Andrew James Kerwin's research while affiliated with Florida State College at Jacksonville and other places

Background Patients who sustain blunt solid organ injury to the liver, spleen, or kidney and are treated nonoperatively frequently undergo serial monitoring of their hemoglobin (Hb). We hypothesized that among initially hemodynamically stable patients with blunt splenic, hepatic, or renal injuries treated without an operation, scheduled monitoring of serum Hb values may be unnecessary as hemodynamic instability, not merely Hb drop, would prompt intervention. Methods We performed a retrospective review of patients admitted to our urban Level 1 trauma center following blunt trauma with any grade III, IV, or V liver, spleen, or kidney injury from January 1, 2016 to December 31, 2016. Patients who were hemodynamically unstable and went directly to the operating room or interventional radiology were excluded. Patients who required any urgent or unplanned operative or angiographic intervention were compared with patients who did not require an intervention. Routine demographic and outcome variables were obtained and bivariate and multivariate regression statistics were performed using Stata V.10. Results A total of 138 patients were included in the study. Age (39.3 vs 41.4, p=0.51), mean injury severity score (26.7 vs 22.1, p=0.12), and admission Hb (11.9 vs 12.8, p=0.06) did not differ significantly between the two groups. The number of Hb draws (9.2 vs 10, p=0.69) and the associated change in Hb (3.7 vs 3.5, p=0.71) did not differ significantly between the two groups. Only splenic grade predicted need for urgent intervention (3.5 vs 2, p<0.001). All patients who required an operative or radiologic intervention did so based on change in hemodynamics or severity of splenic grade, per our institutional protocol, and not Hb trend. Discussion Among patients with blunt solid organ injury, a need for emergent intervention in the form of laparotomy or angioembolization occurs within the first hours of injury. Routine scheduled Hb measurements did not change management in our cohort. Level of evidence Level III.

Purpose/Hypothesis Cervical spinal cord injury (CSCI) causes severe respiratory impairment and respiratory complications are a leading cause of illness and death. Although mechanical ventilation (MV) is lifesaving, MV use is associated with diaphragm atrophy and high respiratory infection rates. Intramuscular diaphragm stimulation, or diaphragm pacing (DP), is now used acutely to promote MV weaning. Preliminary reports suggest that DP may improve diaphragm activation, respiratory function, and promote recovery of independent respiration. The effects of DP, however, have not been systematically evaluated. Our purpose was to test the hypothesis that DP leads to an increase in voluntary diaphragm activation and improvements in respiratory function. Subjects Eleven adults with acute, traumatic CSCIs (6 males, mean age 40.8±12 years) who underwent implantation of DP wires due to failure to wean from MV participated (mean time on MV until DP wire implantation 16±10 days). Injuries were classified as C1 to C4 based on the ASIA Impairment Scale A or B (motor complete, n=10) and C (motor incomplete, n=1). Materials/Methods Respiratory function and diaphragm activation were assessed within 3 days post implantation of the DP wires and assessments were repeated at regular intervals up to four months post DP implantation. Respiratory function was assessed using standard measures of tidal volume (Vt), forced vital capacity (FVC), and maximal inspiratory and expiratory pressures (MIP, MEP). Diaphragm activation was assessed by recording electromyograms (EMGs) from the intramuscular DP wires during maximal inspiratory maneuvers. All tests were conducted without assistance from DP and with the lowest ventilator setting tolerated. Results Following onset of DP, 9 of 11 individuals weaned from MV (mean time 35±24 days) and 6 individuals resumed independent respiration without use of DP. All measures of respiratory function increased over time (p<0.05). Average gains in respiratory function were: Vt, +24±31% (range −31 – 77%); FVC, +37±16% (range 17 – 63%); MIP, +43±56% (range −45 – 124%); MEP +67±64% (range −31 – 176%). Mean peak EMG burst amplitude during maximal inspiratory maneuvers increased 20% (range 0 – 92%). Conclusions During an extended period of DP, adults with severe CSCIs demonstrated gains in respiratory function and volitional diaphragm activation. Nearly all individuals weaned from MV and over half progressed to independent respiration following onset of DP. Stimulation of the diaphragm is likely to promote muscle health which would contribute to weaning. In addition, the increased diaphragm muscle activation in many subject raises the possibility that DP and associated activation of sensory afferents evokes beneficial plasticity in the respiratory neural control system. Support or Funding Information Craig H. Neilsen Foundation (EJF); NIH/NICHD K12 HD055929 (EJF); T32‐HD043730 (MDS) This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Background Recent legislation repealing the Sustainable Growth Rate mandates gradual replacement of fee for service with alternative payment models (APMs), which will include service bundling. We analyzed the 2 years’ experience at our state-designated level I trauma center to determine the feasibility of such an approach for trauma care. Methods De-identified data from all injured patients treated by the trauma service during 2014 and 2015 were reviewed to determine individual patient injury profiles. Using these injury profiles we created the ‘trauma bundle’ by concatenating the highest Abbreviated Injury Scale score for each of the six body regions to produce a single ‘signature’ of injury by region for every patient. These trauma bundles were analyzed by frequency over 2 years and by each year. The impacts of physiology and resource consumption were evaluated by determination of the correlation of the mean and SD of calculated survival probability (Ps) and intensive care unit length of stay (ICU LOS) for each profile group occurring more than 12 times in 2 years. Results The 5813 patients treated over 2 years produced 858 distinct injury profiles, only 8% (71) of which occurred more than 12 times in 2 years. Comparison of 2014 and 2015 profiles demonstrated high frequency variation among profiles between the 2 years. Analysis of injury patterns occurring >12 times in 2 years demonstrated an inverse correlation between the mean and SD for Ps (R²=0.68) and a direct correlation for ICU LOS (R²=0.84). Discussion These data indicate that the disease of injury is too inconsistent a mix of injury pattern and physiologic response to be predictably bundled for an APM. The inverse correlation of increasing SD with increasing ICU LOS and decreasing Ps suggests an opportunity for measurable process improvement. Level of evidence Economic and value-based evaluations, level IV. Study type Economic/decision.

Background: Recent federal legislation driving transition from fee-for-service to alternative methods of payment makes risk recognition essential for determination of appropriate payment systems. Because negotiations will include bundled population cohorts, we compared risk and results of an urban safety net teaching hospital's surgical population with state and national cohorts. Study design: Deidentified summary data for 2013 and 2014 were analyzed to compare the safety net teaching hospital with a statewide collaborative and a national cohort from similar academic centers. Incidence of preoperative risk factors were compared, identifying those that were >50% higher than both state and national experiences. These were compared for change in incidence between years. Outcomes were evaluated by 30-day mortality, readmissions, return to operating room, length of stay, and adverse events incidence. Results: For both years, incidence of smoking, ventilator dependence, and CHF within 30 days was >50% higher than in the state and national cohorts. In 2014, septic shock was added to this, along with increased diabetes (14.3% to 19.8%), CHF (1.9% to 2.8%), and hypertension (39.9% to 52.5%). Despite these changes, 30-day mortality, return to operating room, length of stay, and readmissions were within ±5% of state and national results. Unplanned intubation, ventilation longer than 48 hours, and acute renal failure were 10th decile outliers. Median and interquartile range for length of stay were similar for all 3 populations across both years. Conclusions: The incidence of comorbid conditions defines greater risk in this safety net teaching hospital population. Increased smoking-related pathology reflects local population disease burden, and increased ventilator support defines additional cost for this care. As disease-, procedure-, or population-based payment alternatives evolve, risk recognition, reduction, and resolution will be essential for determination of cost-efficient, optimal, surgical outcomes.

Organ transplantation has become a life-saving procedure for patients with end stage kidney, liver, lung, and heart disease. However, these patients are typically debilitated and malnourished prior to undergoing transplantation. The surgical literature is replete with studies documenting the increased morbidity and mortality following non-transplant surgery on malnourished patients. In an effort to achieve the best outcomes following organ transplantation transplant surgeons have also tried to study the effects of malnutrition on outcomes following organ transplantation. They have looked at the relationship of malnutrition to infectious complications, graft function, hospital length of stay, intensive care unit length of stay, and mortality. The etiology of malnutrition in patients with end stage disease is complex and multifactorial. In patients with renal failure the loss of kidney function results in acidosis that induces protein catabolism and alters amino acid uptake thus negatively affecting nitrogen balance. There is also a negative effect on albumin synthesis and albumin concentration. The hormonal milieu is deranged as well. In addition, nutritional intake can be poor due to anorexia, hospitalization, gastroparesis, nausea, vomiting, and poor tasting specialized diets among other things.