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  1. Article ; Online: Contemporary Rural Trauma Care.

    Gongola, AlleaBelle / Bradshaw, Jace C / Valdez, Carrie / Bhavaraju, Avi

    The American surgeon

    2023  Volume 89, Issue 6, Page(s) 2207–2212

    Abstract: The development of organized trauma systems has led to improved care for trauma patients, including those injured in rural areas. However, persistent disparities have led to increased awareness of the ongoing need for improvement. Our objective is to ... ...

    Abstract The development of organized trauma systems has led to improved care for trauma patients, including those injured in rural areas. However, persistent disparities have led to increased awareness of the ongoing need for improvement. Our objective is to highlight distinctive aspects of rural trauma and propose opportunities for advancing rural trauma care.
    MeSH term(s) Humans ; Emergency Medical Services ; Wounds and Injuries/therapy ; Trauma Centers ; Hospitals, Rural
    Language English
    Publishing date 2023-02-07
    Publishing country United States
    Document type Journal Article
    ZDB-ID 202465-2
    ISSN 1555-9823 ; 0003-1348
    ISSN (online) 1555-9823
    ISSN 0003-1348
    DOI 10.1177/00031348231156764
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  2. Article ; Online: Higher Doses of Calcium Associated With Survival in Trauma Patients.

    Wade, Dillon J / Pilkington, Collin / Henson, J Curran / Jensen, Hanna K / Kalkwarf, Kyle / Bhavaraju, Avi / Bruce, Nolan / Bowman, Stephen / Margolick, Joseph

    The Journal of surgical research

    2024  

    Abstract: Introduction: Calcium is required for coagulation, cardiac output, and peripheral vascular resistance. Between 85% and 94% of trauma patients treated with massive blood transfusion develop hypocalcemia.: Methods: We performed a retrospective analysis ...

    Abstract Introduction: Calcium is required for coagulation, cardiac output, and peripheral vascular resistance. Between 85% and 94% of trauma patients treated with massive blood transfusion develop hypocalcemia.
    Methods: We performed a retrospective analysis of trauma patients who received massive transfusion over a 2-y period. Doses of elemental calcium administered per unit of blood product transfused were calculated by calcium to blood product ratio (CBR). Chi-square test evaluated association between coagulopathy and 30-d mortality. Two-sample t-test evaluated association between CBR and coagulopathy. Bivariate regression analysis evaluated association between CBR and blood products transfused per patient. Multivariable logistic regression analysis, controlling for age, sex, coagulopathy, and Injury Severity Score evaluated the association between CBR and mortality.
    Results: The study included 77 patients. Coagulopathy was associated with increased 30-d mortality (P < 0.05). Patients who survived had higher CBR than those who died (P < 0.05). CBR was associated with a significant reduction in total blood products transfused per patient (P < 0.05). CBR was not associated with coagulopathy (P = 0.24). Multivariable logistic regression analysis demonstrated that Injury Severity Score ≥16, coagulopathy and decreased CBR were significant predictors of mortality (P < 0.05). CBR above 50 mg was a predictor of survival (P < 0.05).
    Conclusions: Higher doses of calcium given per blood product transfused were associated with improved 30-d survival and decreased blood product transfusions.
    Language English
    Publishing date 2024-03-21
    Publishing country United States
    Document type Journal Article
    ZDB-ID 80170-7
    ISSN 1095-8673 ; 0022-4804
    ISSN (online) 1095-8673
    ISSN 0022-4804
    DOI 10.1016/j.jss.2024.02.014
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  3. Article ; Online: Weight-Based Dosing for Low-Molecular-Weight Heparin (Enoxaparin) Administration to Achieve Optimal VTE Prophylaxis in Trauma Patients.

    Thind, Tarendeep / Heye, Thomas / Henson, Curran / Reif, Rebecca / Jensen, Hanna K / Kalkwarf, Kyle J / Bhavaraju, Avi / Robertson, Ronald / Jenkins, Allison

    The American surgeon

    2024  Volume 90, Issue 6, Page(s) 1406–1411

    Abstract: Introduction: Patients admitted after traumatic injuries are at high risk for developing venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is commonly used to prevent VTE in this patient population; however, the optimal dosing strategy ... ...

    Abstract Introduction: Patients admitted after traumatic injuries are at high risk for developing venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is commonly used to prevent VTE in this patient population; however, the optimal dosing strategy has yet to be determined. To address this question, a fixed-dosing strategy of LMWH was compared to a weight-based dosing strategy of LMWH for VTE prophylaxis.
    Methods: A retrospective, pre-post implementation cohort study compared a fixed vs a weight-based dosing strategy of LMWH for VTE prophylaxis. Patients admitted to our level 1 trauma center were included if they had an estimated glomerular filtration rate >30 mL/min/1.73 m
    Results: There were 817 patients in the fixed-dosing group (FDG) and 874 patients in the weight-based dosing group (WBDG). In the FDG, 42.8% of the patients achieved the goal initial anti-Xa level, with 54.1% and 3.1% reaching sub- and supratherapeutic doses, respectively. In the WBDG, 66.5% of patients reached goal initial anti-Xa levels, with 23.5% and 10.1% at sub- and supratherapeutic levels. The distribution of dose ranges was significantly different between the dosing strategies (
    Conclusions: In our study, weight-based dosing of LMWH yielded a significantly higher proportion of patients who achieved goal prophylactic anti-Xa levels than fixed-dosing of LMWH. Larger-scale studies are needed to assess the risk of VTE events and bleeding with these dosing strategies.
    MeSH term(s) Humans ; Venous Thromboembolism/prevention & control ; Venous Thromboembolism/etiology ; Retrospective Studies ; Male ; Female ; Middle Aged ; Enoxaparin/administration & dosage ; Wounds and Injuries/complications ; Anticoagulants/administration & dosage ; Adult ; Aged ; Body Weight ; Dose-Response Relationship, Drug ; Heparin, Low-Molecular-Weight/administration & dosage
    Language English
    Publishing date 2024-03-22
    Publishing country United States
    Document type Journal Article
    ZDB-ID 202465-2
    ISSN 1555-9823 ; 0003-1348
    ISSN (online) 1555-9823
    ISSN 0003-1348
    DOI 10.1177/00031348241241620
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  4. Article ; Online: Increased Lengths of Stay, ICU, and Ventilator Days in Trauma Patients with Asymptomatic COVID-19 Infection.

    Klutts, Garrett N / Squires, Austin / Bowman, Stephen M / Bhavaraju, Avi / Kalkwarf, Kyle J

    The American surgeon

    2022  Volume 88, Issue 7, Page(s) 1522–1525

    Abstract: Background: The SARS-Cov-2 coronavirus has varying clinical effects-from asymptomatic patients to life-threatening illness and death. At the only Level 1 Trauma Center in a rural state, outcomes appeared worse in trauma patients who tested positive for ... ...

    Abstract Background: The SARS-Cov-2 coronavirus has varying clinical effects-from asymptomatic patients to life-threatening illness and death. At the only Level 1 Trauma Center in a rural state, outcomes appeared worse in trauma patients who tested positive for COVID despite these patients presumably being asymptomatic or only mildly affected before their traumatic event. This study compares all trauma admissions that were COVID-positive to those who were not.
    Methods: The institutional database was queried for all level 1 and 2 trauma activations from March 2020-July 2021. The analysis consisted of a multivariate regression between COVID-negative and the COVID-positive group controlling for age, injury severity score (ISS), and Glasgow Coma Score (GCS). Outcomes compared were hospital length-of-stay (LOS), ICU LOS, ventilator days, days to discharge to a facility, and in-hospital mortality.
    Results: Hospital LOS was 2.7 days longer in the COVID-positive group (
    Conclusion: Trauma patients presenting positive for COVID-19 are presumed to be asymptomatic before their traumatic event. Despite this, the physiologic toll of trauma combined with the COVID infection causes significantly worse clinical outcomes, including increasing hospital days in this patient population, which continues to tax the already burdened healthcare system.
    MeSH term(s) COVID-19/therapy ; Humans ; Intensive Care Units ; Length of Stay ; Retrospective Studies ; SARS-CoV-2 ; Trauma Centers ; Ventilators, Mechanical
    Language English
    Publishing date 2022-04-13
    Publishing country United States
    Document type Journal Article
    ZDB-ID 202465-2
    ISSN 1555-9823 ; 0003-1348
    ISSN (online) 1555-9823
    ISSN 0003-1348
    DOI 10.1177/00031348221082290
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  5. Article ; Online: Improved Confidence and Clinical Application: The Effects of a Longitudinal Suture Curriculum for Medical Students.

    Shewmake, Connor / Speed, Olivia / Gammill, Sarah / Hartzell, Larry D / Thrush, Carol / Phelan, Kevin D / Golinko, Michael / Bhavaraju, Avi

    Southern medical journal

    2023  Volume 116, Issue 10, Page(s) 806–811

    Abstract: Objective: The ability to competently suture is an expected skill for graduating medical students, but many graduates report feeling unprepared to perform this skill. This study aimed to improve student confidence and clinical readiness for third-year ... ...

    Abstract Objective: The ability to competently suture is an expected skill for graduating medical students, but many graduates report feeling unprepared to perform this skill. This study aimed to improve student confidence and clinical readiness for third-year clerkships by implementing a novel, mandatory 7.5-hour longitudinal suturing skills curriculum across the first 3 years of medical school.
    Methods: The required suturing skills curriculum was implemented for all medical students throughout the first 3 years of medical school at a large academic health center in the mid-South United States. Precurriculum (n = 167) and postcourse (n = 148) surveys were administered to first-year students in the first year of the curriculum (2017-2018), and a parallel follow-up survey was administered to this cohort in 2020 after students completed their clinical clerkship year (n = 82). Aggregate changes in students' survey responses were analyzed for proper instrument position, simple interrupted sutures, and instrument ties using independent groups Mann-Whitney
    Results: Statistically significant improvement from pre to post was observed in student comfort in performing three basic skills: proper instrument position (
    Conclusions: We found that a longitudinal suture curriculum with dedicated faculty involvement can improve student confidence in suturing and overall preparedness for third-year clerkships. Although the study is limited to ratings of student comfort and self-reported performance as well as some attrition of responses at postcourse survey and postclerkship survey, the findings highlight the importance of a focused curriculum dedicated to teaching basic suturing skills. Our findings also contribute to the limited body of work examining longitudinal surgical skills development for medical students.
    MeSH term(s) Humans ; United States ; Students, Medical ; Clinical Competence ; Curriculum ; Surveys and Questionnaires ; Clinical Clerkship ; Sutures
    Language English
    Publishing date 2023-10-11
    Publishing country United States
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 185329-6
    ISSN 1541-8243 ; 0038-4348
    ISSN (online) 1541-8243
    ISSN 0038-4348
    DOI 10.14423/SMJ.0000000000001612
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  6. Article ; Online: Are Chest Radiographs or Ultrasound More Accurate in Predicting a Pneumothorax or Need for a Thoracostomy Tube in Trauma Patients?

    DeLoach, Joseph P / Reif, Rebecca J / Smedley, Westin A / Klutts, Garrett N / Bhavaraju, Avi / Collins, Terry H / Kalkwarf, Kyle J

    The American surgeon

    2023  Volume 89, Issue 9, Page(s) 3751–3756

    Abstract: Background: Historically, chest radiographs (CXR) have been used to quickly diagnose pneumothorax (PTX) and hemothorax in trauma patients. Over the last 2 decades, chest ultrasound (CUS) as part of Extended Focused Assessment with Sonography in Trauma ( ... ...

    Abstract Background: Historically, chest radiographs (CXR) have been used to quickly diagnose pneumothorax (PTX) and hemothorax in trauma patients. Over the last 2 decades, chest ultrasound (CUS) as part of Extended Focused Assessment with Sonography in Trauma (eFAST) has also become accepted as a modality for the early diagnosis of PTX in trauma patients.
    Methods: We queried our institution's trauma databases for all trauma team activations from 2021 for patients with eFAST results. Demographics, injury variables, and the following were collected: initial eFAST CUS, CXR, computed tomography (CT) scan, and thoracostomy tube procedure notes. We then compared PTX detection rates on initial CXR and CUS to those on thoracic CT scans.
    Results: 580 patients were included in the analysis after excluding patients without a chest CT scan within 2 hours of arrival. Extended Focused Assessment with Sonography in Trauma was 68.4% sensitive and 87.5% specific for detecting a moderate-to-large PTX on chest CT, while CXR was 23.5% sensitive and 86.3% specific. Extended Focused Assessment with Sonography in Trauma was 69.8% sensitive for predicting the need for tube thoracostomy, while CXR was 40.0% sensitive.
    Discussion: At our institution, eFAST CUS was superior to CXR for diagnosing the presence of a PTX and predicting the need for a thoracostomy tube. However, neither test is accurate enough to diagnose a PTX nor predict if the patient will require a thoracostomy tube. Based on the specificity of both tests, a negative CXR or eFAST means there is a high probability that the patient does not have a PTX and will not need a chest tube.
    MeSH term(s) Humans ; Chest Tubes ; Pneumothorax/diagnostic imaging ; Pneumothorax/etiology ; Pneumothorax/surgery ; Thoracostomy ; Radiography ; Ultrasonography/methods ; Thoracic Injuries/complications ; Thoracic Injuries/diagnostic imaging ; Retrospective Studies
    Language English
    Publishing date 2023-05-12
    Publishing country United States
    Document type Journal Article
    ZDB-ID 202465-2
    ISSN 1555-9823 ; 0003-1348
    ISSN (online) 1555-9823
    ISSN 0003-1348
    DOI 10.1177/00031348231175105
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  7. Article ; Online: Weight-Based Dosing for Venous Thromboembolism Prophylaxis in Spinal Trauma Patients Appears Safe.

    Heye, Thomas / Thind, Tarendeep / Jenkins, Allison / Reif, Rebecca / Jensen, Hanna K / Sexton, Kevin / Kalkwarf, Kyle / Bhavaraju, Avi

    The Journal of surgical research

    2023  Volume 290, Page(s) 209–214

    Abstract: Introduction: Venous thromboembolism (VTE) is a substantial cause of morbidity and mortality in trauma patients. VTE prophylaxis (VTEP) initiation is often delayed in certain patients due to the perceived risk of bleeding complications. Our VTEP ... ...

    Abstract Introduction: Venous thromboembolism (VTE) is a substantial cause of morbidity and mortality in trauma patients. VTE prophylaxis (VTEP) initiation is often delayed in certain patients due to the perceived risk of bleeding complications. Our VTEP guideline was changed from fixed-dosing to a weight-based dosing strategy using enoxaparin in June 2019. We investigated the rate of postoperative bleeding complications with a weight-based and a standard dosing protocol in traumatic spine injury patients requiring surgical stabilization.
    Methods: A retrospective pre-post cohort study using an institutional trauma database was conducted, comparing bleeding complications between fixed and weight-based VTEP protocols. Patients undergoing surgical stabilization of a spine injury were included. The preintervention cohort received fixed-dose thromboprophylaxis (30 mg twice daily or 40 mg daily); the postcohort received weight-based thromboprophylaxis (0.5 mg/kg q12 h with anti-factor Xa monitoring). All patients received VTEP 24-48 h after surgery. International Classification of Diseases codes were used to identify bleeding complications.
    Results: There were 68 patients in the pregroup and 68 in the postgroup with comparable demographics. Incidence of bleeding complications in the pre- and postgroups were 2.94% and 0% respectively.
    Conclusions: VTEP initiated 24-48 h after surgical stabilization of a spine fracture using a weight-based dosing strategy and has a similar rate of bleeding complications as a standard dose protocol. Our study is limited by the low overall incidence of bleeding complications and small sample size. These findings could be validated by a larger multicenter trial.
    MeSH term(s) Humans ; Anticoagulants ; Venous Thromboembolism/epidemiology ; Venous Thromboembolism/etiology ; Venous Thromboembolism/prevention & control ; Cohort Studies ; Retrospective Studies ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Postoperative Complications/prevention & control ; Postoperative Hemorrhage
    Chemical Substances Anticoagulants
    Language English
    Publishing date 2023-06-06
    Publishing country United States
    Document type Multicenter Study ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 80170-7
    ISSN 1095-8673 ; 0022-4804
    ISSN (online) 1095-8673
    ISSN 0022-4804
    DOI 10.1016/j.jss.2023.04.019
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  8. Article ; Online: Readmissions After Traumatic Brain Injury in the Nationwide Readmissions Database.

    Pilkington, Collin / Thind, Tarendeep / Bowman, Stephen M / Sexton, Kevin / Kimbrough, Mary Katherine / Porter, Austin / Davis, Ben / Bennett, Judy / Bhavaraju, Avi / Jensen, Hanna K

    The Journal of surgical research

    2024  Volume 298, Page(s) 36–40

    Abstract: Introduction: Readmissions after a traumatic brain injury (TBI) can have severe impacts on long-term health outcomes as well as rehabilitation. The aim of this descriptive study was to analyze the Nationwide Readmissions Database to determine possible ... ...

    Abstract Introduction: Readmissions after a traumatic brain injury (TBI) can have severe impacts on long-term health outcomes as well as rehabilitation. The aim of this descriptive study was to analyze the Nationwide Readmissions Database to determine possible risk factors associated with readmission for patients who previously sustained a TBI.
    Methods: This retrospective study used data from the Nationwide Readmissions Database to explore gender, age, injury severity score, comorbidities, index admission hospital size, discharge disposition of the patient, and cause for readmission for adults admitted with a TBI. Multivariable logistic regression was used to assess likelihood of readmission.
    Results: There was a readmission rate of 28.7% (n = 31,757) among the study population. The primary cause of readmission was either subsequent injury or sequelae of the original injury (n = 8825; 29%) followed by circulatory (n = 5894; 19%) and nervous system issues (n = 2904; 9%). There was a significantly higher risk of being readmitted in males (Female odds ratio: 0.87; confidence interval [0.851-0.922), older patients (65-79: 32.3%; > 80: 37.1%), patients with three or more comorbidities (≥ 3: 32.9%), or in patients discharged to a skilled nursing facility/intermediate care facility/rehab (SNF/ICF/Rehab odds ratio: 1.55; confidence interval [0.234-0.262]).
    Conclusions: This study demonstrates a large proportion of patients are readmitted after sustaining a TBI. A significant number of patients are readmitted for subsequent injuries, circulatory issues, nervous system problems, and infections. Although readmissions cannot be completely avoided, defining at-risk populations is the first step of understanding how to reduce readmissions.
    Language English
    Publishing date 2024-03-28
    Publishing country United States
    Document type Journal Article
    ZDB-ID 80170-7
    ISSN 1095-8673 ; 0022-4804
    ISSN (online) 1095-8673
    ISSN 0022-4804
    DOI 10.1016/j.jss.2024.02.018
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  9. Article ; Online: An Evaluation of Pediatric Gastrocutaneous Fistula Closure Through the Punch Excision of Epithelized Tract Procedure.

    Stephenson, Krista J / Bonasso, Patrick C / Vasquez, Isabel L / Burford, Jeffrey M / Wyrick, Deidre L / Bhavaraju, Avi / Dassinger, Melvin S

    The American surgeon

    2022  Volume 88, Issue 8, Page(s) 1822–1826

    Abstract: Background: Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently ... ...

    Abstract Background: Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence.
    Methods: We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018-12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database.
    Results: Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality.
    Discussion: Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.
    MeSH term(s) Child ; Cutaneous Fistula/etiology ; Cutaneous Fistula/surgery ; Gastric Fistula/etiology ; Gastric Fistula/surgery ; Gastrostomy/methods ; Humans ; Postoperative Complications/etiology ; Retrospective Studies ; Surgical Wound Infection
    Language English
    Publishing date 2022-04-14
    Publishing country United States
    Document type Journal Article
    ZDB-ID 202465-2
    ISSN 1555-9823 ; 0003-1348
    ISSN (online) 1555-9823
    ISSN 0003-1348
    DOI 10.1177/00031348221084945
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  10. Article ; Online: Blue Rubber Bleb Nevus Syndrome: A Rare Case of Gastrointestinal Hemorrhage Necessitating Bowel Resection.

    Shewmake, Connor N / Stephenson, Krista J / Bonasso, Patrick C / Odiase, Elaine / Richter, Gresham T / Bhavaraju, Avi V / Dassinger, Melvin S

    The American surgeon

    2022  Volume 89, Issue 6, Page(s) 2934–2936

    Abstract: Blue Rubber Bleb Nevus Syndrome is a congenital rarity that manifests as vascular malformations throughout the body, including the gastrointestinal tract. With fewer than 300 cases reported, the etiology and clinical course is poorly understood; however, ...

    Abstract Blue Rubber Bleb Nevus Syndrome is a congenital rarity that manifests as vascular malformations throughout the body, including the gastrointestinal tract. With fewer than 300 cases reported, the etiology and clinical course is poorly understood; however, the literature suggests
    MeSH term(s) Female ; Humans ; Nevus, Blue/complications ; Nevus, Blue/diagnosis ; Nevus, Blue/genetics ; Gastrointestinal Neoplasms/complications ; Gastrointestinal Neoplasms/surgery ; Skin Neoplasms/complications ; Skin Neoplasms/surgery ; Vascular Malformations/complications ; Vascular Malformations/diagnosis ; Vascular Malformations/surgery ; Gastrointestinal Hemorrhage/surgery ; Gastrointestinal Hemorrhage/complications
    Language English
    Publishing date 2022-04-17
    Publishing country United States
    Document type Case Reports ; Journal Article
    ZDB-ID 202465-2
    ISSN 1555-9823 ; 0003-1348
    ISSN (online) 1555-9823
    ISSN 0003-1348
    DOI 10.1177/00031348221084949
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