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Scanning the aged to minimize missed injury: An EAST multicenter study
Ho, Vanessa P; Kishawi, Sami K; Hill, Hannah; O'Brien, Joseph; Ratnasekera, Asanthi; Seng, Sirivan Suon; Ton, Trieu Hai; Butts, Christopher A; Muller, Alison; Diaz, Bernardo Fabian; Baltazar, Gerard A; Petrone, Patrizio; Pacheco, Tulio Brasileiro Silva; Morrissey, Shawna; Chung, Timothy; Biller, Jessica; Jacobson, Lewis E; Williams, Jamie M; Nebughr, Cole S; Udekwu, Pascal O; Tann, Kimberly; Piehl, Charles; Veatch, Jessica M; Capasso, Thomas J; Kuncir, Eric J; Kodadek, Lisa M; Miller, Samuel M; Altan, Defne; Mentzer, Caleb; Damiano, Nicholas; Burke, Rachel; Earley, Angela; Doris, Stephanie; Villa, Erica; Wilkinson, Michael C; Dixon, Jacob K; Wu, Esther; Moncrief, Melissa L; Palmer, Brandi; Herzing, Karen; Egodage, Tanya; Williams, Jennifer; Haan, James; Lightwine, Kelly; Colling, Kristin P; Harry, Melissa L; Nahmias, Jeffry; Tay-Lasso, Erika; Cuschieri, Joseph; Hinojosa, Christopher J; Claridge, Jeffrey A
BACKGROUND:Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a Pan-Scan (Head/C-spine/Torso) or a Selective Scan (Head/C-spine ± Torso). We hypothesized that a patient's initial history and exam could be used to guide imaging. METHODS:We prospectively studied blunt trauma patients aged 65+ at 18 Level I/II trauma centers. Patients presenting >24 h after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of Head/C-spine or Torso (chest, abdomen/pelvis, and T/L spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our dataset. Our priority was to identify a simple rule which could be applied at the bedside, maximizing sensitivity (Sens) and negative predictive value (NPV) to minimize missed injuries. RESULTS:We enrolled 5,498 patients with 3,082 injuries. Nearly half (47.1%, n = 2,587) had an injury within the defined CT body regions. No rule to guide a Pan-Scan could be identified with suitable Sens/NPV for clinical use. A clinical algorithm to identify patients for Pan-Scan, using a combination of physical exam findings and specific high-risk criteria, was identified and had a Sens of 0.94 and NPV of 0.86 This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. CONCLUSIONS:Our findings advocate for Head/Cspine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. LEVEL OF EVIDENCE/METHODS:Level 2, Diagnostic Tests or Criteria.
PMID: 38797882
ISSN: 2163-0763
CID: 5663222
Response to letter to the editor regarding article: Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma
Mahoney, Eric J; Bugaev, Nikolay; Appelbaum, Rachel; Goldenberg-Sandau, Anna; Baltazar, Gerard A; Posluszny, Joseph; Dultz, Linda; Kartiko, Susan; Kasotakis, George; Como, John; Klein, Eric
PMID: 37683253
ISSN: 2163-0763
CID: 5590912
Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma
Aziz, Hiba Abdel; Bugaev, Nikolay; Baltazar, Gerard; Brown, Zachary; Haines, Krista; Gupta, Sameer; Yeung, Lawrence; Posluszny, Joseph; Como, John; Freeman, Jennifer; Kasotakis, George
BACKGROUND:The kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma. METHODS:The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation. RESULTS:A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends. CONCLUSION/CONCLUSIONS:In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury. LEVEL OF EVIDENCE/METHODS:Guideline; systematic review, level III.
PMCID:9881253
PMID: 36707832
ISSN: 1471-2482
CID: 5419842
A POSSIBLE MEROPENEM-ASSOCIATED DRESS SYNDROME [Meeting Abstract]
Wang, Shan; Banta, Erin; Backer, Martin; Baltazar, Gerard; Joseph, D\Andrea; Winner, Megan
ISI:000921450901067
ISSN: 0090-3493
CID: 5496522
Racial Differences and Injury Pattern Variation: Impact of COVID-19 on a Bronx Trauma Center
Kiernan, Risa N; Salvitti, Madison S; Baltazar, Gerard; Kivitz, Scott; Sosulski, Amanda; Karev, Dmitriy; Celebi, Taner B; De Mel, Stephanie; Amanat, Sonia; Schulz, Dana; Talty, Nanette; Feliciano, Jennifer; DiRusso, Stephen
BACKGROUND:New York City (NYC) became the epicenter of the COVID-19 pandemic in 2020. The Bronx, with the highest rates of poverty and violent crime of all NYC boroughs and a large Black and Hispanic population, was at increased risk of COVID-19 and its sequelae. We aimed to identify temporal associations among COVID-19 and trauma admission volume, demographics, and mechanism of injury (MOI). METHODS:A retrospective review of prospectively collected data was conducted from a Level II trauma center in the Bronx. January 1st-September 30th for both 2019 (Pre-COVID) and 2020 (COVID) were compared. Pre-COVID and COVID cohorts were subdivided into EARLY (March-May) and LATE (June-September) subgroups. Demographics and trauma outcomes were compared. RESULTS:< .05). Additionally, during LATE COVID, there was a resurgence of total penetrating, total blunt, MVC, falls, cyclists/pedestrians struck, and firearm injuries. DISCUSSION/CONCLUSIONS:Our results emphasize MOI variations and racial differences of trauma admissions to a Level II trauma center in the Bronx during COVID-19. These findings may help trauma centers plan during pandemics and encourage outreach between trauma centers and community level organizations following future healthcare disasters.
PMCID:9806204
PMID: 36571264
ISSN: 1555-9823
CID: 5433392
Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma
Mahoney, Eric J; Bugaev, Nikolay; Appelbaum, Rachel; Goldenberg-Sandau, Anna; Baltazar, Gerard A; Posluszny, Joseph; Dultz, Linda; Kartiko, Susan; Kasotakis, George; Como, John; Klein, Eric
BACKGROUND:Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization. METHODS:A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated. RESULTS:Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity. CONCLUSION:We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema. LEVEL OF EVIDENCE:Systematic Review and Meta-Analysis; Level IV.
PMID: 35546420
ISSN: 2163-0763
CID: 5335132
Coronavirus Disease 2019 and the Injured Patient: A Multicenter Review
Hakmi, Hazim; Islam, Shahidul; Petrone, Patrizio; Sajan, Abin; Baltazar, Gerard; Sohail, Amir H; Goulet, Nicole; Jacquez, Ricardo; Stright, Adam; Velcu, Laura; Divers, Jasmin; Joseph, D'Andrea K
INTRODUCTION/BACKGROUND:Coronavirus disease 2019 (COVID-19) has been shown to affect outcomes among surgical patients. We hypothesized that COVID-19 would be linked to higher mortality and longer length of stay of trauma patients regardless of the injury severity score (ISS). METHODS:We performed a retrospective analysis of trauma registries from two level 1 trauma centers (suburban and urban) from March 1, 2019, to June 30, 2019, and March 1, 2020, to June 30, 2020, comparing baseline characteristics and cumulative adverse events. Data collected included ISS, demographics, and comorbidities. The primary outcome was time from hospitalization to in-hospital death. Outcomes during the height of the first New York COVID-19 wave were also compared with the same time frame in the prior year. Kaplan-Meier method with log-rank test and Cox proportional hazard models were used to compare outcomes. RESULTS:There were 1180 trauma patients admitted during the study period from March 2020 to June 2020. Of these, 596 were never tested for COVID-19 and were excluded from the analysis. A total of 148 COVID+ patients and 436 COVID- patients composed the 2020 cohort for analysis. Compared with the 2019 cohort, the 2020 cohort was older with more associated comorbidities, more adverse events, but lower ISS. Higher rates of historical hypertension, diabetes, neurologic events, and coagulopathy were found among COVID+ patients compared with COVID- patients. D-dimer and ferritin were unreliable indicators of COVID-19 severity; however, C-reactive protein levels were higher in COVID+ relative to COVID- patients. Patients who were COVID+ had a lower median ISS compared with COVID- patients, and COVID+ patients had higher rates of mortality and longer length of stay. CONCLUSIONS:COVID+ trauma patients admitted to our two level 1 trauma centers had increased morbidity and mortality compared with admitted COVID- trauma patients despite age and lower ISS. C-reactive protein may play a role in monitoring COVID-19 activity in trauma patients. A better understanding of the physiological impact of COVID-19 on injured patients warrants further investigation.
PMCID:9263818
PMID: 36084394
ISSN: 1095-8673
CID: 5337332
Stop the Bleed: A Prospective Evaluation and Comparison of Tourniquet Application in Security Personnel Versus Civilian Population
Petrone, Patrizio; Baltazar, Gerard; Jacquez, Ricardo A; Akerman, Meredith; Brathwaite, Collin E M; Joseph, D'Andrea K
INTRODUCTION/BACKGROUND:Stop the Bleed (STB) is a national training program aiming to decrease the mortality associated with life-threatening bleeding due to injury. The purpose of this study was to evaluate the efficacy and confidence level of security personnel placing a tourniquet (TQ) compared to civilians. METHODS:Pre and post questionnaires were shared with security personnel (Group 1) and civilians (Group 2). Both groups were assessed to determine comfort level with TQ placement. Time and success rate for placement was recorded pre- and post-STB training. A generalized linear mixed model or generalized estimating equations was used to compare pre and post measurements. RESULTS:There were 234 subjects enrolled. There was a statistically significant improvement between the pre- and post-training responses in both groups with respect to comfort level in placing a TQ. Participants also demonstrated increased familiarity with the anatomy and bleeding control after STB training. A higher successful TQ placement was obtained in both groups after STB training (Pre-training: Group 1 [17.4%], Group 2 [12.8%]; Post-training: Group 1 [94.8%], Group 2 [92.3%]). Both groups demonstrated improved time to TA placement with a longer mean time improvement achieved in Group 1. Although the time to TQ placement pre-and post-training was statistically significant, we found that the post-training times between Groups 1 and 2 were similar (P = .983). CONCLUSIONS:Participants improved their confidence level with the use of hemorrhage control techniques and dramatically increased the rate and time to successful placement of a TQ. While civilians had the greatest increase in comfort level, the security personnel group saw the most significant reduction in the time to successful TQ placement. These findings highlight the critical role of STB in educating and empowering both civilians and security personnel in bleeding control techniques.
PMID: 35567282
ISSN: 1555-9823
CID: 5215142
Outcomes in Obese vs Non-Obese Injured Patients at a Level 1 Trauma Center and Bariatric Surgery Center of Excellence
Petrone, Patrizio; Joseph, D'Andrea K; Baltazar, Gerard; Akerman, Meredith; Howell, Raelina S; Brathwaite, Collin E M
BACKGROUND:We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). STUDY DESIGN/METHODS:Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). RESULTS:< .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. CONCLUSIONS:Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.
PMID: 35343242
ISSN: 1555-9823
CID: 5200882
Smartphone application alerts for early trauma team activation: Millennial technology in healthcare
Goulet, Nicole D; Liu, Helen; Petrone, Patrizio; Islam, Shahidul; Glinik, Galina; Joseph, D'Andrea K; Baltazar, Gerard A
BACKGROUND:Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS:Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS:Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION/CONCLUSIONS:Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.
PMID: 34210527
ISSN: 1532-7361
CID: 4927182