Haytham Kaafarani - Academia.edu (original) (raw)

Papers by Haytham Kaafarani

Research paper thumbnail of Injury Prevention as an Integral Part of Health System Reform Efforts: Lessons Learned from Recently Enacted Massachusetts Laws

Health Systems & Reform, 2015

Research paper thumbnail of Significant but reasonable radiation exposure from computed tomography-related medical imaging in the ICU

Emergency radiology, Jan 6, 2016

Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiat... more Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiation exposure, yet few studies have estimated the risk of cancer associated with these examinations. The purpose of this study was to review computed tomography (CT) scans performed on patients admitted to two urban academic ICUs, predict their radiation exposure, and calculate their estimated lifetime attributable risk of cancer (LAR). An electronic chart review was performed on all CT scans performed between January 2007 and December 2011. The estimated effective dose of radiation was calculated for each CT, and the LAR for each patient was predicted. Mean radiation exposure was 22.2 ± 25.0 mSv with a mean LAR of 0.1 ± 0.2 % and a median of 0.6 % with a range of <0.001 to 3.4 %. Our cohort received radiation doses higher than recommended by guidelines; however, the critical nature of their admission may have warranted these imaging studies. Estimated risk of cancer in this population...

Research paper thumbnail of Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates

Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, Jan 16, 2015

Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clini... more Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP. This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes. EN was started at a median of 34.0 hours...

Research paper thumbnail of Consensus Building for Development of Outpatient Adverse Drug Event Triggers

Journal of Patient Safety, Jun 1, 2011

Adverse drug event (ADE) detection is an important priority of patient safety research. Trigger t... more Adverse drug event (ADE) detection is an important priority of patient safety research. Trigger tools have been developed to help identify ADEs. As part of a larger study, we developed complex and specific trigger algorithms intended for concurrent use with clinical care to detect outpatient ADEs. This article assesses the use of a modified Delphi process to obtain expert consensus on the value of these triggers. We selected a panel of distinguished clinical and research experts to participate in the modified Delphi process. We created a set of outpatient ADE triggers based on literature review, clinical input, and methodological expertise. The importance of the targeted ADEs, associated drug classes, and trigger logic was used to rate each trigger. Specific criteria were developed to establish consensus. The modified Delphi process established consensus on 6 outpatient ADE triggers to test with patient-level data based on high ratings of utility for patient-level interventions. These triggers focused on detecting ADEs caused by the following drugs or drug classes: bone marrow toxins, potassium raisers, potassium reducers, creatinine, warfarin, and sedative hypnotics. Participants reported including all aspects of the trigger in their ratings, despite our efforts to separate evaluation of clinical need and trigger logic. Participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; expertise affected the evaluation of trigger rules, leading to contradictory feedback on how to improve trigger design. The efficiency of the modified Delphi method could be improved by allowing participants to produce an overall summary score that incorporates both the clinical value and the general logic of the trigger. Revising and improving trigger design should be conducted in a separate process limited only to trigger experts.

Research paper thumbnail of 46: The "July Effect" in the Icu Revisited

Critical care medicine, 2015

Research paper thumbnail of 312: Effect of Race on Icu Mortality: A Multi-Center Retrospective Cohort Study

Critical care medicine, 2015

Research paper thumbnail of Careers in surgical research: Basic science, clinical research, health policy, and surgical innovation

Bulletin of the American College of Surgeons, Jul 1, 2009

Research paper thumbnail of 283: Early Nutritional Inadequacy is Associated With Worse Outcomes in Chronic Critical Illness

Critical care medicine, 2015

Research paper thumbnail of 270: Biomarkers of Nutrition Do Not Correlate With Nutrient Delivery or Outcomes in Surgical Icu Patients

Critical care medicine, 2015

Research paper thumbnail of Noise Levels in Surgical ICUs Are Consistently Above Recommended Standards

Critical care medicine, Jan 9, 2015

The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient ... more The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient care areas in a hospital. Increased sound levels may contribute to worsened outcomes in these particularly vulnerable patients. Our objective was to determine whether ambient sound levels in surgical ICUs comply with recommendations established by the World Health Organization and Environmental Protection Agency, and whether implementation of an overnight "quiet time" intervention is associated with lower ambient sound levels. Prospective, observational cohort study. Two comparable 18-bed, surgical ICUs in a large, teaching hospital. Only one ICU had a formal overnight quiet time policy at the start of the study period. Sound levels were measured in 30-second blocks at preselected locations during the day and night over a period of 6 weeks using a simple, hand-held sound meter. All sound measurements in both units at all times exceeded recommended standards. Median minimum soun...

Research paper thumbnail of Gangrenous cholecystitis: Deceiving ultrasounds, significant delay in surgical consult, and increased postoperative morbidity!

The journal of trauma and acute care surgery, 2015

Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspect... more Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspected acute cholecystitis. We sought to characterize preoperative risk factors and post-operative complications. Pathology reports of all patients undergoing cholecystectomy for suspected acute cholecystitis from June 2010 to January 2014 and admitted through the emergency department were examined. Patients with GC were compared with those with acute/chronic cholecystitis (AC/CC). Data collected included demographics, preoperative signs and symptoms, radiologic studies, operative details, and clinical outcomes. Thirty-eight cases of GC were identified and compared with 171 cases of AC/CC. Compared with AC/CC, GC patients were more likely to be older (57 years vs. 41 years, p < 0.001), of male sex (63% vs. 31%, p < 0.001), hypertensive (47% vs. 22%, p = 0.002), hyperlipidemic (29% vs. 14%, p = 0.026), and diabetic (24% vs. 8%, p = 0.006). GC patients were more likely to have a fever (2...

Research paper thumbnail of Massachusetts Graduated Driver-Licensing Program

Health affairs (Project Hope), 2015

Research paper thumbnail of Computed Tomography Is More Sensitive than Ultrasound for the Diagnosis of Acute Cholecystitis

Surgical infections, Jan 16, 2015

Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is consid... more Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is considered the test of choice for diagnosing acute cholecystitis (AC). However, computed tomography (CT) is used widely for the evaluation of abdominal pain and is often obtained as a first abdominal imaging test, particularly in cases in which typical clinical signs of AC are absent or other possible diagnoses are being considered. We hypothesized that CT is more sensitive than US for diagnosing AC. A prospective registry of all urgent cholecystectomies performed by our acute care surgery service between June 2008 and January 2014 was searched for cases of AC. The final diagnosis was based on operative findings and pathology. Patients were classified into two groups according to pre-operative radiographic work-up: US only or CT and US. The US group was compared with the CT and US group with respect to clinical and demographic characteristics. For patients undergoing both tests the sensitivity...

Research paper thumbnail of Trends in Advanced Imaging Utilization in Intensive Care Units at Two Major Academic Hospitals

Critical Care Medicine

ABSTRACT

Research paper thumbnail of Additional Imaging in Alert Trauma Patients with Cervical Spine Tenderness and a Negative Computed Tomographic Scan: Is it Needed?

World Journal of Surgery, 2015

The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients... more The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear. All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;24 h) repeat physical examination, MRI, and/or flexion-extension films. Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30-53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion-extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging. C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.

Research paper thumbnail of The Deyo-Charlson and Elixhauser-van Walraven Comorbidity Indices as predictors of mortality in critically ill patients

BMJ open, 2015

Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) an... more Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) and Elixhauser-van Walraven Comorbidity Index (EVCI) to predict mortality in intensive care unit (ICU) patients. Observational study of 2 tertiary academic centres located in Boston, Massachusetts. The study cohort consisted of 59 816 patients from admitted to 12 ICUs between January 2007 and December 2012. For the primary analysis, receiver operator characteristic curves were constructed for mortality at 30, 90, 180, and 365 days using the DCCI as well as EVCI, and the areas under the curve (AUCs) were compared. Subgroup analyses were performed within different types of ICUs. Logistic regression was used to add age, race and sex into the model to determine if there was any improvement in discrimination. At 30 days, the AUC for DCCI versus EVCI was 0.65 (95% CI 0.65 to 0.67) vs 0.66 (95% CI 0.65 to 0.66), p=0.02. Discrimination improved at 365 days for both indices (AUC for DCCI 0.72 (95% ...

Research paper thumbnail of Needs Assessment for a Focused Radiology Curriculum in Surgical Residency: A Multicenter Study

The American Journal of Surgery, 2015

Patient instability and limited radiology staffing may compel surgeons to make clinical decisions... more Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency. We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests. Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations. Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation.

Research paper thumbnail of Periprocedural nutrition in the intensive care unit: a pilot study

The Journal of surgical research, Jan 23, 2015

Enteral nutrition (EN) delivery in the surgical intensive care unit (ICU) is often suboptimal as ... more Enteral nutrition (EN) delivery in the surgical intensive care unit (ICU) is often suboptimal as it is commonly interrupted for procedures. We hypothesized that continuing perioperative nutrition or providing compensatory nutrition would improve caloric delivery without increasing morbidity. We enrolled 10 adult surgical ICU patients receiving EN who were scheduled for elective bedside percutaneous tracheostomy. In these patients (fed group), either perioperative EN was maintained or compensatory nutrition was provided. We compared the amount of calories delivered, caloric deficits, and the rate of complications of these patients with those of 22 contemporary controls undergoing tracheostomy while adhering to the traditional American Society of Anesthesiology nil per os guidelines (unfed group). We defined caloric deficit as the difference between prescribed calories and actual delivered calories. There was no difference in demographic characteristics between the two groups. On the ...

Research paper thumbnail of The clinical significance of isolated loss of lordosis on cervical spine computed tomography in blunt trauma patients: a prospective evaluation of 1,007 patients

American journal of surgery, 2015

A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury... more A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury after trauma. Loss of lordosis (LOL) is frequently found as the only CT abnormality. We investigated whether LOL should preclude c-spine clearance. All adult trauma patients with isolated LOL at our Level I trauma center (February 1, 2011 to May 31, 2012) were prospectively evaluated. The primary outcome was clinically significant injury on magnetic resonance imaging (MRI), flexion-extension views, and/or repeat physical examination. Of 3,333 patients (40 ± 17 years, 60% men) with a c-spine CT, 1,007 (30%) had isolated LOL. Among 841 patients with a Glasgow Coma Scale score of 15, no abnormalities were found on MRI, flexion-extension views, and/or repeat examinations, and all collars were removed. Among 166 patients with Glasgow Coma Scale less than 15, 3 (.3%) had minor abnormal MRI findings but no clinically significant injury. Isolated LOL on c-spine CT is not associated with a clini...

Research paper thumbnail of Health Care Utilization and Charges Following the Enactment of the 2007 Graduated Drivers Licensing Law in Massachusetts

Journal of Pediatric Surgery, 2015

Graduated Drivers Licensing (GDL) programs phase in driving privileges for teenagers. In 2007, Ma... more Graduated Drivers Licensing (GDL) programs phase in driving privileges for teenagers. In 2007, Massachusetts implemented a stricter version of the 1998 GDL law, with increased fines and education. This study evaluated the impact of the law on motor vehicle crash (MVC)-related health care utilization and charges. Massachusetts government and US Census Bureau data were analyzed to compare the rates of MVC-related emergency department (ED) visits and hospital charges before (2002-2006) and after (2007-2011) the 2007 GDL law. Three driver age groups were studied: 16-17 (evaluating the law effect), 18-20 (evaluating the sustainability of the effect), and 25-29 years old (control group). MVC-related ED visits per population decreased after the law for all three age groups (16-17: 2326 to 713; 18-20: 2110 to 1304; 25-29: 1694 to 1228; per 100,000, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), but the decrease was greater amongst teenagers (16-17: -69%; 18-20: -38%) compared to the control group (-27%); p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001. MVC-related hospital charges per population also decreased for teenagers but increased for the control group (16-17: 2.70mto2.70m to 2.70mto1.45m; 18-20: 3.52mto3.52m to 3.52mto2.26m; 25-29: 1.86mto1.86m to 1.86mto1.92m; per 100,000, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The 2007 GDL law in Massachusetts was associated with significant decreases in MVC-related health care utilization and hospital charges among teenage drivers.

Research paper thumbnail of Injury Prevention as an Integral Part of Health System Reform Efforts: Lessons Learned from Recently Enacted Massachusetts Laws

Health Systems & Reform, 2015

Research paper thumbnail of Significant but reasonable radiation exposure from computed tomography-related medical imaging in the ICU

Emergency radiology, Jan 6, 2016

Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiat... more Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiation exposure, yet few studies have estimated the risk of cancer associated with these examinations. The purpose of this study was to review computed tomography (CT) scans performed on patients admitted to two urban academic ICUs, predict their radiation exposure, and calculate their estimated lifetime attributable risk of cancer (LAR). An electronic chart review was performed on all CT scans performed between January 2007 and December 2011. The estimated effective dose of radiation was calculated for each CT, and the LAR for each patient was predicted. Mean radiation exposure was 22.2 ± 25.0 mSv with a mean LAR of 0.1 ± 0.2 % and a median of 0.6 % with a range of <0.001 to 3.4 %. Our cohort received radiation doses higher than recommended by guidelines; however, the critical nature of their admission may have warranted these imaging studies. Estimated risk of cancer in this population...

Research paper thumbnail of Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates

Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, Jan 16, 2015

Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clini... more Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP. This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes. EN was started at a median of 34.0 hours...

Research paper thumbnail of Consensus Building for Development of Outpatient Adverse Drug Event Triggers

Journal of Patient Safety, Jun 1, 2011

Adverse drug event (ADE) detection is an important priority of patient safety research. Trigger t... more Adverse drug event (ADE) detection is an important priority of patient safety research. Trigger tools have been developed to help identify ADEs. As part of a larger study, we developed complex and specific trigger algorithms intended for concurrent use with clinical care to detect outpatient ADEs. This article assesses the use of a modified Delphi process to obtain expert consensus on the value of these triggers. We selected a panel of distinguished clinical and research experts to participate in the modified Delphi process. We created a set of outpatient ADE triggers based on literature review, clinical input, and methodological expertise. The importance of the targeted ADEs, associated drug classes, and trigger logic was used to rate each trigger. Specific criteria were developed to establish consensus. The modified Delphi process established consensus on 6 outpatient ADE triggers to test with patient-level data based on high ratings of utility for patient-level interventions. These triggers focused on detecting ADEs caused by the following drugs or drug classes: bone marrow toxins, potassium raisers, potassium reducers, creatinine, warfarin, and sedative hypnotics. Participants reported including all aspects of the trigger in their ratings, despite our efforts to separate evaluation of clinical need and trigger logic. Participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; expertise affected the evaluation of trigger rules, leading to contradictory feedback on how to improve trigger design. The efficiency of the modified Delphi method could be improved by allowing participants to produce an overall summary score that incorporates both the clinical value and the general logic of the trigger. Revising and improving trigger design should be conducted in a separate process limited only to trigger experts.

Research paper thumbnail of 46: The "July Effect" in the Icu Revisited

Critical care medicine, 2015

Research paper thumbnail of 312: Effect of Race on Icu Mortality: A Multi-Center Retrospective Cohort Study

Critical care medicine, 2015

Research paper thumbnail of Careers in surgical research: Basic science, clinical research, health policy, and surgical innovation

Bulletin of the American College of Surgeons, Jul 1, 2009

Research paper thumbnail of 283: Early Nutritional Inadequacy is Associated With Worse Outcomes in Chronic Critical Illness

Critical care medicine, 2015

Research paper thumbnail of 270: Biomarkers of Nutrition Do Not Correlate With Nutrient Delivery or Outcomes in Surgical Icu Patients

Critical care medicine, 2015

Research paper thumbnail of Noise Levels in Surgical ICUs Are Consistently Above Recommended Standards

Critical care medicine, Jan 9, 2015

The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient ... more The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient care areas in a hospital. Increased sound levels may contribute to worsened outcomes in these particularly vulnerable patients. Our objective was to determine whether ambient sound levels in surgical ICUs comply with recommendations established by the World Health Organization and Environmental Protection Agency, and whether implementation of an overnight "quiet time" intervention is associated with lower ambient sound levels. Prospective, observational cohort study. Two comparable 18-bed, surgical ICUs in a large, teaching hospital. Only one ICU had a formal overnight quiet time policy at the start of the study period. Sound levels were measured in 30-second blocks at preselected locations during the day and night over a period of 6 weeks using a simple, hand-held sound meter. All sound measurements in both units at all times exceeded recommended standards. Median minimum soun...

Research paper thumbnail of Gangrenous cholecystitis: Deceiving ultrasounds, significant delay in surgical consult, and increased postoperative morbidity!

The journal of trauma and acute care surgery, 2015

Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspect... more Gangrenous cholecystitis (GC) is difficult to diagnose preoperatively in the patient with suspected acute cholecystitis. We sought to characterize preoperative risk factors and post-operative complications. Pathology reports of all patients undergoing cholecystectomy for suspected acute cholecystitis from June 2010 to January 2014 and admitted through the emergency department were examined. Patients with GC were compared with those with acute/chronic cholecystitis (AC/CC). Data collected included demographics, preoperative signs and symptoms, radiologic studies, operative details, and clinical outcomes. Thirty-eight cases of GC were identified and compared with 171 cases of AC/CC. Compared with AC/CC, GC patients were more likely to be older (57 years vs. 41 years, p < 0.001), of male sex (63% vs. 31%, p < 0.001), hypertensive (47% vs. 22%, p = 0.002), hyperlipidemic (29% vs. 14%, p = 0.026), and diabetic (24% vs. 8%, p = 0.006). GC patients were more likely to have a fever (2...

Research paper thumbnail of Massachusetts Graduated Driver-Licensing Program

Health affairs (Project Hope), 2015

Research paper thumbnail of Computed Tomography Is More Sensitive than Ultrasound for the Diagnosis of Acute Cholecystitis

Surgical infections, Jan 16, 2015

Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is consid... more Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is considered the test of choice for diagnosing acute cholecystitis (AC). However, computed tomography (CT) is used widely for the evaluation of abdominal pain and is often obtained as a first abdominal imaging test, particularly in cases in which typical clinical signs of AC are absent or other possible diagnoses are being considered. We hypothesized that CT is more sensitive than US for diagnosing AC. A prospective registry of all urgent cholecystectomies performed by our acute care surgery service between June 2008 and January 2014 was searched for cases of AC. The final diagnosis was based on operative findings and pathology. Patients were classified into two groups according to pre-operative radiographic work-up: US only or CT and US. The US group was compared with the CT and US group with respect to clinical and demographic characteristics. For patients undergoing both tests the sensitivity...

Research paper thumbnail of Trends in Advanced Imaging Utilization in Intensive Care Units at Two Major Academic Hospitals

Critical Care Medicine

ABSTRACT

Research paper thumbnail of Additional Imaging in Alert Trauma Patients with Cervical Spine Tenderness and a Negative Computed Tomographic Scan: Is it Needed?

World Journal of Surgery, 2015

The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients... more The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear. All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;24 h) repeat physical examination, MRI, and/or flexion-extension films. Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30-53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion-extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging. C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.

Research paper thumbnail of The Deyo-Charlson and Elixhauser-van Walraven Comorbidity Indices as predictors of mortality in critically ill patients

BMJ open, 2015

Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) an... more Our primary objective was to compare the utility of the Deyo-Charlson Comorbidity Index (DCCI) and Elixhauser-van Walraven Comorbidity Index (EVCI) to predict mortality in intensive care unit (ICU) patients. Observational study of 2 tertiary academic centres located in Boston, Massachusetts. The study cohort consisted of 59 816 patients from admitted to 12 ICUs between January 2007 and December 2012. For the primary analysis, receiver operator characteristic curves were constructed for mortality at 30, 90, 180, and 365 days using the DCCI as well as EVCI, and the areas under the curve (AUCs) were compared. Subgroup analyses were performed within different types of ICUs. Logistic regression was used to add age, race and sex into the model to determine if there was any improvement in discrimination. At 30 days, the AUC for DCCI versus EVCI was 0.65 (95% CI 0.65 to 0.67) vs 0.66 (95% CI 0.65 to 0.66), p=0.02. Discrimination improved at 365 days for both indices (AUC for DCCI 0.72 (95% ...

Research paper thumbnail of Needs Assessment for a Focused Radiology Curriculum in Surgical Residency: A Multicenter Study

The American Journal of Surgery, 2015

Patient instability and limited radiology staffing may compel surgeons to make clinical decisions... more Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency. We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests. Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations. Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation.

Research paper thumbnail of Periprocedural nutrition in the intensive care unit: a pilot study

The Journal of surgical research, Jan 23, 2015

Enteral nutrition (EN) delivery in the surgical intensive care unit (ICU) is often suboptimal as ... more Enteral nutrition (EN) delivery in the surgical intensive care unit (ICU) is often suboptimal as it is commonly interrupted for procedures. We hypothesized that continuing perioperative nutrition or providing compensatory nutrition would improve caloric delivery without increasing morbidity. We enrolled 10 adult surgical ICU patients receiving EN who were scheduled for elective bedside percutaneous tracheostomy. In these patients (fed group), either perioperative EN was maintained or compensatory nutrition was provided. We compared the amount of calories delivered, caloric deficits, and the rate of complications of these patients with those of 22 contemporary controls undergoing tracheostomy while adhering to the traditional American Society of Anesthesiology nil per os guidelines (unfed group). We defined caloric deficit as the difference between prescribed calories and actual delivered calories. There was no difference in demographic characteristics between the two groups. On the ...

Research paper thumbnail of The clinical significance of isolated loss of lordosis on cervical spine computed tomography in blunt trauma patients: a prospective evaluation of 1,007 patients

American journal of surgery, 2015

A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury... more A negative computed tomographic (CT) scan may be used to rule out cervical spine (c-spine) injury after trauma. Loss of lordosis (LOL) is frequently found as the only CT abnormality. We investigated whether LOL should preclude c-spine clearance. All adult trauma patients with isolated LOL at our Level I trauma center (February 1, 2011 to May 31, 2012) were prospectively evaluated. The primary outcome was clinically significant injury on magnetic resonance imaging (MRI), flexion-extension views, and/or repeat physical examination. Of 3,333 patients (40 ± 17 years, 60% men) with a c-spine CT, 1,007 (30%) had isolated LOL. Among 841 patients with a Glasgow Coma Scale score of 15, no abnormalities were found on MRI, flexion-extension views, and/or repeat examinations, and all collars were removed. Among 166 patients with Glasgow Coma Scale less than 15, 3 (.3%) had minor abnormal MRI findings but no clinically significant injury. Isolated LOL on c-spine CT is not associated with a clini...

Research paper thumbnail of Health Care Utilization and Charges Following the Enactment of the 2007 Graduated Drivers Licensing Law in Massachusetts

Journal of Pediatric Surgery, 2015

Graduated Drivers Licensing (GDL) programs phase in driving privileges for teenagers. In 2007, Ma... more Graduated Drivers Licensing (GDL) programs phase in driving privileges for teenagers. In 2007, Massachusetts implemented a stricter version of the 1998 GDL law, with increased fines and education. This study evaluated the impact of the law on motor vehicle crash (MVC)-related health care utilization and charges. Massachusetts government and US Census Bureau data were analyzed to compare the rates of MVC-related emergency department (ED) visits and hospital charges before (2002-2006) and after (2007-2011) the 2007 GDL law. Three driver age groups were studied: 16-17 (evaluating the law effect), 18-20 (evaluating the sustainability of the effect), and 25-29 years old (control group). MVC-related ED visits per population decreased after the law for all three age groups (16-17: 2326 to 713; 18-20: 2110 to 1304; 25-29: 1694 to 1228; per 100,000, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), but the decrease was greater amongst teenagers (16-17: -69%; 18-20: -38%) compared to the control group (-27%); p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001. MVC-related hospital charges per population also decreased for teenagers but increased for the control group (16-17: 2.70mto2.70m to 2.70mto1.45m; 18-20: 3.52mto3.52m to 3.52mto2.26m; 25-29: 1.86mto1.86m to 1.86mto1.92m; per 100,000, p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The 2007 GDL law in Massachusetts was associated with significant decreases in MVC-related health care utilization and hospital charges among teenage drivers.