversal (odds ratio 1.005/d; p = 0.037), were independently associated with postoperative complications. A cubic regression best fit quarterly complication rate data (R2 0.526; p Conclusions Ostomy reversal in patients wounded in combat is a major undertaking with a high complication rate. The finding of a shorter interval from ostomy creation to reversal independently associated with a reduction in complications provides a modifiable risk factor to guide future practice and potentially reduce complications. Our modeling suggests reversal in the 3- to 6-month time frame can have the lowest rate of complications. Future research to reduce complications is indicated, especially in older patients with perineal wounds.
- Published
- 2018
45. Prevention of Deep Venous Thromboembolism
- Author
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Matthew D. Tadlock, Matthew J. Bradley, Daniel Grabo, Jason M Seery, Michel J. Kearns, Scott Zakaluzny, and Nathanial Fernandez
- Subjects
medicine.medical_specialty ,Vena Cava Filters ,medicine.drug_class ,Low molecular weight heparin ,Guidelines as Topic ,Inferior vena cava ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Fixed wing ,Risk Factors ,medicine ,Humans ,cardiovascular diseases ,Intensive care medicine ,Venous Thrombosis ,business.industry ,Public Health, Environmental and Occupational Health ,Anticoagulants ,030208 emergency & critical care medicine ,General Medicine ,Guideline ,Heparin ,medicine.disease ,Pulmonary embolism ,Venous thrombosis ,medicine.vein ,Wounds and Injuries ,business ,Venous thromboembolism ,medicine.drug - Abstract
The nature of many combat wounds puts patients at a high risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE), which fall under the broader disease category of venous thromboembolism (VTE). In addition to the hypercoagulable state induced by trauma, massive injuries to the extremities, prolonged immobility, and long fixed wing transport times to higher echelons of care are unique risk factors for venous thromboembolism in the combat-injured patient. These risk factors mandate aggressive prophylaxis for DVT and PE that can effectively be achieved by the use of lower extremity sequential compression devices and low dose unfractionated heparin or low molecular weight heparin. In addition, inferior vena cava filters are often used for PE prophylaxis when chemical DVT prophylaxis fails or is contraindicated. The following Department of Defense (DoD) Joint Trauma System (JTS) Clinical Practice Guideline (CPG) discusses the current recommendations for the prevention of DVT and PE including the use of inferior vena cava filters (IVCFs).
- Published
- 2018
46. Tube Thoracostomy Management in the Combat Wounded
- Author
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Carlos J. Rodriguez, Matthew J. Bradley, Alley E. Ronaldi, Joseph D. Bozzay, Eric A. Elster, and Patrick F. Walker
- Subjects
business.industry ,Incidence (epidemiology) ,030208 emergency & critical care medicine ,General Medicine ,medicine.disease ,Hemothorax ,Thoracostomy ,Confidence interval ,Empyema ,03 medical and health sciences ,Pneumonia ,0302 clinical medicine ,Pneumothorax ,Anesthesia ,medicine ,Injury Severity Score ,030212 general & internal medicine ,business - Abstract
The intent of this study was to characterize the management and subsequent complications of combat injury tube thoracostomies and to determine risk factors for the development of pneumonia (PNA) and retained hemothorax (RH). One hundred fifteen patients with 173 tube thoracostomies met the inclusion criteria and were analyzed. The mean injury severity score was 30.8 1 11.6, 23.5 per cent had traumatic amputations, 49.7 per cent had a hemothorax, and 50.3 per cent had a pneumothorax as indications for tube thoracostomy (TT) placement. Within 24 hours of injury, 89.6 per cent were intubated, the majority (54%) were injured by improvised explosive devices, 35.6 per cent sustained rib fractures, and 12.2 per cent had a diaphragm injury. A mean of 1.5 1 0.7(range 1–4) tube thoracostomies were placed, 18.3 per cent of patients had bilateral tube thoracostomies, and the average TT duration was 6.7 1 3.9 days. The incidence of PNA was 27 per cent (n = 31), RH was 9.6 per cent (n = 11), and empyema was 1.7 per cent (n = 2). Multivariable analysis identified the duration of ventilation [OR 1.2, 95% confidence interval (CI): 1.097–1.313, P < 0.001] as independently associated with the development of PNA. Bilateral TT placement (OR 3.848, 95% CI: 1.219–12.143, P = 0.0216) and injury severity score (OR 1.050, 95% CI: 1.001–1.102, P = 0.0443) were independently associated with PNA development when a patient was intubated for eight days or less. The number of tube thoracostomies placed (OR 3.08, 95% CI: 1.03–9.18, P = 0.0439) was independently associated with the development of RH. Further research is warranted to identify modifiable risk factors to reduce the incidence of PNA and RH in patients with TT placed for traumatic injuries.
- Published
- 2018
47. Battlefield to Bedside: Bringing Precision Medicine to Surgical Care
- Author
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Christopher J. Dente, Arnaud Belard, Matthew J. Bradley, Allan D. Kirk, Seth Schobel, Eric A. Elster, Benjamin K. Potter, and Timothy G. Buchman
- Subjects
Critical Care ,business.industry ,Surgical care ,Decision Making ,MEDLINE ,Bayesian network ,030208 emergency & critical care medicine ,Precision medicine ,medicine.disease ,Clinical decision support system ,Military medicine ,Translational Research, Biomedical ,03 medical and health sciences ,0302 clinical medicine ,Battlefield ,General Surgery ,Humans ,Medicine ,Surgery ,030212 general & internal medicine ,Medical emergency ,Precision Medicine ,Military Medicine ,business ,Biomarkers - Published
- 2018
48. Primary Pulmonary Thrombus in Combat Casualties: Is Treatment Necessary?
- Author
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Carlos J. Rodriguez, Eric A. Elster, Dean E. Baird, Michael D. Baird, Matthew J. Bradley, and Paul G. Peterson
- Subjects
medicine.medical_specialty ,business.industry ,Chest ct ,Military Treatment Facility ,030208 emergency & critical care medicine ,Retrospective cohort study ,General Medicine ,030204 cardiovascular system & hematology ,medicine.disease ,Inferior vena cava ,Surgery ,Natural history ,03 medical and health sciences ,0302 clinical medicine ,medicine.vein ,Medicine ,heterocyclic compounds ,Thrombus ,business - Abstract
The objective of this study was to describe the natural history of primary pulmonary thrombus (PPT) in combat casualties. This was a retrospective study of casualties treated at a major military treatment facility from 2010 to 2012. Patients with a downrange chest CTwere included. CTs were reviewed by two independent, blinded radiologists to confirm PPTon initial imaging. Follow-up CTs, if obtained, were also independently reviewed to determine the extent of clot burden. Two hundred and forty-nine casualties with a downrange, acceptable quality chest CT were included. 9 per cent (23/249) of patients sustained PPT. Thirty nine per cent (9/23) were initially treated with therapeutic anticoagulation (AC). Conversely, 61 per cent (14/23) arrived to our military treatment facility without AC. Seven arriving without AC-developed pulmonary symptoms during their hospitalization and had interval chest CTs. Of those, three had no evidence of pulmonary thrombus. The other four had subsegmental filling defects and three were started AC whereas one had an IVC (Inferior Vena Cava) filter inserted. In total, 11/23 (48%) PPT patients were managed without AC and discharged without complications. This is the first study attempting to look at PPT natural history. There were no adverse sequelae from managing PPT without AC. Further studies are warranted to further characterize PPT.
- Published
- 2018
49. Traumatic Brain Injury in Combat Casualties
- Author
-
Patrick F. Walker, Matthew J. Bradley, Carlos J. Rodriguez, Joseph D. Bozzay, and Randy S. Bell
- Subjects
Damage control ,medicine.medical_specialty ,Rehabilitation ,Traumatic brain injury ,business.industry ,medicine.medical_treatment ,Psychological intervention ,030208 emergency & critical care medicine ,medicine.disease ,03 medical and health sciences ,Intracranial vascular ,0302 clinical medicine ,Cranial decompression ,Intervention (counseling) ,medicine ,Orthopedics and Sports Medicine ,Surgery ,Intensive care medicine ,business ,030217 neurology & neurosurgery - Abstract
The purpose of this review is to give an overview of recent updates in the management of traumatic brain injury (TBI) in military settings. Studies from the recent conflicts in Central and Southwest Asia have demonstrated that appropriate aggressive neurosurgical intervention in austere settings has been associated with improved outcomes. Modern management of military TBI has evolved from the era of Cushing in WWI to damage control and rapid aeromedical evacuation today. Aggressive management of severe injuries has been shown to increase survival. These interventions have included an emphasis on measures to reduce secondary brain injury—aggressive cranial decompression, addressing intracranial vascular injuries, and aeromedical evacuation to facilities with neurosurgical capability. Additionally, advances in the screening of mild TBI have led to increased awareness of the prevalence of this injury and potential associated long-term effects.
- Published
- 2018
50. Management of post-traumatic retained hemothorax
- Author
-
Joseph D. Bozzay and Matthew J. Bradley
- Subjects
medicine.medical_specialty ,Fibrothorax ,business.industry ,medicine.medical_treatment ,Traumatic hemothorax ,030208 emergency & critical care medicine ,Critical Care and Intensive Care Medicine ,Hemothorax ,medicine.disease ,Thoracostomy ,Empyema ,Surgery ,Chest tube ,03 medical and health sciences ,Pneumonia ,0302 clinical medicine ,Video-assisted thoracoscopic surgery ,Emergency Medicine ,medicine ,030212 general & internal medicine ,business - Abstract
Introduction Chest injuries occur in a significant portion of trauma patients and hemothorax is a common result. While the initial management of traumatic hemothorax is most commonly treated with tube thoracostomy, the management of retained hemothorax is a subject of debate. Recent literature has proposed different methods for treating or preventing retained hemothorax, yet the approach to this pathology is not straightforward. Methods The literature was reviewed for relevant studies regarding the prevention and management of post-traumatic retained hemothorax. What follows is a review of the recent literature and an algorithm for the approach to treating a traumatic retained hemothorax. Results Identifying a traumatic retained hemothorax and preventing subsequent complications such as pneumonia, empyema, and fibrothorax are significant issues faced by surgeons. Studies for preventing retained hemothorax have focused on initial chest tube size, location, and peri-procedural placement conditions, as well as thoracic lavage. Several treatment modalities exist, including second drainage procedure and intra-pleural fibrinolytic drug instillation, but video-assisted thoracoscopic surgery is the most common and successful approach. Regardless of the approach to evacuation, early intervention is paramount. Conclusion Further studies will help characterize appropriate candidates, timing, treatment modalities, and guide therapy for retained hemothorax.
- Published
- 2018
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