Tomaz Mesar - Academia.edu (original) (raw)

Papers by Tomaz Mesar

Journal of Special Operations Medicine

Background: Care of trauma casualties in an austere environment presents many challenges, particu... more Background: Care of trauma casualties in an austere environment presents many challenges, particularly when evacuation is not immediately available. Man-packable medical supplies may be consumed by a single casualty, and resupply may not be possible before evacuation, particularly during prolonged field care scenarios. We hypothesized that unmanned aerial drones could successfully deliver life-sustaining medical supplies to a remote, denied environment where vehicle or foot traffic is impossible or impractical. Methods: Using an unmanned, rotary-wing drone, we simulated delivery of a customizable, 4.5kg load of medical equipment, including tourniquets, dressings, analgesics, and blood products. A simulated casualty was positioned in a remote area. The flight was preprogrammed on the basis of grid coordinates and flew on autopilot beyond visual range; data (altitude, flight time, route) were recorded live by high-altitude Shadow drone. Delivery time was compared to the known US military standards for traversing uneven topography by foot or wheeled vehicle. Results: Four flights were performed. Data are given as mean (± standard deviation). Time from launch to delivery was 20.77 ± 0.05 minutes (cruise speed, 34.03 ± 0.15 km/h; mean range, 12.27 ± 0.07 km). Medical supplies were delivered successfully within 1m of the target. The drone successfully returned to the starting point every flight. Resupply by foot would take 5.1 hours with an average speed of 2.4km/h and 61.35 minutes, with an average speed of 12 km/h for a wheeled vehicle, if a rudimentary road existed. Conclusion: Use of unmanned drones is feasible for delivery of life-saving medical supplies in austere environments. Drones repeatedly and accurately delivered medical supplies faster than other methods without additional risk to personnel or manned airframe. This technology may have benefit for austere care of military and civilian casualties.

The Lancet Global Health, 2021

Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outco... more Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.

Background: To determine the frequency of, and factors associated with, death in hospital followi... more Background: To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward.Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments (‘treatment limitations’), and the subpopulations with treatment limitations.Results: 2,186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in ...

Critical Care Medicine, 2013

Journal of Vascular Surgery, 2021

Journal of Vascular Surgery, 2020

Objective: Intramural hematoma (IMH) is on the spectrum of acute aortic syndrome, but optimal man... more Objective: Intramural hematoma (IMH) is on the spectrum of acute aortic syndrome, but optimal management is poorly understood. The aim of this study was to evaluate outcomes of patients with type B IMH (TBIMH) after best medical therapy (BMT) and to assess for risk factors associated with failure of BMT. Methods: This is a single-institution retrospective chart review of all patients with TBIMH between January 2008 and December 2017. Failure of BMT was defined as any of the following end points: aortic rupture, aorta-related death, aortic enlargement to at least 55 mm or growth of >10 mm within 12 months, or need for surgical aortic intervention for failed BMT. Results: We identified 92 patients, of whom 25 received emergent thoracic endovascular aortic repair; 67 patients were initially managed with BMT, and of these, 32 underwent thoracic endovascular aortic repair within 14 days for early BMT failure. Two additional patients had early BMT failure; one died of aortic rupture due to retrograde type A dissection, and one patient was advised to undergo repair but did not comply and was lost to follow-up. Fourteen patients (20.9%) received endovascular therapy for late failure of BMT after the initial hospitalization. Medical management was successful in 19 patients (28.4%), although 5 patients had aortic enlargement but below the threshold for elective repair (maximal aortic diameter of 55 mm). On univariate analysis, presenting IMH thickness and growth of IMH thickness were risk factors for BMT failure. On multivariate analysis, presenting IMH thickness was the sole predictive risk factor for medical therapy failure (odds ratio, 1.083; 95% confidence interval, 1.021-1.149; P ¼ .008), with an odds ratio of 6.810 (95% confidence interval, 1.921-24.146; P ¼ .002) with a presenting IMH thickness of $8.0 mm, which was the calculated IMH thickness cutoff value with highest sensitivity and specificity to predict failure of BMT (area under the receiver operating characteristic curve ¼ 0.795; P ¼ .001; J ¼ 0.62). Conclusions: BMT for TBIMH is associated with a high failure rate and need for interventions. IMH thickness on admission is the most reliable factor to predict failure of BMT.

Journal of Vascular Surgery, 2020

were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with... more were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with dual fluoroscopy (Table). According to device design, procedures performed with four-fenestration or branch devices generated higher operator radiation doses (262 mSv [IQR, 116.5-572 mSv] vs 171 mSv [IQR, 44-325 mSv]; P < .01) compared with procedures with three or fewer fenestrations or branches. In the most complex design (four-vessel), operator radiation dose was significantly lower with dual fluoroscopy compared with standard imaging (59.5 mSv [IQR, 19.5-155 mSv] vs 309 mSv [IQR, 150-611 mSv]; P ¼ .01). Conclusions: Current radiation doses to patients and operating personnel during F/BEVAR are within acceptable limits. Dual fluoroscopy with live-image zooming, however, results in dramatically lower radiation doses compared with the standard image processing and magnification. Operator radiation doses were up to five times lower during procedures performed using more complex device designs when dual fluoroscopy was used.

Journal of Vascular Surgery, 2019

can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascul... more can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascular and open repair of aortic arch disease.

ACS Biomaterials Science & Engineering, 2019

Journal of Vascular Surgery, 2019

data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in ana... more data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.

Anesthesiology, 2018

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New... more Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. Methods This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: “worsening” if moderate or severe acute respiratory distress syndrome cri...

Critical care (London, England), Jan 17, 2018

To better understand the epidemiology and patterns of tracheostomy practice for patients with acu... more To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy ...

Critical care (London, England), Jan 12, 2018

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome o... more The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27...

Journal of the American College of Surgeons, Jan 2, 2018

Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on posto... more Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled in...

JAMA Surgery, 2017

To the Editor We read the study by Mesar et al 1 with great interest. In their retrospective stud... more To the Editor We read the study by Mesar et al 1 with great interest. In their retrospective study, the authors found no significant difference in mortality between 2 strategies of massive transfusion based on a high transfusion ratio or low transfusion ratio of fresh frozen plasma to red blood cells. 1 However, at the opposite end of studies dealing with massive transfusion in trauma patients, the authors do not mention the use of tranexamic acid, which is recommended in massive transfusion protocol, and this medication may have been given in massive transfusion occurring during surgery. 2 Moreover, the use of tranexamic acid has been purposed as a prophylactic agent to decrease surgical bleeding, notably in cardiac surgery, which constituted a large population in the present study. 3,4 We wonder whether this could be a potential confounding factor in the analysis and the interpretation of the results. Indeed, the use of tranexamic acid may have curtailed the requirements of supplementary fresh frozen plasma and thus contributed to minimize the difference between the high and low transfusion ratio of fresh frozen plasma to red blood cells.

Journal of cutaneous pathology, Jan 2, 2017

Dermatopathologists assess wounds secondary to trauma, infection, or oncologic resection that can... more Dermatopathologists assess wounds secondary to trauma, infection, or oncologic resection that can be challenging to reconstruct. OASIS Ultra, an extracellular matrix, has been described for use in chronic and burn wounds. The aim of this pilot study is to assess wound healing in post-traumatic and infective wounds treated with OASIS using histological markers of repair. Adults with traumatic, infective or iatrogenic wound defects with size precluding primary closure were eligible. Half the wound was randomly assigned to receive OASIS plus standard therapy; the other half received standard of care (SOC) therapy. During dressing changes, standardized-scale photographs were taken and biopsies obtained. Histologic sections were reviewed for degree of acute inflammation and extent of tissue repair. Neutrophils, edema, hemorrhage, necrosis, fibroblasts, collagen density and neovascularization were semi-quantitatively assessed. Forty-four skin biopsies from 7 patients with 10 acute wounds ...

Journal of Trauma and Acute Care Surgery, 2017

St Barnabas hospital is a level I trauma center located in the Bronx, that sees patients from div... more St Barnabas hospital is a level I trauma center located in the Bronx, that sees patients from diverse socioeconomic backgrounds. Previous research has located one of highest areas of gunshot violence within the Bronx area, an area that also corresponds with one of highest levels of neighborhood poverty. The investigators hypothesized that non accidental trauma (NAT)injuries caused by penetrating and blunt means with intention of harm-might be associated with specific geographical areas and that undiscovered variables might contribute to NAT. NAT incidents were identified by emergency medical services incident reports at a single institution (St Barnabas) from January 1, 2013, to December 31, 2013. Each report was linked to a latitude and longitude coordinate determined by global positioning software. For patients without location of injury, their home address was used and those without home address and location of injury or those with poorly described locations were excluded. Events were separated into blunt and penetrating trauma-penetrating trauma was further separated into edge weapon and firearms categories. Locations were assigned data points using Crimestat and subsequent regression analysis and kernel density estimates were used to locate areas with the highest incidents of NAT. Of two hundred eight three patients evaluated, two hundred and fifty four patients were included in data mapping, with penetrating trauma barely outnumbering blunt trauma. Epicenters of trauma were identified and subdivided in regards to type (all, blunt, gun shot, and edged). Most incidences of violence happened from 6 pm to 6 am, and there was a 2:1 difference in the amount of trauma occurring during April to September as opposed to colder months of the year. The article identifies several epicenters for NAT in the Bronx areas, as well as the most likely time period and season for these events to occur. While there are identifiable trends, study authors can only speculate about the reasons for these trends, but point out the potential for further study and potential modification of emergency medical services to improve outcomes in at-risk populations.

Surgery During Natural Disasters, Combat, Terrorist Attacks, and Crisis Situations, 2016

The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe ... more The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. Of 243 injured, 152 patients presented to an emergency department within 24 h. Of these 152 patients, there were 66 suffering at least one extremity injury, with ages ranging from less than 15 to 71 years old. Of the 66 patients with extremity injuries, 4 had upper limbs affected, 56 lower limbs only, and 6 combined upper and lower limbs affected. There were 17 lower extremity traumatic amputations in 15 patients. Additionally, there were ten patients with 12 lower extremities suffering major vascular injuries. In total, 29 patients had recognized extremity exsanguination at the scene. Twenty-seven tourniquets were applied to these 29 patients: 16 of 17 traumatic amputations, 5 of 12 lower extremities with major vascular injuries, and six additional limbs with major soft tissue injury. All tourniquets were improvised and no commercial, purpose-designed tourniquets were applied or used. Although the mortality rate among the 243 injured was 0 %, extremity exsanguination at the point-of-injury was either left untreated or treated with an improvised tourniquet in the prehospital environment. An effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the United States, and should mirror the military’s posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland.

ASAIO Journal, 2014

Mortality for patients presenting with acute myocardial infarction (AMI) complicated by ventricul... more Mortality for patients presenting with acute myocardial infarction (AMI) complicated by ventricular septal defect (VSD) and cardiogenic shock is very high even with surgical repair. We report our experience regarding utilization of Tan-demHeart, a percutaneous ventricular assist device (pVAD) as an adjunct to the treatment of these patients. Retrospective case series study design included a total of 11 patients with post-AMI VSD and severe refractory cardiogenic shock who received pVAD support at our institution. Three patients underwent immediate surgical repair and received pVAD support for postcardiotomy cardiogenic shock for 2, 4, and 7 days, respectively. However, all three died. The other eight patients had pVAD implanted prior to surgical repair in order to rest the myocardium before operation. Hemodynamics improved immediately after pVAD placement, and after receiving pVAD support for 7 ± 3 days, they underwent surgical VSD repair. Their total pre-and post-surgical pVAD support was 14 ± 4 days. All eight survived 30 days postoperatively. At 6 months postsurgery overall survival rate was 75%. Our small series of these critically ill patients shows a trend toward better survival after immediate pVAD placement to stabilize the patient and allow for myocardial maturation before surgical VSD repair.

The Journal of surgical research, 2015

Trauma represents a significant public health burden, and hemorrhage alone is responsible for 40%... more Trauma represents a significant public health burden, and hemorrhage alone is responsible for 40% of deaths within the first 24 h after injury. Noncompressible hemorrhage accounts for the majority of hemorrhage-related deaths. Thus, materials which can arrest bleeding rapidly are necessary for improved clinical outcomes. This preliminary study evaluated several self-expanding hydrophobically modified chitosan (HM-CS) foams to determine their efficacy on a noncompressible severe liver injury under resuscitation. Six HM-CS foam formulations (HM-CS1, HM-CS2, HM-CS3, HM-CS4, HM-CS5, and HM-CS6) of different graft types and densities were synthesized, characterized, and packaged into spray canisters using dimethyl ether as the propellant. Expansion profiles of the foams were evaluated in bench testing. Foams were then evaluated in vitro, interaction with blood cells was determined via microscopy, and cytotoxicity was assessed via live-dead cell assay on MCF7 breast cancer cells. For in v...

Journal of Special Operations Medicine

Background: Care of trauma casualties in an austere environment presents many challenges, particu... more Background: Care of trauma casualties in an austere environment presents many challenges, particularly when evacuation is not immediately available. Man-packable medical supplies may be consumed by a single casualty, and resupply may not be possible before evacuation, particularly during prolonged field care scenarios. We hypothesized that unmanned aerial drones could successfully deliver life-sustaining medical supplies to a remote, denied environment where vehicle or foot traffic is impossible or impractical. Methods: Using an unmanned, rotary-wing drone, we simulated delivery of a customizable, 4.5kg load of medical equipment, including tourniquets, dressings, analgesics, and blood products. A simulated casualty was positioned in a remote area. The flight was preprogrammed on the basis of grid coordinates and flew on autopilot beyond visual range; data (altitude, flight time, route) were recorded live by high-altitude Shadow drone. Delivery time was compared to the known US military standards for traversing uneven topography by foot or wheeled vehicle. Results: Four flights were performed. Data are given as mean (± standard deviation). Time from launch to delivery was 20.77 ± 0.05 minutes (cruise speed, 34.03 ± 0.15 km/h; mean range, 12.27 ± 0.07 km). Medical supplies were delivered successfully within 1m of the target. The drone successfully returned to the starting point every flight. Resupply by foot would take 5.1 hours with an average speed of 2.4km/h and 61.35 minutes, with an average speed of 12 km/h for a wheeled vehicle, if a rudimentary road existed. Conclusion: Use of unmanned drones is feasible for delivery of life-saving medical supplies in austere environments. Drones repeatedly and accurately delivered medical supplies faster than other methods without additional risk to personnel or manned airframe. This technology may have benefit for austere care of military and civilian casualties.

The Lancet Global Health, 2021

Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outco... more Summary Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.

Background: To determine the frequency of, and factors associated with, death in hospital followi... more Background: To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward.Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments (‘treatment limitations’), and the subpopulations with treatment limitations.Results: 2,186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in ...

Critical Care Medicine, 2013

Journal of Vascular Surgery, 2021

Journal of Vascular Surgery, 2020

Objective: Intramural hematoma (IMH) is on the spectrum of acute aortic syndrome, but optimal man... more Objective: Intramural hematoma (IMH) is on the spectrum of acute aortic syndrome, but optimal management is poorly understood. The aim of this study was to evaluate outcomes of patients with type B IMH (TBIMH) after best medical therapy (BMT) and to assess for risk factors associated with failure of BMT. Methods: This is a single-institution retrospective chart review of all patients with TBIMH between January 2008 and December 2017. Failure of BMT was defined as any of the following end points: aortic rupture, aorta-related death, aortic enlargement to at least 55 mm or growth of >10 mm within 12 months, or need for surgical aortic intervention for failed BMT. Results: We identified 92 patients, of whom 25 received emergent thoracic endovascular aortic repair; 67 patients were initially managed with BMT, and of these, 32 underwent thoracic endovascular aortic repair within 14 days for early BMT failure. Two additional patients had early BMT failure; one died of aortic rupture due to retrograde type A dissection, and one patient was advised to undergo repair but did not comply and was lost to follow-up. Fourteen patients (20.9%) received endovascular therapy for late failure of BMT after the initial hospitalization. Medical management was successful in 19 patients (28.4%), although 5 patients had aortic enlargement but below the threshold for elective repair (maximal aortic diameter of 55 mm). On univariate analysis, presenting IMH thickness and growth of IMH thickness were risk factors for BMT failure. On multivariate analysis, presenting IMH thickness was the sole predictive risk factor for medical therapy failure (odds ratio, 1.083; 95% confidence interval, 1.021-1.149; P ¼ .008), with an odds ratio of 6.810 (95% confidence interval, 1.921-24.146; P ¼ .002) with a presenting IMH thickness of $8.0 mm, which was the calculated IMH thickness cutoff value with highest sensitivity and specificity to predict failure of BMT (area under the receiver operating characteristic curve ¼ 0.795; P ¼ .001; J ¼ 0.62). Conclusions: BMT for TBIMH is associated with a high failure rate and need for interventions. IMH thickness on admission is the most reliable factor to predict failure of BMT.

Journal of Vascular Surgery, 2020

were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with... more were recorded for first assistant, scrub nurse, and anesthesia staff in procedures performed with dual fluoroscopy (Table). According to device design, procedures performed with four-fenestration or branch devices generated higher operator radiation doses (262 mSv [IQR, 116.5-572 mSv] vs 171 mSv [IQR, 44-325 mSv]; P < .01) compared with procedures with three or fewer fenestrations or branches. In the most complex design (four-vessel), operator radiation dose was significantly lower with dual fluoroscopy compared with standard imaging (59.5 mSv [IQR, 19.5-155 mSv] vs 309 mSv [IQR, 150-611 mSv]; P ¼ .01). Conclusions: Current radiation doses to patients and operating personnel during F/BEVAR are within acceptable limits. Dual fluoroscopy with live-image zooming, however, results in dramatically lower radiation doses compared with the standard image processing and magnification. Operator radiation doses were up to five times lower during procedures performed using more complex device designs when dual fluoroscopy was used.

Journal of Vascular Surgery, 2019

can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascul... more can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascular and open repair of aortic arch disease.

ACS Biomaterials Science & Engineering, 2019

Journal of Vascular Surgery, 2019

data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in ana... more data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.

Anesthesiology, 2018

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New... more Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population. Methods This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: “worsening” if moderate or severe acute respiratory distress syndrome cri...

Critical care (London, England), Jan 17, 2018

To better understand the epidemiology and patterns of tracheostomy practice for patients with acu... more To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy ...

Critical care (London, England), Jan 12, 2018

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome o... more The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27...

Journal of the American College of Surgeons, Jan 2, 2018

Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on posto... more Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled in...

JAMA Surgery, 2017

To the Editor We read the study by Mesar et al 1 with great interest. In their retrospective stud... more To the Editor We read the study by Mesar et al 1 with great interest. In their retrospective study, the authors found no significant difference in mortality between 2 strategies of massive transfusion based on a high transfusion ratio or low transfusion ratio of fresh frozen plasma to red blood cells. 1 However, at the opposite end of studies dealing with massive transfusion in trauma patients, the authors do not mention the use of tranexamic acid, which is recommended in massive transfusion protocol, and this medication may have been given in massive transfusion occurring during surgery. 2 Moreover, the use of tranexamic acid has been purposed as a prophylactic agent to decrease surgical bleeding, notably in cardiac surgery, which constituted a large population in the present study. 3,4 We wonder whether this could be a potential confounding factor in the analysis and the interpretation of the results. Indeed, the use of tranexamic acid may have curtailed the requirements of supplementary fresh frozen plasma and thus contributed to minimize the difference between the high and low transfusion ratio of fresh frozen plasma to red blood cells.

Journal of cutaneous pathology, Jan 2, 2017

Dermatopathologists assess wounds secondary to trauma, infection, or oncologic resection that can... more Dermatopathologists assess wounds secondary to trauma, infection, or oncologic resection that can be challenging to reconstruct. OASIS Ultra, an extracellular matrix, has been described for use in chronic and burn wounds. The aim of this pilot study is to assess wound healing in post-traumatic and infective wounds treated with OASIS using histological markers of repair. Adults with traumatic, infective or iatrogenic wound defects with size precluding primary closure were eligible. Half the wound was randomly assigned to receive OASIS plus standard therapy; the other half received standard of care (SOC) therapy. During dressing changes, standardized-scale photographs were taken and biopsies obtained. Histologic sections were reviewed for degree of acute inflammation and extent of tissue repair. Neutrophils, edema, hemorrhage, necrosis, fibroblasts, collagen density and neovascularization were semi-quantitatively assessed. Forty-four skin biopsies from 7 patients with 10 acute wounds ...

Journal of Trauma and Acute Care Surgery, 2017

St Barnabas hospital is a level I trauma center located in the Bronx, that sees patients from div... more St Barnabas hospital is a level I trauma center located in the Bronx, that sees patients from diverse socioeconomic backgrounds. Previous research has located one of highest areas of gunshot violence within the Bronx area, an area that also corresponds with one of highest levels of neighborhood poverty. The investigators hypothesized that non accidental trauma (NAT)injuries caused by penetrating and blunt means with intention of harm-might be associated with specific geographical areas and that undiscovered variables might contribute to NAT. NAT incidents were identified by emergency medical services incident reports at a single institution (St Barnabas) from January 1, 2013, to December 31, 2013. Each report was linked to a latitude and longitude coordinate determined by global positioning software. For patients without location of injury, their home address was used and those without home address and location of injury or those with poorly described locations were excluded. Events were separated into blunt and penetrating trauma-penetrating trauma was further separated into edge weapon and firearms categories. Locations were assigned data points using Crimestat and subsequent regression analysis and kernel density estimates were used to locate areas with the highest incidents of NAT. Of two hundred eight three patients evaluated, two hundred and fifty four patients were included in data mapping, with penetrating trauma barely outnumbering blunt trauma. Epicenters of trauma were identified and subdivided in regards to type (all, blunt, gun shot, and edged). Most incidences of violence happened from 6 pm to 6 am, and there was a 2:1 difference in the amount of trauma occurring during April to September as opposed to colder months of the year. The article identifies several epicenters for NAT in the Bronx areas, as well as the most likely time period and season for these events to occur. While there are identifiable trends, study authors can only speculate about the reasons for these trends, but point out the potential for further study and potential modification of emergency medical services to improve outcomes in at-risk populations.

Surgery During Natural Disasters, Combat, Terrorist Attacks, and Crisis Situations, 2016

The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe ... more The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. Of 243 injured, 152 patients presented to an emergency department within 24 h. Of these 152 patients, there were 66 suffering at least one extremity injury, with ages ranging from less than 15 to 71 years old. Of the 66 patients with extremity injuries, 4 had upper limbs affected, 56 lower limbs only, and 6 combined upper and lower limbs affected. There were 17 lower extremity traumatic amputations in 15 patients. Additionally, there were ten patients with 12 lower extremities suffering major vascular injuries. In total, 29 patients had recognized extremity exsanguination at the scene. Twenty-seven tourniquets were applied to these 29 patients: 16 of 17 traumatic amputations, 5 of 12 lower extremities with major vascular injuries, and six additional limbs with major soft tissue injury. All tourniquets were improvised and no commercial, purpose-designed tourniquets were applied or used. Although the mortality rate among the 243 injured was 0 %, extremity exsanguination at the point-of-injury was either left untreated or treated with an improvised tourniquet in the prehospital environment. An effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the United States, and should mirror the military’s posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland.

ASAIO Journal, 2014

Mortality for patients presenting with acute myocardial infarction (AMI) complicated by ventricul... more Mortality for patients presenting with acute myocardial infarction (AMI) complicated by ventricular septal defect (VSD) and cardiogenic shock is very high even with surgical repair. We report our experience regarding utilization of Tan-demHeart, a percutaneous ventricular assist device (pVAD) as an adjunct to the treatment of these patients. Retrospective case series study design included a total of 11 patients with post-AMI VSD and severe refractory cardiogenic shock who received pVAD support at our institution. Three patients underwent immediate surgical repair and received pVAD support for postcardiotomy cardiogenic shock for 2, 4, and 7 days, respectively. However, all three died. The other eight patients had pVAD implanted prior to surgical repair in order to rest the myocardium before operation. Hemodynamics improved immediately after pVAD placement, and after receiving pVAD support for 7 ± 3 days, they underwent surgical VSD repair. Their total pre-and post-surgical pVAD support was 14 ± 4 days. All eight survived 30 days postoperatively. At 6 months postsurgery overall survival rate was 75%. Our small series of these critically ill patients shows a trend toward better survival after immediate pVAD placement to stabilize the patient and allow for myocardial maturation before surgical VSD repair.

The Journal of surgical research, 2015

Trauma represents a significant public health burden, and hemorrhage alone is responsible for 40%... more Trauma represents a significant public health burden, and hemorrhage alone is responsible for 40% of deaths within the first 24 h after injury. Noncompressible hemorrhage accounts for the majority of hemorrhage-related deaths. Thus, materials which can arrest bleeding rapidly are necessary for improved clinical outcomes. This preliminary study evaluated several self-expanding hydrophobically modified chitosan (HM-CS) foams to determine their efficacy on a noncompressible severe liver injury under resuscitation. Six HM-CS foam formulations (HM-CS1, HM-CS2, HM-CS3, HM-CS4, HM-CS5, and HM-CS6) of different graft types and densities were synthesized, characterized, and packaged into spray canisters using dimethyl ether as the propellant. Expansion profiles of the foams were evaluated in bench testing. Foams were then evaluated in vitro, interaction with blood cells was determined via microscopy, and cytotoxicity was assessed via live-dead cell assay on MCF7 breast cancer cells. For in v...